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Practice case P2-13 · Face-to-face · simulated patient

“I don’t want the tablets” — a new diagnosis of type 2 diabetes

Three weeks ago a man of 49 was told he has type 2 diabetes. He has not collected his prescription.

Reviewed and kept current

Station family: Counselling / a patient declining treatment · 8-minute station · 1 min 30 s reading · Last editorial review: 19 September 2026.

Candidate instructions

Read this as you would outside the room

You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.

	Information
Your role	Foundation Year 2 doctor in a general practice. Your supervising GP and the practice diabetes nurse are available.
Patient	Mr Tariq Hussain, 49, warehouse shift supervisor
Reason for appointment	Booked by the practice nurse: “Diabetes review. Has not collected metformin prescription issued three weeks ago.”
Records	NHS Health Check five weeks ago: HbA1c 62 mmol/mol; repeated two weeks later: 60 mmol/mol — type 2 diabetes diagnosed. BMI 31 (92 kg). BP 138/84. eGFR 88; urine albumin:creatinine ratio normal. Total cholesterol 5.8, non-HDL 4.3 mmol/L; QRISK3 14%. Non-smoker. No regular medication. No known allergies.
Nurse’s plan	“Metformin modified-release 500 mg once daily with main meal, increase gradually. SGLT-2 inhibitor to be added once metformin is established (NICE NG28, 2026). Referred for structured education and retinal screening.”

Your task

•

Explore why Mr Hussain has not started his medication.

•

Address his concerns and give him the information he needs to decide.

•

Agree a plan with him.

•

No examination is required.

Folded away

For the actor and the examiner

1 · Actor script — role player only

Candidates: do not open until you have consulted.

Persona and manner

Tariq Hussain, 49, married with three children. You supervise night shifts in a distribution warehouse — four nights on, four off.
Polite, a little wary. You are expecting a telling-off and have your answers ready.

Opening line — say this verbatim

“I know why I’m here. The nurse has told on me, hasn’t she? I’ve not been taking the tablets. I’ve not even picked them up.”

Volunteer freely if given the space

“I’d rather sort it out myself — with diet. I’ve cut the sugar out of my tea and I’ve started walking.”
You have lost 2 kg in three weeks.

Only if asked

Your mother had type 2 diabetes. “The more tablets they gave her, the worse she got.” She ended up on dialysis, had a toe amputated and died two years ago at 71. “Everyone in the family says it was the metformin that did her kidneys.”
A workmate had “terrible diarrhoea” on metformin and could not get through a shift — there is one toilet for the whole warehouse floor.
You read online that metformin “damages your kidneys and liver” and that “there was a cancer scare and they recalled it”.
“Once you start, you’re on them for life — and then it’s insulin.”
Symptoms: a bit more tired; up once a night to pass water. No great thirst, no weight loss before the diet, no blurred vision, no thrush or skin infections, no numb feet.
Food: your main meal is at 2 am from the vending machine or a takeaway; until three weeks ago, two litres of cola a shift — now diet cola. No alcohol. You do not smoke.
You fast every Ramadan and wonder whether tablets would stop you.
Other remedies: only if asked about herbal, shop-bought or online products — karela juice every morning, and you are thinking of ordering your cousin’s herbal “diabetes cure” online. Otherwise keep it until you are invited to add anything.
Mood: worried, not low — you still enjoy things; no thoughts of harming yourself.
What you understand by diabetes: “sugar in the blood”. You do not know it affects the heart, eyes and kidneys — apart from what happened to your mum.

Impact on daily life — home and work (only if asked)

Since the diagnosis you lie awake after shifts, thinking about your mother.
Your wife is cooking you separate meals and the children keep asking if you are ill.
Night shifts make regular meals — and remembering tablets — difficult. You cannot be running to the toilet at work.

