Cases/Smoking, Alcohol and Substance Misuse

Teenager Asking for A Confidential Appointment About Drug Use — Free SCA Practice Case

Teenager asking for a confidential appointment about drug use

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Kai Mensah

Age

17 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The young person booked the appointment himself.

Reason for Encounter

"Before I say anything — is this actually confidential? It's about drugs."

Medical Records

●PMH: Hay fever.
●Medications: None currently.
●Allergies: NKDA.
●Recent notes: No recent consultations.

Patient Script

For the friend playing the patient role

Character Overview: You are Kai, 17, in your second year of sixth form. You booked this call yourself. You are nervous and guarded, and the first thing you need is reassurance that this is confidential — you will not say anything substantial until the doctor addresses that properly. You have been using cannabis for about a year: it started socially at weekends and has become almost daily, and increasingly on your own. You have been missing college, your grades have dropped, your motivation and memory feel worse, you are spending most of your part-time earnings on it, and you have been arguing with your mum. You sometimes feel anxious and a bit paranoid afterwards. You have tried to cut down twice and could not, which frightens you — you think you might be dependent. You do not use anything else, have never injected anything, and drink only occasionally. Nobody is pressuring you and you are not involved in selling or carrying anything. You do not want your mum told. If the doctor is calm and non-judgemental you will open up fully; if they lecture you, you will withdraw and say you have to go.

Opening Sentence: "Hi. Um… before I say anything, I need to know — is this properly confidential? Like, you won't tell my mum? It's about… drugs. I've been using cannabis and it's got a bit out of hand, I think."

History if Asked (Data Gathering Phase)

●The use: "Cannabis. It started about a year ago, just weekends with mates. Now it's most days, and a lot of the time on my own."
●Why he's called: "I've tried to stop twice and I couldn't. That's what scared me. I think I might be hooked."
●Impact on college: "I've been missing classes. My grades have dropped a lot. I can't concentrate and my memory's rubbish."
●Impact on mood: "I feel flat most of the time. And sometimes after using I get anxious and a bit paranoid."
●Money: "Most of what I earn from my Saturday job goes on it. That's not great."
●Home: "Me and Mum argue about it — she knows I smoke something but not how much. I don't want her told the full picture."
●What he wants: "I want to stop, or at least cut right down. I don't know how."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted, and will not engage at all until confidentiality is addressed.

●Ideas: Kai believes he has become dependent on cannabis. "I think I'm dependent on it. That's what it feels like."
●Concerns: His dominant concerns are that he cannot stop, that he is wrecking his education, and — if explored — that something is happening to his mind (the memory problems and the paranoia). "I'm scared I can't stop, that I'll blow my A-levels, and honestly that it's messing with my head."
●Expectations: He wants help to stop or cut down, and reassurance that his mother will not be told. "I want help to stop. And I need to know Mum won't be told."

If Asked — Substance, Mental Health, and Safeguarding Screen

The patient answers these only when directly asked, and only if the candidate has established a non-judgemental tone.

●If asked about frequency and pattern of use, and whether it is escalating: "Most days now, and it's crept up over the year. It used to be just weekends with friends; now it's mostly alone."
●If asked about using alone versus socially: "Mostly alone now. That's what worries me."
●If asked about features of dependence (cravings, failed attempts to cut down, using despite harm, tolerance, withdrawal): "I get cravings, I've tried twice to stop and couldn't, and I keep using even though it's wrecking college. I feel irritable and can't sleep when I don't have it."
●If asked about other substances, ever: "Nothing else. Never injected anything. I drink occasionally, not much."
●If asked about smoking tobacco: "I smoke a bit of tobacco with it, yeah."
●If asked, sensitively, about psychotic symptoms (hearing or seeing things others don't, feeling people are against him): "I get a bit paranoid after using — like people are looking at me or talking about me. It passes. I don't hear voices."
●If asked about mood, and sensitively about self-harm or thoughts of not wanting to be here: "My mood's flat, but no — I've never harmed myself and I don't have thoughts like that."
●If asked about driving or learning to drive: "I'm having lessons. I hadn't thought about that at all, actually."
●If asked about money, debt, or owing anyone: "I pay for it from my job. I don't owe anyone anything."
●If asked about being asked to carry, hold, or sell anything — safeguarding: "No, nothing like that. Nobody's asked me to do anything like that." (No exploitation/county-lines indicators.)
●If asked about pressure or coercion: "No one's pressuring me. It's my own doing."
●If asked about college and attendance: "Missing a lot. Nobody at college knows why."
●If asked about home and who he could talk to: "Just me and Mum. We row about it. Maybe my older sister — I could talk to her."
●If asked about previous help or services: "No, I've never spoken to anyone about it before. You're the first."

