Cases/Metabolic Problems and Endocrinology

Type 2 Diabetes and Rising Hba1c — Free SCA Practice Case

Airline pilot with Type 2 Diabetes and rising HbA1c

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

Captain David Sterling

Age

52 years

Consultation Type

Video

Age

52 (DOB: 14/09/1973)

Situation

Face-to-Face Consultation.

Reason for Encounter

"Routine annual diabetic review following recent blood tests. HbA1c has increased to 68 mmol/mol."

Medical Records

●PMH: Type 2 Diabetes (Diagnosed 6 years ago), Hypertension.
●Medications: Metformin 1g BD
●Empagliflozin 25mg OD
●Sitagliptin 100mg OD
●Ramipril 5mg OD (Patient is currently on maximum tolerated triple oral therapy).
●Allergies: NKDA.
●Occupation: Commercial Airline Pilot (Long-haul Captain).

Recent Notes

●Last Year: HbA1c was 54 mmol/mol.
●Today's Bloods: HbA1c 68 mmol/mol. eGFR \>90. LFTs normal.

Patient Script

For the friend playing the patient role

Character Overview: You are David. You have been a long-haul commercial pilot for 25 years; flying is your entire identity and your livelihood. You are usually confident and in control, but today you are secretly terrified. You saw your HbA1c result on the NHS app this morning. You know that an HbA1c nearing 70, or starting insulin, can mean the instant revocation of your Class 1 Medical Certificate by the Civil Aviation Authority (CAA), effectively grounding you and ending your career. To avoid any treatment changes, you will downplay all your symptoms. You intend to beg the doctor for "just three more months" to fix this with extreme dieting. You will not volunteer your fear about the CAA or losing your license unless the doctor suggests changing your medication (specifically injections) or actively explores what is worrying you.

Consultation Flow & Responses:

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The Opening
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If the doctor asks an open question: "Morning, Doc. I know I'm here for my diabetes review, and I saw the blood test was a bit higher than last year. I've just had a chaotic flight roster lately—lots of long-haul to Tokyo—so my diet slipped. I just need my usual repeat prescriptions, and I promise I'll get back to the gym."
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Data Gathering (The Layers)
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Layer 1: Symptom Masking (The Clinical Screen):
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"No, no symptoms at all. I don't need to pee in the night, no extreme thirst. I feel completely fit and well."
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"My vision is 20/20, I have to pass strict eye exams for work anyway."
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"No tingling in my feet, no chest pain."
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Layer 2: Current Adherence & Lifestyle:
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"I take all my tablets perfectly. Metformin, Empagliflozin, Sitagliptin. Never miss a dose."
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"I admit my diet on layovers has been rubbish—lots of hotel room service. That's why the number is up."
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Layer 3: ICE & The Core Revelation (The Occupational Terror) - ONLY REVEAL IF ASKED:
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If the doctor suggests starting an injectable (GLP-1 or Insulin) or asks why he is so resistant to changing his medication:
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Reaction (The Reveal): You drop the confident pilot persona. You look desperate. "Doctor, you can't put me on injections. If you put 'insulin' on my medical record, I have to declare it to my Aeromedical Examiner. The CAA will pull my Class 1 Medical Certificate. I will be grounded immediately. My career, my pension, everything is gone. Please, just give me three months to starve myself and get this number down. Don't end my career today."

ICE — Ideas, Concerns, Expectations

Actor guidance: Do not volunteer any of this unprompted. These responses surface only if the candidate directly explores the patient's perspective.

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Ideas: You assume the HbA1c has gone up purely because of poor diet on long-haul layovers — too much hotel room service, irregular meal times crossing time zones, and not enough exercise. You don't think there is anything else going on medically. "I know exactly why it's gone up — I've been eating rubbish on layovers and not getting to the gym. It's just a lifestyle thing. If I sort my diet out, the number will come back down."
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Concerns: Your overwhelming fear is losing your flying career. Beyond the CAA and licence anxiety (which you only reveal under pressure), you are privately worried that your diabetes is getting worse and that you are heading towards insulin regardless of what you do. You are also anxious about what your airline's occupational health team would say if they found out. "Honestly? I'm scared this thing is running away from me. I've always managed it, kept it controlled, and now it feels like it's slipping no matter what I do."
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Expectations: You want the doctor to reassure you that the number can come back down with lifestyle changes alone, refill your usual prescriptions, and not make any changes to your medication. "I just want my usual prescriptions and a bit of time to sort this out myself. I've managed it for six years — I just need to get back on track."