Ideas, concerns and expectations

Idea: the tablets are what damaged your mother; diet alone can cure this.
Concerns: ending up like her — dialysis, amputation; side effects at work; being on medication for life.
Expectation: a lecture. What you hope for: “Give me three months to fix it myself.”

Cues to deliver, timed

Minute 2, with some bitterness: “My mum did everything the doctors told her.”
Minute 4: “Is it true you can reverse it? I saw it on the telly.”

If the doctor summarises and asks whether you want to add anything

If herbal remedies have not come up: “I’ve started drinking karela juice every morning — bitter gourd. And my cousin swears by a herbal diabetes cure you can order online. Is that all right?”
If they have: “Would tablets stop me fasting at Ramadan?”

How to respond to the doctor

If the doctor acknowledges your mother first, and then corrects the kidney belief — it was years of diabetes, not metformin, that damaged her kidneys: you soften — “Nobody explained that about Mum.”
If the doctor also explains that stomach upset is much less with the slow-release form taken with food and increased slowly, and that the recall was about an impurity in one batch, not the medicine itself: you nod — “Right. I didn’t know that.”
If the doctor explains that the medicines are recommended to protect your heart and kidneys, not only to lower sugar, and that remission through weight loss is real but takes a loss of around 10–15 kg: interested — “So I could do both?”
A good outcome: “I’ll do the diet programme properly — and… all right, I’ll try the slow-release one. If it upsets my stomach, I’m stopping.” An equally acceptable outcome, if the doctor has been respectful and you are still unsure: three months of serious lifestyle change with a repeat blood test and a clear agreement about what happens if the result is not good enough.
If the doctor lectures or frightens you (“you’ll end up like your mother”): you close down — “I’ll think about it” — and leave.
If the doctor simply accepts your refusal without exploring or informing: “Great. Thanks, doc.” You leave none the wiser.
If the online “cure” is dismissed with contempt: “It’s been used for a thousand years, doctor.” If it is handled respectfully: you agree not to order it and to keep the karela as food.

Do not

Volunteer your mother’s story, the workmate or what you read online unless asked why you are reluctant.
Volunteer the karela juice or the online “cure” unless asked about other remedies, or invited to add anything.
Agree to anything you have not had explained.

2 · Examiner mark sheet — generic scheme plus the key facts for this case

Domain marks — with the key facts that earn a 4 at this station

Domain (GMC wording) · key facts for this case	1	2	3	4	Score
1 · Data gathering, technical and assessment skills Open, non-judgemental start; explores why* before informing* ICE: mother’s dialysis and amputation blamed on metformin; a workmate’s diarrhoea; the online “recall”; “tablets for life, then insulin”; wants three months to try himself Red flags: symptoms of marked hyperglycaemia — thirst, polyuria, weight loss, blurred vision, infections; low mood; herbal and online remedies Impact and practicalities: night shifts, a 2 am main meal, one toilet at work, Ramadan, sleep, family; what he understands diabetes to be	☐	☐	☐	☐	/4
2 · Clinical management skills Summary and check, then the formulation: confirmed type 2 diabetes in a man with capacity, declining treatment because of specific, understandable, mistaken beliefs — not denial or low mood Corrects each belief; why treat now; NICE first line — modified-release metformin started low with food, then an SGLT-2 inhibitor — protects heart and kidneys as well as glucose Shared decision: medication, the NHS remission programme, or both; education and eye screening; HbA1c recheck with an agreed threshold; respects and records his choice Safety-net: thirst, passing lots of urine, weight loss or blurred vision → same-day appointment; vomiting with drowsiness, abdominal pain or fast breathing → NHS 111 / 999 · Follow-up: nurse in 4 weeks; HbA1c at 3 months with an agreed threshold	☐	☐	☐	☐	/4
3 · Interpersonal skills Disarms “the nurse has told on me” — no blame, non-judgemental language Acknowledges his mother’s story before correcting anything Respectful of karela, faith and family beliefs Informs rather than persuades; he does more of the deciding; teach-back	☐	☐	☐	☐	/4
Station total					/12

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory ☐ Borderline ☐ Satisfactory ☐ Good

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4.

