Ethics · Advanced · Rheumatology

Polymyalgia Rheumatica Patient Refusing Steroids

Practise this PLAB 2 ethics station on Polymyalgia Rheumatica. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor reviewing a 71-year-old woman with confirmed polymyalgia rheumatica. She has been diagnosed with elevated inflammatory markers and classical presentation. However, she is refusing prednisolone because she has read about steroid side effects and is very fearful. You need to explore her concerns, discuss the risks of untreated PMR, and attempt to negotiate a management plan she will accept. This is a counselling and ethical scenario.

Background notes: PMH: Osteoporosis, Hypertension (on amlodipine), Polymyalgia rheumatica (newly diagnosed)

What this station tests

  • Exploring the reasons for treatment refusal before responding: her ICU nursing experience makes her concerns informed, not irrational
  • Reframing steroid risk proportionately: PMR doses (15mg) are very different from ICU doses (40-60mg+)
  • Explaining the risk of untreated PMR: progressive disability and potential GCA progression, presented as information not coercion
  • Offering a time-limited trial as a compromise: 2 weeks to assess response and tolerability
  • Respecting autonomy genuinely: documenting informed refusal, maintaining follow-up, not withdrawing care

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself. Establish the ethical issue and your role.
  • 1-3 min — Explore Perspective: Listen to patient/relative perspective. Understand their reasoning and concerns.
  • 3-5 min — Ethical Framework: Apply ethical principles: autonomy, beneficence, non-maleficence, justice. Reference relevant guidelines (GMC, Mental Capacity Act).
  • 5-7 min — Negotiate and Plan: Find common ground. Explain your professional obligations. Involve MDT where appropriate. Document plan.
  • 7-8 min — Closing: Summarise agreed position. Outline next steps. Offer further discussion.

Consultation approach

The opening

Treatment refusal stations test the candidate's ability to respect autonomy while providing balanced information. The key is exploring why the patient is refusing, not arguing against the refusal. Mrs Basu is 71, newly diagnosed PMR with elevated inflammatory markers and classical presentation. She is refusing prednisolone because of steroid side effects she witnessed as an ICU nurse for 30 years. Open with: 'Mrs Basu, I understand you have concerns about the prednisolone. I would really like to hear what is worrying you before we discuss options.'

Core approach

Listen to her concerns fully before responding. She has 30 years of ICU nursing experience. She saw patients with Cushing's features, steroid myopathy, osteoporotic fractures, diabetes, and infections on long-term steroids. Her concerns are informed and legitimate, not irrational. Acknowledge this: 'Your experience gives you a very real understanding of what high-dose steroids can do. Those complications are real. But I want to explain how PMR treatment differs from what you saw in ICU.'

Reframe the risk proportionately. ICU patients receive much higher steroid doses for different conditions. PMR starts at 15mg prednisolone and tapers gradually to very low doses. The side effect profile at 15mg is very different from 40 to 60mg. With bone protection (calcium, vitamin D, bisphosphonate given her osteoporosis), the fracture risk is mitigated. With monitoring (blood glucose, BP), metabolic complications are caught early.

Explain the risk of not treating. PMR causes significant disability and can progress to GCA (with risk of blindness). She is already unable to dress, wash her hair, or enjoy her grandchildren. The disease will not resolve spontaneously. Present this as balanced information, not as coercion.

Explore alternatives honestly. There is no good alternative to steroids for PMR. Methotrexate is sometimes used as a steroid-sparing agent but not as monotherapy. NSAIDs do not work. She needs to understand this, but the decision remains hers.

Closing and safety netting

Offer a compromise if she remains reluctant: 'Would you be willing to try a low dose for 2 weeks and see how you respond? If the side effects are intolerable, we can discuss stopping. If you feel dramatically better, that tells us both something important.' This gives her a sense of control and a way to test the treatment without committing indefinitely.

