This is the blank page. And for candidates who have prepared by revising clinical topics, it is the most disorienting case type in the SCA.

It is also, if you understand what it is testing, one of the most winnable.

The RCGP includes undifferentiated presentations deliberately. They appear in the blueprint as "new presentations of undifferentiated illness" — and they are there because undifferentiated illness is the reality of general practice. Patients do not arrive with a diagnosis. They arrive with something they cannot name, and the job of a GP is to create the conditions in which that something can surface.

The blank page case strips away the scaffolding that clinical preparation provides. It removes the working hypothesis you might form in your three-minute reading window. It forces you to consult without a map.

What it is testing, specifically, is whether you can hold that uncertainty without flinching — and whether your structure is robust enough to carry you through a case when content alone cannot.

The RCGP's own marking descriptors for DG&D at passing level include the ability to "rely on first principles where the presentation is undifferentiated, uncertain, or complex." That phrase is the key to this case type. First principles means your consultation structure. Not a topic revision list. Not a memorised set of questions for a particular condition. The shape of a good GP consultation, applied cleanly.

Candidates who struggle with the blank page do one of two things.

The first is freezing. The vignette gives them nothing to prepare, the case opens and they have no hypothesis to organise around, so the consultation stalls in the opening seconds. They ask a vague question, get a vague answer, and never find the thread.

The second is narrowing too fast. Uncomfortable with the openness, they reach for the first clinical detail the patient offers and start building a symptom inventory around it — closing down the consultation before the real picture has had a chance to emerge. The patient's story gets squeezed into a clinical framework before it is ready.

Both failures have the same root cause: an absence of structure that can function independently of clinical content.

Your opening needs to do more work here than in any other case type. It needs to create genuine space.

Not "what brings you in today" — that is a fine question but it is narrow, and it invites a narrow answer. Something more open: "Tell me what's been on your mind" or "What made you want to talk to someone today?" These questions give the patient permission to tell you their story rather than their symptom.

Then stay quiet. This is harder than it sounds, particularly on a video or telephone call where silence feels amplified. But the blank page case rewards the candidate who can open wide and wait — because the patient will tell you something, and what they tell you in that unguided opening moment is often the most important thing in the case.

Resist the pull to organise what you are hearing into a clinical framework too early. Listen first. Let the narrative settle. Only then start to focus — using the story you have heard to decide where your targeted questions should go, rather than applying a generic checklist.

By the midpoint of the consultation you should have: the presenting complaint in the patient's own words, their ideas about what might be happening, their concerns, their expectations, and enough psychosocial context to understand who this person is and what this presentation means to them. That is a data-gathering foundation you can build a management plan on — regardless of whether the diagnosis is clear.

If the clinical picture is genuinely uncertain at the point of pivot, say so. "I want to be honest with you — I'm not certain yet what's causing this, and here's what I think we should do about that" is a legitimate clinical position. The DG&D descriptors explicitly credit the ability to manage uncertainty. Uncertainty handled well scores. Uncertainty avoided or papered over does not.

In a blank page case, the examiner has the patient brief. They know what the case is about. They are watching whether you find it.

They are looking for a genuine, patient-led opening. They want to see you resist the pull to narrow early. They are watching whether ICE appears naturally, whether the psychosocial context surfaces, and whether your working hypothesis — once you form one — is built from what the patient told you rather than imposed on top of it.

They are also watching what happens when the picture is incomplete. Do you make a proportionate decision with the information available? Do you use time as a diagnostic tool where appropriate — acknowledging that not everything needs resolving today? Or do you defer, refer, and safety-net vaguely because you were not sure what the case was about?

The blank page is a test of how you consult when content cannot carry you. Structure is your answer.

Deliberately remove clinical preparation from some of your practice cases. Do not look up the topic. Open the case with no hypothesis and no revision framework in mind. Practise holding the opening wide, staying with uncertainty, and forming your working hypothesis from the consultation rather than the vignette.

Ask a study partner to give you a blank vignette — age, gender, a single vague reason for booking — and nothing else. Then consult. The discomfort of not knowing what the case is about in advance is exactly the discomfort the exam produces. Getting comfortable with it before the day is the preparation.

Related in this series

• How to Structure Your SCA Consultation — the full structure reference
• The SCA is a play: know your consultation type — the series overview
• Why people fail the RCGP SCA — common failure patterns
• The Negotiation Consultation — both require holding uncertainty