3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here

The top row is the full picture of what a competent F2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

Mark	Domain 1 · Data gathering, technical and assessment skills	Domain 2 · Clinical management skills	Domain 3 · Interpersonal skills
4	Opens without blame; makes clear this is not a telling-off; asks an open question about how he has been since the diagnosis Explores the reasons before giving any information: his mother’s dialysis and amputation, the workmate’s diarrhoea, the online “recall” and kidney damage stories, “tablets for life, then insulin” ICE: believes the tablets harmed his mother and that diet can cure this; fears ending up like her and side effects at work; expects a lecture and hopes for three months to try himself Red flags: symptoms of marked hyperglycaemia (thirst, polyuria, weight loss, blurred vision, recurrent infections); low mood or denial; over-the-counter, herbal or online remedies What he already understands about diabetes and what he has already changed (sugar, walking, 2 kg lost) Impact on daily living: sleep since the diagnosis, family meals, night shifts and a 2 am main meal, one toilet on the warehouse floor, Ramadan fasting	Summarises his reasons back to him and checks whether there is anything he wants to add Working diagnosis (formulation) with justified differentials: type 2 diabetes confirmed on two HbA1c results (62 and 60 mmol/mol) in a man with obesity; he has capacity and is declining medication because of specific, understandable but mistaken beliefs rooted in his mother’s illness — this is not denial, depression or lack of motivation (he has already lost 2 kg), and he has no symptoms of dangerously high glucose, so there is time for a shared decision Corrects each belief accurately: diabetes, not metformin, damaged his mother’s kidneys; metformin does not harm healthy kidneys (eGFR 88) — the dose is reduced when kidney function is already low; gut side effects are common early but much less with modified-release, taken with food and increased slowly; the recall concerned an impurity in certain batches; starting tablets does not make insulin inevitable Explains why treatment is advised now: early control protects eyes, kidneys, nerves and heart; current NICE first-line is modified-release metformin, then an SGLT-2 inhibitor once metformin is settled — for heart and kidney protection as well as glucose; neither causes low blood sugar on its own, so both suit shift work, driving and — with advice beforehand — fasting Offers real options: start modified-release metformin 500 mg with his main meal; and / or the NHS Type 2 Diabetes Path to Remission Programme — remission is possible with a weight loss of about 10–15 kg; structured education Herbal remedies handled respectfully and safely: karela as food is fine but does not replace treatment; do not buy online “cures” — some contain undeclared drugs Wider care: retinal screening and foot check booked; blood pressure and a statin (QRISK3 14%) flagged for the next visit; respects his decision, agrees a review point and threshold, and records the discussion Safety-net: marked thirst, passing a lot of urine, unintended weight loss, blurred vision or recurrent thrush or skin infections → same-day appointment; vomiting, drowsiness, abdominal pain or fast breathing → NHS 111 or 999; if he starts metformin and has persistent vomiting or diarrhoea, or becomes dehydrated with another illness → stop it and ring the practice (sick-day rules given in writing). Follow-up: the practice diabetes nurse in four weeks — weight, how the diet is going, and tablets if started; HbA1c repeated at three months with the F2 or a named GP, with an agreement made today about what happens if it is not below the agreed level; referral to structured education and, if he wishes, the NHS Type 2 Diabetes Path to Remission Programme; eye screening and foot check booked; the statin conversation at the next visit.	Disarms the opening line: no blame, thanks him for coming, non-judgemental language throughout Acknowledges his mother’s illness and death before correcting anything Respectful curiosity about karela, family advice and faith Gives information in small pieces and checks what he makes of it; he does as much of the talking as the doctor Supports autonomy: makes clear that the decision is his, and that the door stays open Teach-back: asks him to say what the plan is and what would make him call sooner
3	His main reasons and concerns elicited before information is given; one of the hyperglycaemia screen, herbal remedies or the practical barriers of shift work missing.	Beliefs corrected accurately and genuine options offered with a review date; one of the rationale for early treatment, the remission programme, herbal safety or the specific safety-net missing.	Respectful and clear; acknowledges the mother’s story; decision mostly shared.
2	Asks why but moves to persuasion after the first answer; misses the mother’s story or the work barrier; ICE partial.	Information given but generic; pushes tablets without addressing his reasons, or agrees to “diet only” with no education, no review threshold and no safety-net.	Pleasant but doctor-centred; information delivered as a talk; limited checking.
1	Starts with information or a warning; reasons for declining never explored. Or unsafe: no exploration — a lecture; or simply accepts the refusal and ends the consultation.	Incorrect information (for example agrees that metformin damages kidneys), or no plan or follow-up. Or unsafe: coerces or frightens (“you’ll end up on dialysis like your mother”); or accepts refusal with no information, no safety-net and no review — an uninformed refusal.	Lecturing, paternalistic or dismissive of his beliefs. Or unsafe: threatening, contemptuous or blaming.

