The SPIKES framework: breaking bad news in PLAB 2
SPIKES is the six-step protocol for breaking bad news, and it is the structure examiners expect to recognise in every PLAB 2 bad-news station: a new cancer diagnosis, an unexpected scan finding, a death. You do not get marks for naming it. You get marks for doing it: the setting controlled, the patient's understanding explored before you speak, the warning shot fired, the silence tolerated.
Step by step, with exam phrasing
| Step | What it means in the cubicle | |
|---|---|---|
| S | Setting | Control the room before the conversation. Privacy, seats at the same level, tissues within reach, bleep handed over, the right people present. "I've asked a colleague to hold my bleep so we won't be disturbed. Would you like anyone with you?" |
| P | Perception | Find out what the patient already knows or suspects before you add anything. Their answer calibrates everything that follows. "Can I start by asking what you've already been told about the tests?" |
| I | Invitation | Ask how much they want to know today. Some patients want everything; some want headlines only. Both are their right. "Some people like all the details straight away and others prefer the overall picture first. What would you prefer?" |
| K | Knowledge | Fire a warning shot, pause, then give the news in plain words, in small pieces. No euphemisms that leave room for doubt: if it is cancer, say cancer. "I'm afraid the results are not what we were hoping for... The biopsy shows that this is cancer." |
| E | Empathy | Stop. The next move belongs to the patient. Tolerate the silence, acknowledge the emotion by name, and do not rescue yourself with information. "I can see this is a huge shock. Take whatever time you need." |
| S | Strategy and summary | Only when they are ready: what happens next, in one or two concrete steps, with a follow-up anchored and understanding checked. "You won't be facing this alone. The specialist team will see you this week - can I check what you'll take away from today?" |
When it carries the marks
Any station involving a life-changing diagnosis, an unexpected result, a death notification to relatives, or disclosure of a serious error. The marks sit in the interpersonal-skills domain, and the station is usually lost at P (telling before asking) or E (filling the silence).
Where candidates lose the marks
- Delivering the news in the first minute. The S, P and I steps exist so the news lands on prepared ground.
- Euphemisms that leave doubt: 'a growth', 'something sinister', 'the big C'. Say the word once, kindly.
- Filling the silence after the news with a lecture about treatment options. Empathy first, information later.
- False reassurance: 'I'm sure it will all be fine' is a mark deduction, not kindness.
- Forgetting the warning shot, so the news arrives mid-sentence with no brace moment.
- Ending without a concrete next step and safety-net, leaving the patient in freefall.
Apply it in a real station
These station guides use this framework directly:
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Frequently asked questions
What does SPIKES stand for?
Setting, Perception, Invitation, Knowledge, Empathy, Strategy and summary. It is the standard six-step protocol for delivering bad news, developed for oncology and expected in UK clinical exams including PLAB 2.
Do I have to follow SPIKES in order?
Broadly yes, because the order is the logic: prepare the room, learn what they know, learn what they want to know, deliver with a warning shot, respond to the emotion, then plan. Examiners do not tick letters; they recognise the shape, especially perception before knowledge and empathy before strategy.
What is a warning shot in breaking bad news?
A one-sentence signal that difficult news is coming, such as 'I'm afraid the results are more serious than we hoped'. It gives the patient a moment to brace, and its absence makes the news feel brutal regardless of your tone.
How is breaking bad news marked in PLAB 2?
Mostly in the interpersonal-skills domain: exploring what the patient knows, pacing, plain language, tolerating emotion and checking understanding. Clinical management marks come from a sensible, concrete next-steps plan with follow-up and support.
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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