PLAB 2 / PRES 3: How to Break Bad News Using the SPIKES Framework

Breaking bad news is one of the most challenging communication stations in PLAB 2 and PRES 3. The examiner is not looking for the perfect script. They want to see empathy, structure, and the ability to respond to a patient's emotions.

The SPIKES framework provides a simple approach that helps keep difficult conversations organised and patient-centred.

What is SPIKES?

SPIKES stands for:

S – Setting
P – Perception
I – Invitation
K – Knowledge
E – Empathy
S – Strategy and Summary

You do not need to mention the acronym during the consultation. Use it as your mental checklist.

1. Setting

Create a suitable environment.

Introduce yourself.
Confirm the patient's identity.
Ensure privacy.
Sit at eye level.
Minimise interruptions.

Simple actions help patients feel supported before difficult information is shared.

2. Perception

Find out what the patient already knows.

Examples:

"Can you tell me what you understand about your test results?"
"What have the doctors told you so far?"

This prevents misunderstandings and helps you tailor your explanation.

3. Invitation

Ask how much information the patient wants.

For example:

"Would it be alright if I explained the results now?"

Most patients want full information, but asking first respects their preferences.

4. Knowledge

Give information clearly and honestly.

Avoid long medical explanations.

Instead of saying:

"The biopsy confirmed a malignant neoplasm."

Say:

"The results show that you have cancer."

Pause after important information and allow the patient time to respond.

5. Empathy

Patients may become silent, cry, or ask repeated questions.

Acknowledge their emotions.

Examples:

"I'm sorry you're hearing this."
"I can see this is a lot to take in."
"Take your time."

Avoid changing the subject too quickly.

6. Strategy and Summary

Before finishing:

Summarise what has been discussed.
Explain the next steps.
Answer questions.
Offer support.

For example:

"We'll arrange an appointment with the specialist team, and we'll support you throughout the process."

Common mistakes

Avoid:

Delivering bad news too quickly.
Using medical jargon.
Talking continuously without allowing pauses.
Ignoring the patient's emotions.
Giving false reassurance.
Ending the consultation without explaining what happens next.

Examiner tip

You are not expected to remove the patient's distress.

You are expected to communicate honestly, respond with empathy, and provide a clear plan.

That is what examiners reward.

Key takeaway

Breaking bad news is about more than delivering information. It is about supporting patients through one of the most difficult conversations they may ever have.

A calm, structured, and compassionate approach will help you perform well in both PLAB 2 and PRES 3—and, more importantly, in real clinical practice.

Practise realistic breaking bad news stations with AI patients on OSCEPilot and receive examiner-style feedback after every consultation.