4 · GMC feedback statements — where underperformance was identified — with case-specific examples

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

GMC feedback statement	Underperformance it signals (generic)	Case-specific examples
1 · Consultation	Disorganised or unstructured consultation	Launches into a talk on diabetes complications, then asks why he has not taken the tablets, then returns to complications; no explore → summarise → inform → decide sequence.
2 · Issues	Key issues or priorities not recognised	Treats the task as getting him to take metformin; does not recognise that the station is about understanding his reasons and enabling an informed decision.
3 · Time	Poor time management	Eight minutes of information; no agreed plan, review date or safety-net by the end.
4 · Findings	Abnormal findings or results, or their implications, not identified	Does not use the results on the page — HbA1c 62 and 60, eGFR 88, BMI 31, QRISK3 14% — to personalise the conversation (for example that his kidneys are healthy now).
5 · Examination	Physical examination or use of instruments not competent	No examination is required; none should be attempted.
6 · Diagnosis	Working diagnosis or differential diagnoses not correct	Labels him “non-compliant” or “in denial”; does not identify the real barriers — his mother’s story, a workmate’s side effects, online misinformation, night shifts.
7 · Management	Management plan not reflecting current best practice	Agrees that metformin harms the kidneys; standard-release metformin at full dose; no mention of the remission programme, education or eye screening; “diet only” with no recheck and no threshold; nothing about symptoms of high sugar or sick-day rules.
8 · Rapport	Rapport and sensitivity to the patient’s feelings and concerns not shown	“The nurse is only doing her job”; “you’ll end up like your mother if you carry on”; no acknowledgement of his loss.
9 · Listening	Verbal and non-verbal cues not used; poor active listening	Misses “my mum did everything the doctors told her” and “is it true you can reverse it?”; never invites him to add anything, so the online “cure” stays hidden.
10 · Language	Language or explanations not understandable; understanding not checked	“Metformin is a biguanide that reduces hepatic gluconeogenesis; your HbA1c is 62 so NICE says dual therapy with an SGLT-2 inhibitor” — no plain English and no teach-back.