If Asked — Medical History and Medications

Actor guidance: Respond naturally and in character if the candidate asks about specific items from your medical history or medication list. Do not volunteer this information unprompted.

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If asked about Ramipril / blood pressure medication: "Yes, I take that for my blood pressure. I've been on it for about three years now. My blood pressure is always fine when they check it — I have to get it checked regularly for my medical certificate anyway, so it's well controlled. I never get any side effects from it."
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If asked about blood pressure control or symptoms of hypertension: "No problems at all. No headaches, no dizziness. It's always been well controlled since I started the tablet."
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If asked about Metformin side effects or tolerance: "It was rough when I first started it years ago — upset stomach, lots of wind, that sort of thing. But I've been fine on it for a long time now. No problems."
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If asked about Empagliflozin side effects: "No issues. No thrush or anything like that. I do drink a bit more water maybe, but I put that down to being in a dry aircraft cabin all day."
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If asked about when the diabetes was diagnosed or how it was found: "About six years ago. It was picked up on a routine medical for work — my fasting glucose was high and they did more tests. I was gutted. But the airline let me keep flying because I didn't need insulin."
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If asked about diabetic eye screening: "Yes, I get that done every year. Always been normal. And I have to pass a full aviation eye exam too — colour vision, distance, the lot. Never had a problem."
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If asked about foot checks or diabetic foot reviews: "I think the practice nurse does it at these reviews. I've never had any issues — no numbness, no sores, nothing like that."
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If asked about kidney function or recent blood results: "I saw on the app that my kidney test was normal — the eGFR thing. Liver tests were fine too. It's just the sugar one that's gone up."

Social History and Lifestyle Impact

Actor guidance: Weave these details into the conversation naturally if the candidate explores your daily life, work, or how the diabetes affects you. Do not deliver as a monologue.

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Occupation and daily life: You are a long-haul captain flying mainly transatlantic and Asia-Pacific routes. You are away from home for 4–5 days at a time, often crossing 8–10 time zones. Your wife is used to it but your two teenage children are starting to notice you are away more than you are home. You have been flying commercially for 25 years and cannot imagine doing anything else. "Flying is all I've ever done. I joined the RAF at 18, went commercial at 27. There's nothing else I know how to do."
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Lifestyle impact of the condition: The irregular schedule makes consistent meal timing almost impossible. On layovers, you eat whatever the hotel has — often late-night room service after a 12-hour flight. Your gym routine has collapsed because you're too fatigued after long-haul sectors to do anything except sleep. You have also noticed in the last couple of months that you feel more drained after flights than you used to — you put this down to age rather than the diabetes, but it has crossed your mind. "To be honest, the last few months I've been wiped out after every trip. I used to bounce back, but now I'm sleeping for 14 hours after a Tokyo run and still feeling groggy. I just assumed it's because I'm 52, not 32 anymore."

If Asked — Associated Symptoms

Actor guidance: Respond only if the candidate directly asks about these symptoms. Keep answers brief and natural. You are inclined to minimise and dismiss symptoms.

