"I know it's a tumour" — the headache she can't stop checking

PLAB 2 & PRES 3 · mental health / communication skills · medium · 10 minutes

Candidate brief

You are an FY2 doctor in a GP surgery. Mrs Rachel Donnelly, 41, attends for the third time in two months with headaches. The headaches have been present for three months. Two colleagues have examined her, found a normal neurological examination, and reassured her. She arrives with a printed symptom checklist and says: "I know you all think I'm wasting your time. But I need an MRI. I know it's a tumour — I can feel that it's a tumour." Please assess her and agree a way forward.

What examiners look for

In health anxiety, the examination is a treatment and must be performed like one: full history, complete red-flag screen, proper neurology, and the negatives reported back item by item — "your headache is better after sleep, tumours typically are not; there is no vomiting, no weakness, and the back of your eye was normal" — because specificity is the only currency reassurance has, and "you're fine" is small change she has already spent three times. Answer the counterexample, don't evade it. Her colleague's husband is not an anecdote to be managed; he is her evidence base, and he is genuinely tragic. The honest response distinguishes pattern from pattern and shows the screen working — and quietly concedes that medicine's certainty is probabilistic, then prices the probabilities with her. Candidates who promise "definitely no tumour" will be believed less than candidates who explain why it is very unlikely and what would change their mind today. A scan is not a sedative. In a red-flag-negative tension-type headache, MRI finds a cause in almost no one — but finds incidental abnormalities in a meaningful minority of healthy people, each one a cascade of follow-ups and a fresh object for the anxiety. And where health anxiety is the engine, a normal result's half-life is days: the fear was never really about this headache, so no picture of this brain can cure it. Decline with the reasoning shared, and pair the refusal with a safety net and a review date — refusal alone is abandonment; refusal with structure is treatment. Name the second diagnosis. Health anxiety is common, recognised and treatable — CBT works, Talking Therapies takes self-referrals, and the checking rituals (pupils, grip, 3 a.m. forums) are symptoms to be treated, not secrets to be shamed. The planned review — booked regardless of symptoms — replaces her impossible nightly triage ("is THIS the one?") with the practice's calendar, which is where that decision belonged all along.

Guideline references

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