The prescribing dilemma case is not just a test of whether you know the guideline. It is a test of whether you can make a prescribing decision, explain it clearly, manage the patient's response to it, and safety-net appropriately. The clinical knowledge and the consultation skill are both on display at the same time.

Prescribing cases split broadly into two shapes, and the structure you need differs between them.

The first is the straightforward prescribing decision — medication is clinically indicated, the discussion is about which option, concordance, and monitoring. Statin counselling following a QRISK calculation. Starting an antidepressant in someone with moderate depression. Titrating a long-term medication based on monitoring results. The tension here is about shared decision-making, not clinical conflict. The patient needs enough information to make an informed choice, and your job is to give it to them in a way that lands.

The second is the contested prescribing request — the patient wants something you cannot or should not prescribe. Antibiotics for a clear viral illness. Benzodiazepines for chronic anxiety. A controlled drug that is not clinically justified. A medication outside its licensed indication. Here the clinical position is clear, and the difficulty is the consultation — holding your position while the patient pushes back, sometimes firmly.

Both versions test prescribing knowledge. But the second also tests negotiation, resilience under pressure, and the ability to stay clinically honest without becoming dismissive.

The structure here follows the standard shape — history to establish the clinical picture, explanation of the diagnosis or indication, then the prescribing conversation as part of the management section.

What lifts a good prescribing consultation above a generic one is the quality of the medication discussion. Not just "I'd like to start you on X" but: what it is and what it does, why you are recommending it for this person specifically, the common side effects they should know about, what to do if those occur, the monitoring plan, and what you expect it to achieve. That is a shared decision, not a prescription.

Also important: the patient's perspective on medication. Before you write the prescription — metaphorically, in the SCA — check what the patient thinks. Do they have concerns about taking it? Have they tried something similar before? Is there anything that might affect their ability to take it as prescribed? These questions are not just courteous. They directly address RtO and CM&C, and they often reveal information that changes the plan.

Safety-netting for prescribing cases is specific. It names the side effects the patient should watch for, explains when those side effects would warrant contacting the surgery, gives a timeframe for expected effect, and clarifies when review will happen. "Take it and see how you get on" is not safety-netting.

This is where the prescribing case becomes uncomfortable, and where a lot of candidates make their most visible errors.

The temptation when a patient requests something clinically inappropriate is to decline quickly and move on. "I'm afraid that's not something I'm able to prescribe." Said clearly, said once, and the candidate moves to an alternative plan. The problem is that by declining before the patient has been genuinely heard, the consultation becomes positional — and the patient's pushback, when it comes, has nowhere to go.

Before you say no, understand why they are asking. What is driving this specific request? A patient asking for antibiotics for a cold who mentions they have a job interview in three days is not the same as someone who just wants them out of habit. A patient requesting benzodiazepines who discloses they have not slept in a week following a bereavement is asking for something different from their stated request. The request is the surface. What is underneath it shapes the whole consultation.

Take the patient's concern seriously. Then explain your position — with a clinical rationale, not just a policy statement. "I can't prescribe this because it's not our policy" closes down the consultation. "I'm not going to prescribe antibiotics today, and here's why I think they would actually do more harm than good in your situation" is a clinical explanation that respects the patient's intelligence.

Then offer something. Not as a consolation prize, but as a genuine alternative that addresses what the patient actually needs. If the patient needs antibiotics reassurance, offer a delayed prescription with clear criteria for when to use it. If the patient needs sleep, address sleep, not sedation.

Prescribing refusals generate frustration. Sometimes that frustration escalates. The candidate who caves under pressure — who prescribes something inappropriate to end the conflict — has failed clinically and the examiner knows it. The candidate who becomes defensive and repeats their position more firmly each time it is challenged has handled the communication poorly.

The middle ground is acknowledgement without capitulation. "I can see this is really frustrating — you've come in hoping for something specific and I'm telling you I can't provide it. That's genuinely difficult, and I want to make sure we find something that does help." That sentence does not change your clinical position. It changes the dynamic. The patient feels heard. The conversation can move.

Hold your ground. But hold it warmly.

They are watching whether your prescribing rationale is clinically sound and whether it is explained in a way the patient can understand. They are watching whether shared decision-making is genuine — not a monologue about the medication followed by "any questions?" They are watching how you handle pushback — whether you cave, whether you escalate, or whether you acknowledge and hold.

They are also watching the safety-netting. Prescribing cases have specific, identifiable safety-netting requirements. Leaving these vague when the clinical picture is clear is a missed CM&C opportunity.

Practise both shapes. Do cases where the prescribing is appropriate and the challenge is shared decision-making. Do cases where the prescribing is not appropriate and the challenge is handling the patient's response.

Specifically practise the moment after a refusal — after you have said no and the patient has pushed back. That is the moment most candidates have not rehearsed, and it shows.

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 — contested requests overlap