Medical School Interview: Breaking Bad News & SPIKES

Breaking bad news is, sadly, part of a doctor’s job. You must therefore be ready to show an awareness of this fact, an appreciation of the importance of dealing with these situations correctly, and some thought as to how you might approach it and the attributes required to do so. Consider the role of empathy, understanding and acknowledging the feelings of others, providing information as needed and honestly, and checking understanding.
 
You should be aware of the SPIKES method – it provides a simple framework for delivering bad news to patients and their families. SPIKES was first proposed for work in oncology, and has since been adopted throughout Medicine. It is an acronym, and the letters have the following meanings:

S – Setting. This means that you should have the consultation in an appropriate place – not over the phone or in a public place. Try to find a pirate area, and ensure that you set yourself up in such a way that you are able to make eye contact and use appropriate physical touch if necessary.

P – Perception. You should begin the process by asking the patient what they understand of the situation – letting you better realise their knowledge. You should listen carefully in order to check that the patient hasn’t made any mistakes, and that they are aware of their position.

I – Invitation. You should check that the patient is ready for you to deliver the news. You might use a phrase like, ‘Is now a suitable time for me to share the test results with you?’ This permits the patient to decide if they are in the right frame of mind to receive the news at this time, and lets them consent to the sharing of information.

K – Knowledge. This refers to the imparting of knowledge to the patient. You should use clear phrases with no jargon, and ensure that you speak in a slow and understandable manner. Try to avoid complicating the situation with less vital information that might be better delivered later.

E – Empathy. You should do your utmost to understand what the patient or their family are feeling. You might therefore wish to remain in silence, and you should never discourage displays of emotion – be it them crying or remaining in silence. Small gestures like offering a tissue if a patient appears upset can be a simple way of showing that you are aware of their emotions.

S – Strategy. You should summarise the contents of what has been said thus far, and then plan what to do next. You might wish to set up another meeting, or discuss treatment options. Consider the position the patient is in and their emotions when proceeding – no two patients are the same. 

Let’s now briefly consider an example question on breaking bad news.

‘Imagine that you are a doctor and have been asked to tell a patient that their test result shows a malignancy. How might you approach this situation?’

A poor answer might be as follows:

‘I would tell them honestly what the test result was and make sure I didn’t lie. If they were upset I would make sure that I sympathised with them and made appropriate comments.’

This answer doesn’t show a strategy for dealing with the situation, nor a true awareness of how the patient might be feeling and the impact of this,
 
A good answer could be:

“I would use the SPIKES protocol for delivering bad news. I would first ensure an appropriate setting – a private place. Then I would check the patient’s understanding of the situation. I would then ask the patient to invite me to deliver the news – checking with them that it is the right time to do so. I would speak slowly and clearly and avoid jargon. I would show empathy throughout and allow the patient time to display emotion. Lastly, I would sum up what we had discussed, and develop an appropriate strategy to move forward, bearing in mind the patient’s emotional state and understanding of their position.’