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If asked about fatigue or tiredness: "Well, yes, I suppose I have been more tired than usual. But I put that down to the roster — I've had back-to-back long-haul for months. It's just jet lag catching up with me." (Pertinent positive — fatigue is consistent with worsening glycaemic control but the patient attributes it to work.)
●
If asked about weight changes: "I've put on about half a stone in the last year, maybe a bit more. Layover food, no gym. I know I need to sort it out." (Pertinent positive — weight gain is consistent with worsening control and poor diet; does not shift diagnosis.)
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If asked about increased urination or polyuria: "No, not really. Well — maybe I go a bit more often on the flight deck, but I'm also drinking more water up there. I wouldn't call it excessive." (Pertinent positive — mild, minimised by the patient, consistent with worsening glycaemic control.)
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If asked about polydipsia or excessive thirst: "I drink a lot of water, but the cockpit is incredibly dry. I've always drunk a lot during flights. It hasn't changed much." (Pertinent negative — patient denies notable change, attributes fluid intake to occupational environment.)
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If asked about blurred vision or visual changes: "Absolutely not. My eyesight is perfect — I couldn't do my job otherwise. Last aviation eye exam was three months ago, passed with flying colours." (Pertinent negative.)
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If asked about recurrent infections or thrush: "No, nothing like that." (Pertinent negative.)
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If asked about skin changes, slow wound healing, or cuts taking longer to heal: "No, I heal up fine. No problems there." (Pertinent negative.)
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If asked about erectile dysfunction or sexual health: Hesitant, slightly uncomfortable. "Actually... things haven't been great in that department for a while. I assumed it was stress and being away so much. I haven't mentioned it to anyone." (Pertinent positive — erectile dysfunction is a recognised complication of T2DM and cardiovascular risk; does not shift the primary diagnosis or management conclusion.)
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If asked about mood, low mood, or depression: "I'm not depressed. I'm stressed. There's a difference. This job is high-pressure and the diabetes doesn't help, but I'm coping. I'm not sitting around crying or anything." (Pertinent negative for clinical depression — but acknowledges stress, consistent with the occupational pressure established in the script.)
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If asked about chest pain, palpitations, or shortness of breath: "No, nothing like that. I pass a full cardiovascular assessment every year for my medical. ECG, the lot. Always normal." (Pertinent negative — important for cardiovascular risk assessment in T2DM.)
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If asked about numbness, tingling, or pins and needles in hands or feet: "No, nothing. My feet are fine." (Pertinent negative — peripheral neuropathy screen.)
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If asked about alcohol intake: "Social only. A beer with the crew on layover sometimes, but I can't drink within 8 hours of flying, so it's pretty limited. Maybe four or five pints a week at most." (Pertinent negative for excess alcohol contributing to metabolic derangement.)
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If asked about smoking: "Never. You can't smoke on an aircraft and I never picked up the habit." (Pertinent negative.)
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If asked about family history of diabetes: "My dad had Type 2 as well — diagnosed in his sixties. He ended up on insulin eventually. That's partly why this scares me." (Contextual detail — reinforces the patient's fear of insulin without shifting the clinical picture.)

Negotiation & Collaborative Management Plan

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If the Doctor agrees to "just give you 3 months" without any medication change:
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Reaction: "Thank you, thank you. I swear I'll fix it." (Note: Candidate fails for clinical negligence. He is on max orals with an HbA1c of 68; delaying treatment poses a risk of symptomatic hyperglycemia and cognitive fatigue while flying a commercial airliner).
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If the Doctor bluntly says, "I have to inform the CAA/DVLA right now":
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Reaction: Furious and panicked. "You can't do that! That's a breach of confidentiality! It's my responsibility to tell them, not yours!" (Testing the doctor's knowledge of GMC guidance on occupational reporting).
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If the Doctor suggests a GLP-1 Agonist (e.g., Semaglutide/Dulaglutide) instead of Insulin:
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Reaction: "A weekly injection? Does that cause hypos? If it doesn't cause low blood sugar, will the CAA still ground me for it?" (Doctor must explain that while it's safer than insulin, he still needs to inform his AME and will likely be temporarily grounded until side effects are ruled out).
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If the Doctor thoughtfully discusses liaising with the Aeromedical Examiner (AME):
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Reaction: "So you think if we talk to my AME, there's a pathway where I keep my license even if I go on these new injections? If you can promise me we do this together, I'll agree."

Safety Netting / Follow-up

●If the Doctor sets a plan to review his blood sugars and liaise with the AME:
●Reaction: "Okay. I will ground myself on sick leave for the next two weeks while we sort this out, so I'm not flying unsafely. I'll call my AME this afternoon."

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 / 28 indicators checked+0−0

Positive (0/14)

Negative (0/14)

Domain 3: Relating to Others

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Clinical Learning Points

Recognising Maximum Oral Therapy and the Escalation Imperative

David is on metformin 1g BD, empagliflozin 25mg OD, and sitagliptin 100mg OD — the maximum tolerated non-hypoglycaemic triple oral regimen for Type 2 diabetes. With an HbA1c of 68 mmol/mol and rising, further oral agents are not appropriate and represent a prescribing error.

