The SPIES framework: ethical dilemmas in PLAB 2
SPIES is the five-step escalation framework for professional-dilemma stations: the colleague who smells of alcohol, the registrar making errors, the friend asking you to prescribe. Its power is its order - it stops you jumping to confrontation or to telling the consultant before you have gathered information, and it keeps patient safety explicitly at the centre, which is where the marks are.
Step by step, with exam phrasing
| Step | What it means in the cubicle | |
|---|---|---|
| S | Seek information | Establish the facts before acting on the story. Talk to the person involved; there may be an innocent explanation, and fairness is being marked. "Before anything else, I'd want to speak to my colleague privately and understand what's actually happening." |
| P | Patient safety | The non-negotiable step. If there is any current risk to patients, it is addressed now - a colleague unfit to work does not finish the shift. "My first responsibility is to make sure no patient is at risk today, so I'd make sure he isn't seeing patients while this is unclear." |
| I | Initiative | What can you do yourself, at your level, before escalating? Support, cover arrangements, encouraging self-referral to occupational health. "I'd encourage her to speak to her educational supervisor herself, and offer to go with her." |
| E | Escalate | If the problem persists or is serious, take it up the ladder: senior, consultant, clinical director, and beyond that the GMC. Escalation is a duty, not a betrayal. "If patients remained at risk, I would have to involve the consultant - I'd tell my colleague that first, not go behind his back." |
| S | Support | The step candidates forget: the colleague is often unwell, not bad. Occupational health, counselling services, keeping the relationship intact. "Whatever happens with the process, he's clearly struggling, and I'd want him to know where to get support." |
When it carries the marks
Ethics and communication stations involving a colleague's behaviour, fitness to practise, or pressure to act outside guidelines. Usually delivered as a discussion with an examiner or senior rather than a patient consultation, which changes the register: structured, professional, thinking out loud.
Where candidates lose the marks
- Jumping straight to 'I would tell the consultant' - escalation without information-gathering reads as both unfair and evasive.
- Forgetting patient safety entirely while focusing on the colleague's feelings; the priority order is the point.
- Promising confidentiality you cannot keep: if patients are at risk, you cannot sit on it.
- Treating the colleague as a villain. The support step exists because impaired colleagues are usually unwell.
- No mention of documentation or the GMC when the scenario clearly warrants it.
- Rigidly reciting the letters instead of applying them to the actual scenario details.
Apply it in a real station
These station guides use this framework directly:
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Frequently asked questions
What does SPIES stand for?
Seek information, Patient safety, Initiative, Escalate, Support. It is the standard approach to professional and ethical dilemma questions in UK medical exams, ordered so that fact-finding and patient protection come before escalation.
When do I use SPIES in PLAB 2?
In colleague-problem and professional-dilemma stations: a colleague who may be drunk, tired, incompetent or dishonest, or pressure to act outside your competence. It structures your spoken reasoning, usually to an examiner rather than a patient.
Should I always escalate to the GMC?
No. The ladder matters: colleague, then local seniors (consultant, clinical or educational supervisor), then formal routes. The GMC enters when local escalation fails or the risk is grave. Jumping the ladder loses marks for judgement; refusing to climb it loses marks for safety.
What if the scenario says the colleague is my friend?
The friendship is the test. Acknowledge the conflict openly, be honest that it is uncomfortable, and show that patient safety still wins: 'Because he's my friend, the kindest thing I can do is be straight with him about what has to happen.'
Frameworks stick when you say them out loud.
Sit a free timed station and practise the phrasing against a patient who answers back.
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