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How To Break Bad News In An MMI (Scripts Included)

How To Break Bad News In An MMI (Scripts Included)

Updated on: December 3, 2023
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Written By Dr Ollie

Every article is fact-checked by a medical professional. However, inaccuracies may still persist.

When I was applying to medical school I was completely clueless about how to break bad news in a role-play station.

And funnily enough, I did actually end up having to do it in my MMI interview for Leicester Medical School!

My role-play performance was far from perfect but luckily the rest of my interview carried me through.

And that’s why I wanted to write this article: to teach you a six step process to breaking bad news like a pro.

Using ‘SPIKES’ To Break Bad News

Breaking bad news can be a daunting task in an MMI role-play station. Luckily, SPIKES is a six-step process for breaking bad news that I was taught at medical school- and you probably will be too.

It covers everything from the setting to giving warning shots

To be clear, the interviewers won’t be expecting ‘doctor-level perfect’ as breaking bad news is an incredibly difficult thing to do that takes years to master.

However, I think the SPIKES framework is incredibly helpful for tackling these sorts of medicine interview role-play stations.

SPIKES stands for:

SSetting
PPerception
IInvitation
KKnowledge
EEmotion
SSummary


It’s literally a step-by-step guide for how to break bad news.

Something I wish I’d known at my interview for Leicester!

Now being asked to break bad news in a medicine MMI isn’t always as obvious as having to tell someone they have cancer.

It could be that their operation has been cancelled, you just saw their cat get run over, they can’t visit their family member in hospital or even that you just stepped on their glasses!

Here’s a realistic MMI station example that we can use to work through each of the SPIKES headings:

You’re a first year medical student working on a ward in hospital. You’ve just been asked by the head nurse to have a difficult conversation with one of the patients.

Due to an administrative error the patient has been receiving antibiotics for the last three days that they didn’t need. They were meant for another patient on the ward with a similar sounding name.

How To Break Bad News – Setting

The first S in SPIKES stands for setting.

This refers to the environment that you choose to break the bad news in.

Now in an MMI this is somewhat artificial- as you’ll be in the setting they’ve laid out for you.

However, there are still some key things to consider about your surroundings before launching into delivering the news.

Ideally, you and the actor should both be seated- this makes the conversation a lot more natural and less confrontational than a standing encounter.

If there are chairs present, offer the actor a seat and sit down yourself.

If you can, angle your chairs at 90° from each other. This helps build a rapport and is less direct than being head-on.

You also want to try and avoid any barriers, such as a desk, between you and the actor.

A medicine applicant sits next to an actor in an MMI

The next thing to think about is who needs to be present for this conversation. Is there anyone that the actor would like here?

Or indeed conversely, should anyone be asked to leave if the actor doesn’t want them listening in to a private medical discussion?

Suggesting to the actor that they might want family members present can help forewarn them that a serious conversation is incoming.

But we’ll get more onto warning shots later…

In our example scenario, you would ideally seat yourself next to the actor at a 90° angle. You might say you were there for a discussion about their medical treatment and ask if they’d like any family or friends present for it.

How To Break Bad News – Perception

Perception is all about what the actor currently understands about their situation.

This is such an important part of the process.

If you don’t check what the actor already knows, you run the risk of starting the discussion holding the complete wrong end of the stick.

This could be as simple as asking:

“What have you been told about what’s going on so far?”

Or

“Tell me what you understand about the current situation”

Once you’ve established the actor’s baseline knowledge, you can then work to bring them up to speed with what’s happened.

Another important aspect of the ‘perception’ stage is assessing the actor’s expectations.

Are they fully aware they’ve been called into the hospital to have a sombre discussion about turning off their mum’s life support?

Or is this a phone call completely out of the blue to tell them their brother has had a heart attack?

The actor’s expectations should help guide how direct you are in delivering the bad news and how careful you have to be easing them into the sober conversation.

The actor in our scenario would very likely have no idea they’d been receiving unnecessary treatment for the last three days. Because of this you’d want to gently ease them into the idea that there’s been a mistake in their medical treatment.

How To Break Bad News – Invitation

The ‘invitation’ stage is the actor inviting you to tell them the bad news.

It’s important because in real life a patient may not always want to receive bad news at that particular moment.

They may want family members present before you tell them, they may know they’ve got to go out with friends immediately after the consultation, or they may just not want to know the details at all.

In an MMI the actor will always want to hear the news but it’s still good practice to check.

Some phrases you can use for this are:

“I’ve got the results from your latest scan here, would you like me to share them with you?”

Or

“Is there anyone you’d like to be here before we continue this discussion?”

Once you’ve got the actor’s permission you can then move on to the next stage…

How To Break Bad News – Knowledge

‘Knowledge’ is the stage of the conversation that you actually deliver the bad news.

However, there’s a vital step you need to take before diving in…

Giving A Warning shot

A warning shot is you giving the actor a heads-up that the news coming isn’t going to be pleasant.

