Breaking bad news in PLAB 2: using SPIKES in an 8-minute station

The short version

• PLAB 2 has 16 scenarios of eight minutes each, at Foundation Year 2 (F2) level [1].
• Every scenario is marked in three domains: Data gathering, technical and assessment skills; Clinical management skills; Interpersonal skills [2].
• SPIKES has six steps: Setting up the interview, the patient's Perception, the patient's Invitation, giving Knowledge, addressing Emotions with empathic responses, and Strategy and summary [3].
• Find out what they already know before you tell them anything.
• Give a warning first, then the news in one or two plain sentences, then stop and wait.
• Spend real time on emotions. The plan comes after the person is ready to hear it.
• End with a clear next step, who they can contact, and an offer of support.

What SPIKES is

SPIKES is a six-step protocol for delivering bad news, published by Walter Baile and colleagues in The Oncologist in 2000 [3]. It was written for patients with cancer, and it is widely taught for any serious news. The six steps are [3]:

The GMC pages we read don't require SPIKES or any named model. It is simply a clear structure that fits the interpersonal and management parts of the station.

Timing SPIKES in 8 minutes

This is a practice plan from Confetto, not a GMC rule. Emotions come up throughout, so treat these times as a guide.

Worked example: a biopsy result in a surgical clinic

Example written by Confetto for practice. It is not a real PLAB 2 station and not a GMC sample.

Candidate instructions (example): You are an F2 doctor in a colorectal surgical clinic. Mr David Hughes, 64, had a colonoscopy last week because of a change in bowel habit, and a biopsy was taken. The biopsy shows bowel cancer. The consultant has asked you to give him the result and explain the next steps. He has come alone.

What the simulated patient knows (hidden): he thinks the camera test was "just to be safe"; his wife died of cancer four years ago and he cared for her; his main worry is "going through what she went through" and being alone; he wants to know if it can be treated. He becomes quiet after the news and then asks, "Am I going to die?"

The walkthrough

S: Setting up (0:00 to 0:45)

Doctor: Hello, Mr Hughes. I'm Dr Okafor, one of the doctors working with Mr Lee's team. Can I check your full name and date of birth? ... Thank you. Is this a good time to talk? I see you've come on your own today. Would you like anyone to join us, either here or by phone?

Patient: No, it's fine. Let's just get on with it.

P: Perception (0:45 to 1:45)

Doctor: Before I go through the results, can you tell me what you understand about why you had the camera test?

Patient: My bowels changed a bit, so the GP sent me. I think it was just to be safe.

Doctor: And have you had any thoughts about what it might show?

Patient: Not really. Well... my wife had cancer. You try not to think about it.

Note the cue about his wife. You don't need to follow it fully yet, but remember it.

I: Invitation (1:45 to 2:15)

Doctor: I have the results of the biopsy here. Some people like all the details, others prefer the main points first. What would you prefer?

Patient: Just tell me straight.

K: Knowledge (2:15 to 3:15)

Doctor: I'm afraid it isn't the news we were hoping for. (pause) The biopsy shows that the growth in your bowel is a cancer. (pause, silence)

Then stop. Don't fill the silence with treatment details.

E: Emotions (3:15 to 5:30)

Patient: (long pause) Am I going to die?

Doctor: That's a really important question, and I can see this is a huge shock. (pause) I can't tell you yet what this means for the future, because we need more tests to see the size of the cancer and whether it has spread. Many bowel cancers can be treated. The specialist team will be able to talk about that with you once those tests are done.

Patient: I watched my wife go through all of this.

Doctor: I'm so sorry. That must make today even harder. Can you tell me what's going through your mind?

Patient: That I'll be on my own with it. She had me. I've got nobody.

Doctor: You won't be on your own with this. We'll make sure you have support, and I'd like to talk about who could be with you.

This is where the hidden concern comes out. A candidate who skipped Perception and Emotions never hears it.

S: Strategy and summary (5:30 to 8:00)

Doctor: Can I explain what happens next? You'll have a scan to look at the rest of your body, to see whether the cancer has spread. Then the specialist team, which includes surgeons, cancer doctors and nurses, will meet to plan the best treatment for you, and they will see you to talk it through. You'll also have a specialist nurse who will be your main contact. I'll write their number down for you. Is there someone, a friend, neighbor or family member, who could come with you to the next appointment?

Patient: My son, maybe. He lives in Leeds.

Doctor: That sounds like a good idea. If you feel very unwell before then, for example bleeding from the bottom, severe tummy pain or vomiting, please call 111 or come to A&E, or 999 in an emergency. Just so I know I've explained it well, can you tell me what you understand will happen next?

What scores in each domain (labelled practice breakdown)

Sample breakdown written by Confetto for practice. It is not the GMC marking sheet.

Phrase bank for each SPIKES step

Common mistakes in PLAB 2 bad news stations

Practice this station

Confetto isn't affiliated with the GMC.