PLAB 2 Clinical Communication & Breaking Bad News — Questions and Answers
Question 1: Which framework is commonly used for breaking bad news in UK clinical practice?
- ABCDE (Airway, Breathing, Circulation, Disability, Exposure)
- SPIKES: Setting, Perception, Invitation, Knowledge, Emotions/Empathy, Strategy/Summary (Correct answer)
- SBAR: Situation, Background, Assessment, Recommendation
- ISBAR: Introduction, Situation, Background, Assessment, Recommendation
Correct answer: SPIKES: Setting, Perception, Invitation, Knowledge, Emotions/Empathy, Strategy/Summary
SPIKES (Buckman, 1992) is the widely used framework for breaking bad news: S — set up the meeting (private, seated, support person); P — assess the patient's Perception; I — obtain the patient's Invitation to discuss findings; K — give Knowledge/information gradually; E — address Emotions with Empathy; S — Strategy and Summary with a plan.
Question 2: When breaking bad news, what does 'warning shot' mean?
- Informing security staff before a difficult consultation
- Giving a preparatory phrase before delivering bad news to allow the patient to mentally prepare ('I'm afraid the results are more serious than we hoped...') (Correct answer)
- Asking a colleague to be present in case of adverse reactions
- Checking that emergency equipment is available
Correct answer: Giving a preparatory phrase before delivering bad news to allow the patient to mentally prepare ('I'm afraid the results are more serious than we hoped...')
A 'warning shot' is a brief phrase that signals difficult news is coming, giving the patient a moment to prepare emotionally before hearing the details. Examples: 'I'm afraid the news is not as good as we hoped' or 'The results have shown something we need to discuss seriously.' It prevents the patient from being completely blindsided.
Question 3: After breaking bad news of a cancer diagnosis, the patient becomes angry and says 'You must have made a mistake — how could you have missed this earlier?' How should you respond?
- Defend yourself and explain the diagnostic timeline in detail immediately
- Acknowledge the patient's anger with empathy ('I understand you're very angry and this must be a terrible shock'), allow them to express feelings, and avoid becoming defensive (Correct answer)
- Ask the patient to calm down before continuing
- Immediately arrange a formal complaint process
Correct answer: Acknowledge the patient's anger with empathy ('I understand you're very angry and this must be a terrible shock'), allow them to express feelings, and avoid becoming defensive
Anger is a common and normal response to bad news (part of the Kübler-Ross model: denial, anger, bargaining, depression, acceptance). The most effective response is to acknowledge and validate the emotion without becoming defensive. Once the patient feels heard, you can address factual questions. Responding defensively escalates the situation.
Question 4: A patient has been told they have terminal cancer. They ask 'How long have I got?' How should you respond?
- Give a specific number of weeks or months based on statistics
- Explore what the patient is really asking; give a range if asked for specifics; avoid false certainty while not removing all hope; check what they want to plan for (Correct answer)
- Tell them it is impossible to say and change the subject
- Refer them to oncology without answering
Correct answer: Explore what the patient is really asking; give a range if asked for specifics; avoid false certainty while not removing all hope; check what they want to plan for
Prognosis questions require a careful, honest, and compassionate approach. First clarify what the patient really wants to know and why. If they want specifics, provide a range honestly but acknowledge uncertainty. Maintain realistic hope (for quality of life, symptom control, meaningful time). False reassurance or overly pessimistic statistics are both harmful.
Question 5: During a consultation about a patient's terminal illness, what is the purpose of checking understanding (the 'chunk and check' technique)?
- To test the patient's intelligence
- To deliver information in small pieces and regularly check comprehension, so the patient can absorb what they have been told and ask questions (Correct answer)
- To speed up the consultation by skipping already-known information
- To document that information was given for medico-legal purposes
Correct answer: To deliver information in small pieces and regularly check comprehension, so the patient can absorb what they have been told and ask questions
'Chunk and check' involves giving a small amount of information, then pausing to check understanding and invite questions before continuing. In emotionally charged consultations (breaking bad news), patients retain little after the initial shock — chunking ensures information is absorbed and allows the patient to guide the pace of the consultation.
Question 6: A patient requires a lifestyle change (stopping smoking, starting exercise). Which communication approach is most likely to be effective according to evidence?
- Telling the patient repeatedly about the health risks until they comply
- Motivational interviewing — exploring the patient's own motivation, identifying ambivalence, and supporting self-efficacy, rather than directing or lecturing (Correct answer)
- Prescribing nicotine replacement without further discussion
- Referring all lifestyle issues to the specialist nurse
Correct answer: Motivational interviewing — exploring the patient's own motivation, identifying ambivalence, and supporting self-efficacy, rather than directing or lecturing
Motivational interviewing (Miller and Rollnick) is an evidence-based communication style for behaviour change. Key elements: express empathy, develop discrepancy between current behaviour and the patient's own goals, roll with resistance rather than confront it, and support self-efficacy. It is more effective than advice-giving or direct confrontation.
PLAB 2 Clinical Communication & Breaking Bad News
Which framework is commonly used for breaking bad news in UK clinical practice?