●Per NICE NG28, when HbA1c is not controlled on triple oral therapy, the next step is injectable therapy — either a GLP-1 receptor agonist or insulin.
●The correct escalation choice here is a GLP-1 RA (e.g. semaglutide once weekly, or dulaglutide once weekly), not insulin and not an additional oral agent such as a sulfonylurea or pioglitazone.
●Agreeing to a three-month lifestyle trial without any treatment escalation in a patient on maximum oral therapy with a rising HbA1c is clinically unsafe — and in this specific case, constitutes a public safety risk given his occupation.

Type 2 Diabetes and the CAA Class 1 Medical Certificate

Commercial airline pilots in the UK hold a Class 1 Medical Certificate regulated by the Civil Aviation Authority (CAA). This creates specific constraints on diabetes management that a GP must understand.

●The hyperglycaemia threshold: The CAA threshold for mandatory grounding is an HbA1c of approximately 69 mmol/mol. At 68, David is one poor month from automatic suspension — making inaction the greatest career risk, not treatment escalation.
●The hypoglycaemia hazard: Sudden cognitive impairment or incapacitation from hypoglycaemia is the primary aviation safety concern. This is why insulin and sulfonylureas carry the most restrictive CAA pathways.
●Insulin and the OML: Pilots can fly on insulin under UK CAA protocols, but only with an Operational Multi-Crew Limitation (OML) — meaning they may never act as sole pilot and must comply with a strict pre-flight and in-flight blood glucose monitoring regime. This is an onerous pathway David is right to want to avoid.
●GLP-1 RAs and aviation: GLP-1 receptor agonists do not inherently cause hypoglycaemia and are therefore a more favourable regulatory pathway. However, pilots must be grounded on initiation until the CAA and AME are satisfied that side effects (particularly nausea and vomiting, which are hazardous on the flight deck) have resolved and the medication is well tolerated.

GLP-1 Receptor Agonists — Prescribing Detail

GLP-1 receptor agonists are the preferred injectable escalation in this case for their glycaemic, weight, and cardiovascular profile.

●Agents: Semaglutide (Ozempic, once weekly SC) and dulaglutide (Trulicity, once weekly SC) are the most commonly used. Both are NICE-approved as add-on therapy when HbA1c is not controlled on oral therapy.
●Glycaemic efficacy: GLP-1 RAs produce meaningful HbA1c reductions (typically 10–15 mmol/mol) and promote weight loss — both relevant for David given his half-stone weight gain.
●Hypoglycaemia risk: When used without concurrent sulfonylurea or insulin, GLP-1 RAs do not cause hypoglycaemia — a critical distinction for this patient.
●Side effects: Nausea, vomiting, and diarrhoea are common, particularly during dose titration, and typically resolve over 4–8 weeks. In an aviation context, these symptoms are grounds for temporary grounding during initiation.
●Cardiovascular benefit: Semaglutide and dulaglutide both have proven cardiovascular outcome data (SUSTAIN-6, REWIND trials), an additional benefit in a patient with T2DM and hypertension.

The GP's Role, the AME's Role, and GMC Confidentiality

Understanding the boundary between clinical and occupational decision-making is essential in this case.

●The GP's role is to manage David's diabetes according to NICE guidelines. The GP must not delay or modify clinically indicated treatment to help a patient pass a licensing medical.
●The Aeromedical Examiner (AME)'s role is to make the occupational licensing decision. The AME, not the GP, determines fitness to fly.
●Declaration duty: Starting any new diabetes medication — including a GLP-1 RA — requires David to notify his AME. This is his legal and professional responsibility, not the GP's. The GP's role is to counsel him about this duty clearly and document that this advice was given.
●GMC confidentiality guidance: If a patient's medical condition poses an ongoing risk to public safety and the patient refuses to self-declare or self-ground, the GP has grounds to consider breaching confidentiality to inform the relevant authority. This is a last resort — the priority is always to reach a collaborative agreement. The GP should not threaten disclosure prematurely or use it as a lever in negotiation.
●Practical action: The safest immediate step is to support David in taking self-certified sick leave of approximately two weeks — removing the immediate aviation safety risk, giving time for GLP-1 initiation, and demonstrating proactive responsibility to the AME.

Cardiovascular Risk and Annual Review Completeness

David has T2DM and hypertension — a combination that substantially elevates cardiovascular risk and mandates a systematic annual review.