5 · Examiner points of fact and guidelines

Points of fact the examiner should have to hand

Diagnosis: HbA1c of 48 mmol/mol or more; in someone without symptoms, confirmed on a second sample. His results — 62 and 60 — confirm type 2 diabetes.
NICE NG28 (updated February 2026): for adults with type 2 diabetes — including those with no other comorbidity, and those living with obesity — offer modified-release metformin and an SGLT-2 inhibitor (rec 1.13.1, 1.17.1). Introduce medicines one at a time: start metformin, check tolerability, and start the SGLT-2 inhibitor once metformin is at the maximum tolerated dose (rec 1.20.2). If metformin is not tolerated or contraindicated, offer an SGLT-2 inhibitor alone.
NICE now recommends SGLT-2 inhibitors as much for cardiovascular and renal protection as for glucose lowering. Before starting one, check for risk of diabetic ketoacidosis — including a very-low-carbohydrate or ketogenic diet (rec 1.21). An SGLT-2 inhibitor (like a sulfonylurea or meglitinide) must not be taken from the first day of the NHS Path to Remission Programme’s total-diet-replacement phase; medication changes are agreed with the practice at referral (NHS England service specification, updated February 2026).
NICE NG28: discuss diet and lifestyle alongside medicines, including the NHS Type 2 Diabetes Path to Remission Programme (rec 1.9.1); support an informed decision (1.9.2); use non-judgemental language (1.9.5); give sick-day rules (1.10.1).
Metformin (BNF): modified-release 500 mg once daily with the evening meal — for a night worker, his main meal — increased every 10–15 days to a maximum of 2 g once daily. Avoid if eGFR is below 30 mL/min/1.73 m² and review the dose below 45 (BNF; NICE CKS). It does not damage healthy kidneys. Gastrointestinal effects are the commonest problem; lactic acidosis is rare; long-term use can lower vitamin B12 (MHRA, 2022). Alone it does not cause hypoglycaemia.
The “recall”: in August 2021 the MHRA recalled one batch of metformin oral solution because a nitrosamine impurity (NDMA) exceeded the acceptable limit; patients were told not to stop treatment. The problem was a manufacturing impurity, not metformin itself.
Remission: in the DiRECT trial almost half of participants on a structured low-calorie programme were in remission at one year, and most of those who lost 15 kg or more. The NHS programme is for people aged 18–65, diagnosed within the last six years, with a BMI of 27 or more (25 or more in people from Black, Asian and other minority ethnic groups).
Herbal products: karela (bitter gourd) is safe as food, but the evidence that it lowers glucose is weak — a Cochrane review found insufficient evidence, and later meta-analyses of small, low-quality trials suggest an HbA1c fall of only about 0.3–0.4 percentage points; unlicensed “herbal diabetes cures” bought online have been found to contain undeclared prescription drugs. Ask, without judgement, what people are taking.
Ramadan: metformin and SGLT-2 inhibitors carry a low risk of hypoglycaemia, but fasting with diabetes needs an individual plan made before Ramadan — particularly hydration with an SGLT-2 inhibitor.
GMC, Decision making and consent: an adult with capacity may decline treatment, including for reasons that seem mistaken. The doctor’s duty is to make sure the decision is informed, not to pressure; record the discussion and keep the door open.
Care at diagnosis also includes structured education, retinal screening, a foot check, blood pressure and lipid management (offer atorvastatin 20 mg when QRISK3 is 10% or more), and an annual review.

Where candidates lose marks at this station

Starting with the complications.
“You’ll end up like your mother.”
Agreeing that metformin damages kidneys.
Standard-release metformin at full dose on day one.
Accepting “I’ll try diet” with no recheck, no threshold and no safety-net.
Sneering at the karela.

Guidelines for this station

6 · MLA content map tags for this case

MLA content map	This station
Domain 1 · Areas of clinical practice	Endocrine, diabetes and metabolic · General practice and primary healthcare
Domain 3 · Clinical and professional capabilities	Communication with patients, relatives and carers · Capacity, consent and confidentiality · Safe prescribing · Health promotion and disease prevention · Chronic condition management plans
Domain 5 · Patient presentations	Wellbeing checks · Fatigue
Domain 6 · Conditions	Diabetes mellitus · Obesity
Station family	Explanation, counselling and breaking bad news — Counselling / a patient declining treatment

7 · My marks and reflection — practice log form

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-13

Revision link for this case: acumenprimarycare.com/plab-2-osce/case-13-declining-metformin

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Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.

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