Document her informed refusal if she still declines. Arrange follow-up in 1 to 2 weeks regardless of her decision. GCA safety netting remains essential: 'Whether or not you take the prednisolone, please come in immediately if you develop a new headache, jaw pain on chewing, or any visual changes.' Respect her autonomy genuinely: 'This is your decision. I want to support you whatever you choose.'

How examiners mark this station

Examiners will assess your ethical reasoning and interpersonal skills. Domain 2 (Clinical Management) is primary: marks for applying an ethical framework, referencing relevant legislation and guidelines, and reaching a reasoned position. Domain 3 (Interpersonal Skills) is equally weighted: marks for non-judgmental exploration, empathic communication, and negotiation skills. Domain 1 (Data Gathering) assesses your ability to fully explore the situation before forming a view.

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

Scores well: Exploring her specific concerns in detail. Understanding her nursing background and how it shapes her views. Assessing current functional impact. Checking osteoporosis status for bone protection planning.

Costs marks: Not exploring her reasons. Dismissing her nursing knowledge. Not assessing functional impact.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Proportionate risk-benefit communication (PMR doses vs ICU doses). Bone protection offered to mitigate her fracture concern. Alternative options discussed honestly (limited). Time-limited trial offered. GCA safety netting maintained. Documented informed refusal.

Costs marks: Inaccurate risk communication. No bone protection. Not acknowledging limited alternatives. No GCA safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Listening fully before responding. Validating her ICU experience. Not being coercive or dismissive. Offering compromise. Respecting autonomy genuinely. Maintaining the therapeutic relationship regardless of her decision.

Costs marks: Dismissing concerns. Being coercive. Not offering compromise. Withdrawing engagement if she refuses.

Common examiner feedback (and how to fix it)

Did not demonstrate adequate ethical reasoning or application of relevant guidelines

Fix: Structure your response around the four ethical pillars (autonomy, beneficence, non-maleficence, justice). Reference specific guidelines (GMC, Mental Capacity Act) where relevant.

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

Fix: Acknowledge the emotional weight of the situation early. Show that you understand why this is difficult before applying ethical reasoning.

Common mistakes in this station

  1. Dismissing her concerns as irrational. She has 30 years of ICU experience watching steroid complications. Her concerns are evidence-based. Candidates who say 'the benefits outweigh the risks' without engaging with her specific experiences lose her trust.
  2. Being coercive. Using fear ('you could go blind from GCA') to pressure her into accepting treatment is ethically inappropriate. Present the risks of non-treatment as information, not as threats.
  3. Not offering a compromise. An all-or-nothing approach (take steroids or refuse completely) misses the middle ground. A 2-week trial gives her agency and allows her to experience the dramatic response that characterises PMR.

Resitting PLAB 2?

If you have found ethics stations difficult, focus on learning a clear ethical framework (the four pillars) and practising how to apply it conversationally rather than reciting principles. Examiners reward candidates who can explore the tension between competing ethical principles while remaining empathic and non-judgmental.

Example opening

Thank you for coming in to speak with me. My name is Dr [Name]. I understand there is something important we need to discuss. Could you tell me your understanding of the situation?

Frequently asked questions

How should I approach this polymyalgia rheumatica ethics station in PLAB 2?

Treatment refusal stations test the candidate's ability to respect autonomy while providing balanced information. The key is exploring why the patient is refusing, not arguing against the refusal. Mrs Basu is 71, newly diagnosed PMR with elevated inflammatory markers and classical presentation.

What are examiners marking in this polymyalgia rheumatica station?

Marks are won for: Exploring her specific concerns in detail. Understanding her nursing background and how it shapes her views. Assessing current functional impact. Marks are lost for: Not exploring her reasons. Dismissing her nursing knowledge. Not assessing functional impact.

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

Dismissing her concerns as irrational. She has 30 years of ICU experience watching steroid complications. Her concerns are evidence-based.

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

Structure beats experience here. Focus on reframing steroid risk proportionately: PMR doses (15mg) are very different from ICU doses (40-60mg+). Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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