Antibiotics for a cold — managing the demand
PLAB 2 & PRES 3 · prescribing / general practice · medium · 8 minutes
Candidate brief
You are an FY2 doctor in a GP surgery. Mr Darren Cole, 34, has come in on day 4 of an illness: blocked and runny nose, sore throat (his worst symptom), a mild cough and pressure in his ears. He had a temperature of 37.9 °C on day 1; today it is 37.3 °C and falling. He is otherwise fit and well. He opens with: "I'll save us both some time, doctor — I need antibiotics. Every time I get this it goes on my chest unless I get amoxicillin early. Last time I was right as rain in three days on them." On examination: throat mildly red; NO tonsillar exudate; no tender anterior cervical nodes; tympanic membranes normal; chest clear; SpO2 99%. Please assess him, and manage his request.
What examiners look for
This consultation is won or lost on sequence: examine first, explain second, decline third — and never let the decline be the whole consultation. The patient who feels examined and explained-to hears "no antibiotic" as a clinical decision; the patient who is refused at the door hears it as a rationing decision and simply goes elsewhere. FeverPAIN exists to give the refusal a spine: score 0 means the bacterial features are absent, the streptococcus probability is low and antibiotics change nothing. Saying "the score is 0 — none of the features we'd need are there" is evidence; saying "we're not allowed" is bureaucracy. Patients accept the first and resent the second. His strongest argument — "they worked last time" — is the post hoc fallacy in a duffel coat, and it deserves a kind answer, because his reasoning was natural: colds peak around day 3–4 and resolve towards day 7–10, so any ritual performed on day 3 collects the credit. Dismantle the inference, never the man; you will need his trust when a prescription really matters. Resistance lands when it is personal. "Superbugs" are abstract; "the next time your daughter has a real ear infection, we want amoxicillin to still work for her — and every unnecessary course spends some of that" is a reason a warehouse team leader can take back to work with him. And prescribe the self-care like you mean it: scheduled full-dose analgesia instead of his apologetic "couple of paracetamol", gargles, lozenges, fluids, a day-by-day map of the illness and a red-flag list with dates on it. A good non-antibiotic consultation contains more medicine, not less.
Guideline references
Practise this station
Role-play it with an AI patient and get feedback against the full marking scheme. Create a free account — 3 stations per month free.