Responses to Management (The Negotiation Phase)

●If the Doctor addresses confidentiality properly and early — the gateway to the whole consultation: "Okay. So it stays between us unless you thought I was in real danger, and you'd talk to me first? Right — then I'll tell you properly." (The tested point is explaining confidentiality and its limits honestly, which is what unlocks the history.)
●If the Doctor assesses without judgement: "I expected to be told off, to be honest. Nobody's actually just asked me about it before." (The tested point is non-judgemental engagement.)
●If the Doctor names dependence and explains it: "So the cravings and not being able to stop — that is dependence? At least it's got a name." (The tested point is recognising and explaining cannabis dependence to a young person.)
●If the Doctor discusses the paranoia and mental-health risk: "You're saying it can affect your mental health, and the paranoia is a warning sign? That's what I was scared of." (The tested point is screening for and explaining the mental-health risks, including psychosis.)
●If the Doctor offers referral to a young people's service: "There's a service just for people my age? Would they tell my mum?" (The tested point is referral to age-appropriate specialist support, with the confidentiality question handled again.)
●If the Doctor raises drug-driving: "I genuinely hadn't thought about the driving. That's a good point."
●If the Doctor encourages involving a trusted adult: "Maybe my sister. I'm not ready for Mum yet — but maybe eventually, if you helped."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

Confidentiality Is the Gateway to Adolescent Consultations

●Young people frequently open with the confidentiality question, and will disclose little until it is answered. Explain honestly that the consultation is confidential, and that information would be shared only where there is a serious risk of harm, ideally with the young person's knowledge and involvement. Never promise absolute confidentiality.

Gillick Competence

●A competent young person can consent to their own care and to confidential treatment. Assess and document competence, and treat a competent 17-year-old accordingly rather than assuming parental involvement is required.

Recognising Cannabis Dependence

●Features include escalating frequency, shift from social to solitary use, cravings, repeated failed attempts to cut down, continued use despite harm (education, finances, relationships), tolerance, and withdrawal (irritability, disturbed sleep, low mood). Naming it gives the young person a framework and validates their insight.

Mental-Health Risks — Take Paranoia Seriously

●Cannabis is associated with anxiety, low mood, impaired memory and concentration, and an increased risk of psychosis, particularly with early-onset, frequent, and high-potency use. Post-use paranoia is a warning sign — screen for psychotic symptoms, explain the significance, and safety-net for persistence.

Engagement Without Lecturing

●Adolescents disengage from moralising. Provide factual information, work with the young person's own goals, and commend help-seeking. A young person who feels judged will not come back — and continued contact is what makes change possible.

Age-Appropriate Referral and Practical Harm Reduction

●Refer to a young people's substance-misuse service (not an adult service), confirming its confidentiality. Address drug-driving (a criminal offence and a genuine danger, particularly for a learner driver), combining with alcohol, and the tobacco/respiratory dimension with cessation support.

Screen for Exploitation, and Address the Wider Impact

●Screen for criminal exploitation — debt, being asked to carry, hold, or sell anything, coercion. Address education, finances, and family relationships, encourage a trusted adult without coercion, and arrange follow-up.

Common Candidate Mistakes in This Case

●Mishandling the confidentiality question: promising absolute secrecy, or failing to answer it — either way the consultation fails immediately.
●Lecturing or minimising: moralising about drug use, or dismissing it as "only cannabis" and missing dependence.
●Not screening for psychosis or mental health: overlooking the post-use paranoia and mood.
●Omitting the exploitation screen or drug-driving advice: missing safeguarding and a real safety risk.
●No age-appropriate referral or follow-up: leaving a young person who asked for help without support or continuity.

Free MRCGP SCA practice case for GP registrars covering Teenager Asking for A Confidential Appointment About Drug Use — Smoking, Alcohol and Substance Misuse. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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