●Empagliflozin (an SGLT2 inhibitor) has proven cardiovascular and renal protective benefits (EMPA-REG OUTCOME trial) and is already appropriately prescribed. Confirm it remains well tolerated and is continued at the correct dose.
●Ramipril is appropriate for blood pressure control and renal protection in T2DM. Blood pressure target in T2DM with established cardiovascular risk is <130/80 mmHg per NICE NG28.
●Lipid management: A fasting lipid panel should be reviewed or arranged. Statin therapy is typically indicated in T2DM aged over 40 with any additional cardiovascular risk factor — check whether this has been addressed.
●Annual review components to confirm or plan: diabetic foot examination, retinal screening status (David has annual aviation eye exams but dedicated diabetic retinal screening is a separate requirement), urine albumin:creatinine ratio (uACR) for nephropathy, and HbA1c — all should be documented as completed or pending.

Erectile Dysfunction as a Diabetic Complication

David discloses erectile dysfunction (ED) if directly asked — a recognised and common complication of Type 2 diabetes with both vascular and autonomic aetiology.

●ED in T2DM reflects microvascular and autonomic nerve damage and is a marker of overall cardiometabolic risk. Do not dismiss it as purely psychogenic or solely attributable to stress.
●First-line management includes improved glycaemic control (which may itself improve ED), addressing cardiovascular risk factors, and discussion of a phosphodiesterase type-5 (PDE5) inhibitor (e.g. sildenafil or tadalafil) where not contraindicated.
●Check for contraindications to PDE5 inhibitors — in this patient, note that he is not on nitrates, which is the key pharmacological contraindication.
●Normalise the conversation: ED is common in T2DM and often undisclosed. Asking directly and responding without embarrassment is part of a thorough diabetic review.

Reframing Treatment as Career-Protective

The most effective communication strategy in this consultation is repositioning treatment escalation — not inaction — as the strategy most likely to preserve David's flying career.

●At HbA1c 68 and rising, the patient is a single poor month from the CAA automatic grounding threshold of 69. Doing nothing guarantees grounding.
●A proactive plan — two weeks' sick leave, GLP-1 initiation, AME notification, GP support letter — gives David the best chance of a managed, temporary grounding followed by a return-to-flying pathway.
●Language matters: avoid framing this as a restriction being imposed. Instead: "The treatment I'm recommending is your best route back to the cockpit."
●Offering to write a supportive clinical letter to the AME — outlining the GLP-1 RA's non-hypoglycaemic profile and the monitoring plan — is a concrete act of advocacy that significantly shifts the patient's willingness to engage.

Common Candidate Mistakes in This Station

●Agreeing to three months without escalation is the most common critical error. It may feel empathic, but it is clinically unsafe and represents a failure of patient safety in the context of commercial aviation. The marking scheme treats this as a clear fail.
●Jumping straight to insulin is the second most common error. Insulin is not the preferred first injectable step here — GLP-1 RAs are guideline-recommended first and are the appropriate choice for this patient's regulatory situation.
●Missing maximum oral therapy: Candidates who do not recognise that the patient is already on triple oral therapy may suggest adding a sulfonylurea or pioglitazone, which is a prescribing error.
●Failing to explore ICE: The occupational terror driving David's resistance only emerges if directly probed. Candidates who accept his surface-level request for "three more months" without exploring why he is so resistant will miss the entire axis of the consultation.
●Threatening to contact the CAA directly: This breaches confidentiality prematurely and is contrary to GMC guidance. The GP's role is to counsel the patient about their self-declaration duty, not to act as the regulator.
●Failing to address erectile dysfunction: This is explicitly assessed in the marking scheme. If a candidate does not ask, the information is never volunteered.

Safety Netting and Follow-up

●Arrange a repeat HbA1c at three months following GLP-1 RA initiation, with a structured review to assess tolerability and glycaemic response.
●Advise David to contact the practice before the review if he experiences worsening osmotic symptoms (increased thirst, urinary frequency), significant fatigue, or any cognitive symptoms — particularly during flight preparation, where impaired cognition would be an immediate safety concern.
●Confirm the agreed interim plan is clear: self-certified sick leave, self-declaration to AME, GP to write supporting letter, GLP-1 RA started with appropriate titration schedule.
●Document in the clinical record that the patient has been counselled about his duty to self-declare to his AME, and that he has agreed to do so.

Free MRCGP SCA practice case for GP registrars covering Type 2 Diabetes and Rising Hba1c — Metabolic Problems and Endocrinology. 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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