It’s essential to do because it helps make the news less of a shock when it comes.

A warning shot can come in many different forms and doesn’t have to be given as part of the ‘knowledge’ stage.

For example, a doctor calling a family into hospital to see their unwell grandmother at 5am is a warning shot that she may be about to pass away.

As we touched on in the ‘setting’ section, just by suggesting to a patient that they may want their family present for a particular discussion is a warning shot that it’s likely going to be regarding a serious topic.

In your medicine MMI I’d recommend using a simple phrase to make it obvious that you’re giving the actor a warning:

“I’m really sorry but the news I’ve got for you isn’t good”

Or

“I hate to say this but it’s not the news we were hoping for”

Once you’ve given the warning shot you can then progress with delivering the bad news.

Use Of Silence When Delivering Bad News

Effective use of silence and pauses is what can set an excellent candidate apart from an average one in a role-play MMI station.

Under the pressure of the day it can be so easy just to immediately spew out everything you were told in the scenario card to the actor.

However, this can easily overwhelm people in real life and may lead to an emotional overload where they just won’t take anything in.

Although you may initially find it unnatural, it’s far more effective to break bad news with pauses between everything you say so the patient/actor can take it in.

“I’m very sorry Mr Evans but I’ve got some bad news to tell you”

PAUSE

“There’s been a serious error in your medical treatment”


PAUSE

“You’ve been receiving unnecessary antibiotics for the last three days of your admission”

Immediately after breaking the bad news it’s also best to give the actor some time to process it.

Allow a lull in conversation while the news sinks in and only continue the consultation after the actor initiates it.

Chunk And Check

Chunk and check is a technique you should use when explaining the situation to the actor during the ‘knowledge’ stage.

You essentially deliver information in chunks, then check the actor’s understanding after each section.

You can do this by asking the actor to briefly repeat back to you what you’ve just said:

“Would you mind quickly summarising what we’ve just talked about?”

Or by asking a quick question about the topic at hand:

“So in how many weeks will I see you for a follow-up?”

These two methods are more reliable than simply asking if the actor has any questions as they have to actively prove they’ve comprehended the information you’ve just given.

It is however still important to regularly ask them if they do have any questions as you progress through the consultation.

By chunking and checking you make sure you’re not just talking at the actor and that they’re actually taking in what you’re saying.

It’s also a key technique that you should use in an MMI ‘giving instructions’ station.

How To Break Bad News – Emotion

‘Emotion’ is all about the actor’s reaction to the bad news and emotional response.

There’s lots of different ways the actor, and indeed real people, might react to being given bad news.

A young woman after receiving some bad news

They might go silent, start crying, get angry, not believe you or start asking non-stop questions.

They’re all natural reactions to being given bad news so don’t panic.

Just stay calm and empathise with the actor in a caring and respectful manner.

Emotional Acknowledgement

Emotional acknowledgement is a technique I find really helpful in highly charged emotional scenarios.

That can be anything from extreme sadness, to confusion, to complete denial or anger.

You simply verbalise what the actor is feeling, acknowledging the emotional state they’re in. For example:

“I can see you’re really upset, I’m so sorry I had to give you that news today”

Or

“I understand why that’s made you so angry, what can I do to help the situation?”

It’s not your job to change the situation when breaking bad news, but what you can do is support the actor through a considerate and empathetic response.

How To Break Bad News – Summary

This is the last stage in the six step process.

You need to start winding the consultation down and bring things to a close.

Summarise all the important details you’ve talked about and the outcome of any discussions.

The value of this summary is two-fold:

  1. It signals to all parties that the consultation is drawing to a close
  2. It provides a useful refresher of key points that may not have sunk in if there was a highly emotional response

It can also be beneficial to strategise a plan for moving forward in the future in this final stage.

“So what we’ve talked about today Mr Evans is that there was a serious error in your medical treatment- you were given three days worth of antibiotics that were meant for another patient.

From our observations so far this has had no detrimental impact on your health. However, we will be keeping a close eye on you over the next twenty-four hours.

I can reassure you that this matter will be treated with the upmost sincerity and will be reported via the correct procedures.”

It won’t be applicable to every scenario, but it’s far more reassuring to a patient if they can walk away with a plan from discussions like this.

End the consultation by doing a final check if the actor has any questions, then thank them for their time.

Final Thoughts

Now you know the six-step SPIKES process I’m confident you’re going to perform far better in a breaking bad news station than I did!

Don’t forget that it is an incredibly difficult thing to do and does take years to master- so don’t be disheartened if you find it challenging.

Breaking bad news is a core skill for a doctor and one that I’m still very much developing.

As long as you keep your cool and show yourself to be the caring candidate you are, I know you’ll do fantastically.

About the author
After studying medicine at the University of Leicester, Dr Ollie now works as a junior doctor in London. His interests include medical education and expedition medicine, as well as having a strong belief in the importance of widening access to medicine.