Interview Tips: Breaking Bad News
The aim of the various interview stations in MMIs is to test critical skills which will form the foundation of your training in medical school and beyond. Using your communication skills effectively will be crucial in establishing and maintaining the doctor-patient relationship in the context of clinical scenarios. It is important therefore that you are able to deliver bad news sensitively and honestly, ensuring that patients or families understand the situation and feel supported by the medical team. Handling emotions sensitively can be difficult in such situations, particularly if an actor in a station has been instructed to over-react in order to test you. Knowing how to do this within the 8–10-minute MMI station can be a challenge so we have come up with some tips for you to follow.
The basic principle of a breaking bad news station is to gather information about the situation from the perspective of the actor and how they feel, transmit to them the information that you have which is the main breaking of the news, and then offering to emotionally support them and come up with a plan to move forward. Centring the consultation around the patient’s ICE, ideas concerns and expectations, is something that is frequently practiced in medical school, this involves asking what they already know, are particularly worried about, and hope to achieve from the consultation. A more formalised way to think of this is SPIKES, which is a useful acronym to apply in situations that involve breaking bad news.
S stands for setting, so ensuring the patient is in a comfortable and private environment, where the conversation will not be interrupted by colleagues or bleeps. Something as simple as asking whether they would like any family or friends present for the conversation can build rapport and make it a safe space for discussion. Positioning yourself well here can be useful too, for example angling your chair at 90 degrees from the patient to help build more rapport than directly facing, as well as avoiding any barriers between like tables. P is for perception – this entails asking what the patient already knows about the condition or situation so far, so that you can tailor the discussion based around any misunderstandings they have that you wish to address or any particular concerns. This can be as simple as asking ‘what have you already been told about what is going on’. Invitation is the next letter, which is asking for their permission as to whether they want to be told today about what is going on, and it is also important at this point to offer to answer any questions they might have. K is for knowledge which is where you deliver the information – it can be helpful to deliver what is called a ‘warning shot’ before launching into this, for example by saying ‘I’m sorry to have to tell you that…’ or ‘Unfortunately this isn’t the news we were hoping for’. When delivering the information it is important to ‘chunk and check’ which means to break it up into small chunks without any jargon, and frequently pause to check their understanding for example by asking ‘is there anything you would like me to clarify so far?’. Finding a balance between being realistic and being negative is important here. E is for emotions and empathy, which is recognising the emotions of the patient and making it clear that you understand and empathise with them. You can do this through ‘I am so sorry that you are feeling this way because of…’ or ‘I can’t imagine how difficult this must be for you’. There is also a chance that actors will have been told to start crying, or get very angry at this stage so recognising and dealing with that can be a large part of the marking for stations. Non-verbal communication, and simple actions like offering them a tissue, can make a patient feel at ease here. And finally, strategy and summary – wrap up the conversation by talking about what happens moving forward and what the options are for the patient. This should be a bilateral conversation, ensuring the patient is in control of their own decisions and health. Be careful with the wording of your advice here, for example if there is a scenario with a deceased pet, telling them to buy a new pet is likely not appropriate. Finish up with a brief summary of what you have discussed, once again checking the patient’s understanding.
It is important throughout to remain very calm both in your verbal and non-verbal communication, allowing your body language to mirror the patient/actor, so that they feel comfortable throughout and that you are engaged and not distant. Ensure that you are employing active listening, so making mental notes of what they say, rather than nodding visibly but not actually paying attention. It is key to remain as sensitive as possible, being careful of the wording you choose to use in each case. Whilst being sensitive it is also important not to guarantee, confirm or deny anything to the patient due to the limitations of your role – for example you cannot confirm a cancer diagnosis, or guarantee that the patient will have specific scans. You should make it clear that this is at the discretion of your senior and more qualified colleagues with whom you will confer and ask them to either speak to the patient themselves, or find out the information from them to pass on. Silence can also be a useful technique to employ, giving them time after each section to digest and process the news, but make sure these pauses are not too long that you waste valuable time or make the situation awkward. As aforementioned always wrap up by offering support so that the station seems complete.
Further resources you can refer to include the Geeky Medics OSCE Guide for Breaking Bad News, Quesmed Youtube videos which show how to do this, and this link.
If you’d like to find out how to smash interview role-playing stations, click here.
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Written by Catherine Dominic