Structure is what carries you through the cases you did not prepare for. It is what stops you losing twelve minutes to a thorough history and three minutes to a rushed plan. It is what the examiner sees when they watch a candidate who looks like a safe, independent GP — not because they knew all the answers, but because they always knew where they were.

This is that structure.

You are given roughly three minutes to read the vignette before each case begins. Most candidates use this time to absorb clinical content. That is the floor.

The ceiling is reading the vignette twice. Once for clinical information — the age, the past medical history, the medications, any results attached. Then again for signal — what kind of consultation is this likely to be, which domain is going to lead, is there anything in the booking reason or the notes that tells you something before the patient speaks?

Every detail in a vignette is there for a reason. The RCGP does not include incidental information. If the patient's occupation is mentioned, it matters. If there is a recent result attached, it will come up. If the reason for booking is vague, that vagueness is itself a signal.

Use the three minutes to form a hypothesis about the case. You will not always be right. A hypothesis you update is far more useful than no hypothesis at all.

Data gathering is your opening movement, and it runs from the first moment of the consultation to roughly the six or seven-minute mark. It has its own internal structure.

Open Wide

Start with a genuinely open question. Not "what brings you in today" — that is a fine question, but it invites a presenting complaint rather than a story. Something more open gives the patient room to tell you what actually matters to them: "Tell me what's been going on" or "What made you want to talk to someone today?"

Then stay quiet. Let the patient speak without interruption. What they say in those first unguided moments is often the most important thing in the consultation — the real reason they booked, the concern underneath the presenting complaint, the thing they were not sure how to raise. Cutting across it to ask a clinical question means you may never get back to it.

Focus the History

Once the patient has told you their opening story, move into focused data gathering. This is where clinical preparation earns its place.

For the presenting complaint: explore onset, duration, character, severity, and progression. What makes it better, what makes it worse. What the patient has tried already. Ask the questions that are specific to this presentation — not a generic symptom list, but the questions that matter for this clinical picture.

Then the relevant systems. Not a full systems review — a targeted one, based on what you have heard and what the differential diagnosis requires.

Red Flags

Red flags are high-weight items in the DG&D domain. Missing them risks a clear fail regardless of how well the rest of the case goes.

Do not fire them as a checklist. Frame them: "I want to make sure I ask about a few things — there are some more serious causes I always check for in this situation." Same questions, clinical reasoning made visible, a patient who feels assessed rather than interrogated.

Place the Patient in Context

Before you close data gathering, you need to know who this person is, not just what their symptom is.

Past medical history relevant to this presentation. Current medications — including over-the-counter, herbal, and recent changes. Allergies. At least one psychosocial factor: work, relationships, housing, financial stress, caring responsibilities. Smoking, alcohol, and recreational drug use where clinically relevant.

The psychosocial context is not background noise. It is clinical data. A management plan that does not account for the patient's circumstances is a generic plan, and generic plans do not score well.

ICE — and Mean It

Ideas, concerns, and expectations belong in data gathering. Ask each one separately. They are not a checklist to tick — they are the three questions whose answers should change what you do in the second half of the consultation.

If the patient tells you they are worried about cancer, your explanation needs to address cancer specifically. If they came in hoping for a referral, your management needs to engage with that hope. ICE that is gathered and then never used is not ICE — it is performance. The examiner knows the difference.

Impact

Before you pivot to management, ask one more question: how is this affecting the patient's daily life? Work, relationships, sleep, activities. The answer often surfaces the most important thing in the consultation, and it tells you what success looks like for this patient.

Working Diagnosis

Close data gathering by naming your working diagnosis out loud. Not a hedged list of possibilities. A confident, clearly stated working hypothesis: "From what you've told me, my working diagnosis at this stage is X."

If you are genuinely uncertain, say so — and say what you are doing about it: "I'm not entirely sure yet what's causing this, and here's what I think we should do to find out." Uncertainty acknowledged and managed is a clinical skill. Uncertainty hidden behind a list of differentials is avoidance.

A named working diagnosis is the bridge between data gathering and management. Without it, the pivot into the second half of the consultation has no foundation.

Every consultation has a moment where data gathering ends and management begins. Where it lands, and how cleanly you make it, is one of the most visible things an examiner sees.

A good pivot is a brief summary, a check, a working diagnosis, and a forward movement. It creates a natural moment in the consultation rather than a sudden gear change. Re-addressing the patient's ICE or providing a working diagnosis + explaination can often be a perfect pivot point.

After naming your working diagnosis, explain it in plain language — not a medical lecture, a human explanation. What it is, what causes it, and what it means for this patient specifically. Reference their ICE directly: if they were worried it might be cancer, address that now. If they thought it was stress, acknowledge whether they were right or not and why. Keep it brief — two or three sentences at most — because the management plan needs time, and explanation that runs too long is explanation that crowds out the things that actually need to happen before the consultation ends. Check understanding before you move on: "Does that make sense so far?" One question. Then move to the plan.

The pivot should happen by minute seven at the latest in most cases. Management — the highest-weighted domain at 4.5 out of 10.5 per case — needs at least five minutes to be done properly. If you are past minute seven and still in the history, something needs to change.

Management follows the TIPS framework. Not as a script — as a checklist of components that a complete management plan always contains.

T — Treatment

What are you going to do for this patient today? Pharmacological treatment: if prescribing, name the medication, the dose, the duration, and the rationale. Explain it in plain language. Non-pharmacological treatment: lifestyle advice, physiotherapy, self-management strategies, signposting to community resources.

I — Investigations

What do you need to know that you do not know yet? Blood tests, imaging, swabs, referrals. Be specific — not "some bloods" but which bloods and why.

P — Psychosocial: Readdress ICE

The patient's ideas, concerns, and expectations — gathered in the first half — must reappear here. ICE that does not reappear in the management section was never really used.

S — Social

Address any social factors the patient raised in data gathering. Where relevant, signpost to support — fit notes, occupational health, social prescribing, voluntary sector services.

HP — Health Promotion

Where there is a natural opportunity, take it — not as a lecture, but as a brief, proportionate mention that fits the consultation.

SN — Safety Netting

Safety netting is high-weight. Specific safety netting names the symptoms to watch for, explains why those specific symptoms matter, gives a timeframe for when to act, and tells the patient where to go.

FU — Follow Up

Close the management section with a clear follow-up plan. When will you review? What will you be checking? Who should they contact if things change before then?

Relating to Others is assessed across the entire consultation. There is no point in the twelve minutes when it is switched off.

The examiner is watching: whether you give the patient an uninterrupted opening, whether you respond to what they actually say rather than what you expected them to say, whether you pick up emotional cues when they appear, whether your explanation is in plain language and tailored to this person, whether you check understanding, and whether the management plan is arrived at together rather than delivered at the patient.

Empathy is not a phrase you insert at the beginning and the end. It is built into how you ask questions, how you respond when the patient says something unexpected, how you handle a moment of distress, and how you explain a difficult decision.

One practical check: at the close of the consultation, before you say goodbye, ask the patient if they have any questions and whether they are happy with the plan. That moment, handled well, often makes the difference between a P and a CP in RtO.

That shape does not change. The content inside it does. Learn the shape well enough that it is instinctive, and you will never be lost in a case — even the ones that surprise you.

Related in this series

• The SCA is a play: leverage structure, don't become contained by it — the overview on consultation types
• Why people fail the RCGP SCA — common failure patterns
• The Blank Page · Results · Breaking Bad News · Prescribing · Ethical Dilemma · Negotiation · Complexity