Counselling · Advanced · Respiratory

Persistent Cough and Breathlessness

Practise this PLAB 2 counselling station on COPD. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Robert Shaw, a 67-year-old man, has COPD diagnosed 5 years ago and continues to smoke 20 cigarettes per day despite this. He is here for a routine follow-up. Please counsel him on smoking cessation, discuss the benefits, and outline available pharmacological and non-pharmacological support including NRT, varenicline, and support services.

Background notes: PMH: COPD GOLD Stage 2-3, Hypertension, Hypercholesterolaemia, Type 2 Diabetes, Previous smoking-related disease

What this station tests

  • Motivational interviewing: exploring ambivalence about quitting rather than lecturing, using open questions, rolling with resistance
  • Addressing the 'damage is already done' belief with evidence: FEV1 decline slows to near-normal rate after cessation, exacerbation frequency reduces by 20 to 30%
  • Exploring previous quit attempts: what worked, what triggered relapse, and what has changed since then
  • Recognising the social and identity dimensions of smoking: isolation, pub as social outlet, smoking as identity, and how quitting threatens these
  • Presenting pharmacotherapy options as tools the patient chooses: NRT, varenicline, e-cigarettes, with support services

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Smoking cessation counselling in a patient who has failed previous quit attempts requires motivational interviewing, not instruction. The candidate must resist the urge to lecture and instead explore ambivalence. Mr Shaw is 67, retired, divorced, lives alone, has COPD GOLD 2 to 3, and smokes 20 per day. He has smoked for over 50 years and failed two quit attempts. He expects to be lectured and is pre-emptively defensive. Open differently: 'Mr Shaw, how are things going with your breathing?' Start with his COPD, not his smoking. Let smoking come up naturally.

Core approach

Assess his current COPD status first. Exercise tolerance is down to 50 metres. He has exacerbations in winter. He is on multiple inhalers. This establishes the clinical stakes without lecturing. Then explore his relationship with smoking using open questions, not directives.

Assess motivation using the stages of change model. He is likely in contemplation (knows he should quit, has thought about it, but feels powerless) or pre-contemplation (resigned). His belief is that 'the damage is already done' at 67. Counter this with evidence: 'Quitting now would slow the rate your lung function is declining. Smokers lose lung function about twice as fast as non-smokers. If you quit, that rate slows back toward normal within weeks. It also reduces how often you get chest infections.' Be specific, not generic.

Explore his previous quit attempts. First attempt: 3 years ago, lasted 2 weeks, relapsed during stress. Second: 1 year ago, lasted 3 days, found it too difficult. Ask what worked and what did not. What triggered relapse? Stress and habit are likely the answers. Identify his smoking triggers: after meals, with morning coffee, when stressed, when drinking, and simply out of habit.

Address his emotional relationship with smoking. He views it as part of his identity ('been smoking so long, don't know who I am without a cigarette'). He is socially isolated (divorced, lives alone, pub is his social outlet where smoking is common). Quitting threatens his social connections. This is the barrier that pharmacotherapy alone cannot solve.

His father died of lung cancer. He is scared of the same fate. This fear is real but he suppresses it. If rapport is established: 'Are you worried about your lungs getting worse?' may unlock this.

Closing and safety netting

Present the pharmacological options as tools, not commands. NRT (patches for background craving, inhalator or lozenges for acute urges), varenicline (most effective, doubles quit rates, explain how it works: reduces craving and blocks the pleasure of smoking), or e-cigarettes (less harmful than smoking, increasingly accepted as cessation aid by NICE). Let him express a preference. Explain that the support services (stop smoking service, telephone helpline) provide behavioural support alongside medication, and that the combination is more effective than either alone.

Do not demand a quit date. If he is ambivalent, offer: 'You don't have to decide today. But if you do decide to try, we are here to support you, and the treatments available now are much more effective than what you tried before.' Leave the door open. Give him written information about the local stop smoking service.

Safety net for COPD: 'If your breathing gets worse, you develop a chest infection, or you are using your reliever inhaler more than usual, come in sooner rather than later.' Arrange routine COPD follow-up.

How examiners mark this station

Examiners will assess your ability to explain copd and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Supporting)

Scores well: Assessing current COPD severity and functional impact. Detailed smoking history: pack-years, triggers, previous quit attempts, what helped and what did not. Stages of change assessment. Exploring emotional and social relationship with smoking.

Costs marks: Not assessing COPD severity. Superficial smoking history. Not exploring previous quit attempts. Not identifying triggers.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Evidence-based benefits of quitting at his age (FEV1 decline, exacerbation reduction). All three pharmacological options presented: NRT, varenicline, e-cigarettes. Behavioural support services mentioned. Combination therapy recommended. Not demanding a quit date when patient is ambivalent.

Costs marks: Vague 'you should quit' without evidence. Not knowing pharmacological options. Not mentioning support services. Demanding an immediate quit date from an ambivalent patient.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Motivational interviewing approach: exploring ambivalence, not lecturing. Non-judgmental throughout. Acknowledging the difficulty of quitting after 50 years. Addressing social isolation and identity concerns. Leaving the door open without pressure. Exploring his fear about his father's lung cancer death.

Costs marks: Lecturing about smoking. Being judgmental. Ignoring his social and emotional barriers. Demanding a decision. Not acknowledging his previous failed attempts.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Opening with smoking cessation. Mr Shaw expects to be lectured and is pre-emptively defensive. Candidates who start with 'Let's talk about your smoking' trigger resistance. Starting with his COPD and letting smoking emerge naturally is more effective.
  2. Ignoring his social isolation. He is divorced, lives alone, and his main social outlet is the pub where smoking is part of the culture. Candidates who prescribe NRT without addressing the social dimension of his smoking miss the main barrier to quitting.
  3. Being prescriptive rather than using shared decision-making. Telling him to quit is less effective than helping him explore his own ambivalence. 'You need to stop smoking' scores worse on Domain 3 than 'What would help you most if you decided to try?'

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

How should I approach COPD counselling in this PLAB 2 station?

Smoking cessation counselling in a patient who has failed previous quit attempts requires motivational interviewing, not instruction. The candidate must resist the urge to lecture and instead explore ambivalence. Mr Shaw is 67, retired, divorced, lives alone, has COPD GOLD 2 to 3, and smokes 20 per day.

What are examiners marking in this COPD station?

Marks are won for: Assessing current COPD severity and functional impact. Detailed smoking history: pack-years, triggers, previous quit attempts, what helped and what did not. Marks are lost for: Not assessing COPD severity. Superficial smoking history. Not exploring previous quit attempts. Not identifying triggers.

What is the most common mistake candidates make in this COPD station?

Opening with smoking cessation. Mr Shaw expects to be lectured and is pre-emptively defensive. Another frequent error: Ignoring his social isolation. He is divorced, lives alone, and his main social outlet is the pub where smoking is part of the culture.

How do I prepare for this station if I have not managed COPD in clinical practice?

This station rewards process over personal experience. The skill being assessed: Addressing the 'damage is already done' belief with evidence: FEV1 decline slows to near-normal rate after cessation, exacerbation frequency reduces by 20 to 30%. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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