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Breaking bad news is one of the most difficult tasks in healthcare. It requires a combination of empathy, communication skill, and professional judgement — exactly the qualities the UCAT Situational Judgement Test is designed to assess.
This lesson covers the SPIKES protocol (the most widely taught framework for breaking bad news in UK medical schools), common mistakes, and how these scenarios appear in SJT questions.
Bad news is any information that drastically and negatively alters the patient's view of their future. It is not limited to terminal diagnoses.
| Type of bad news | Example |
|---|---|
| Diagnosis | "The biopsy results show that you have breast cancer" |
| Prognosis | "Unfortunately, the cancer has spread and we cannot cure it" |
| Treatment limitations | "The surgery was not as successful as we hoped — you may not regain full mobility" |
| Lifestyle impact | "With this diagnosis, you will not be able to drive for at least 12 months" |
| Test results | "Your blood test shows your kidney function has deteriorated significantly" |
| Chronic conditions | "You have Type 1 diabetes, which will require lifelong insulin treatment" |
SJT scenarios involving bad news are common. They test whether you understand that breaking bad news is a process, not an event — and that the patient's emotional response must be addressed alongside the clinical information.
SPIKES is a six-step framework for breaking bad news, developed by Buckman and Baile. It is taught in virtually every UK medical school and is the standard against which SJT answers about bad news delivery are judged.
| Element | What it means | Why it matters |
|---|---|---|
| Privacy | Find a quiet, private space free from interruptions | Patients cannot process bad news in a busy corridor or open ward |
| Sitting down | Both the professional and the patient should be seated | Sitting down signals that you have time and that this conversation matters |
| Time | Ensure adequate time; do not rush | Patients need time to absorb information and ask questions |
| Support | Ask if the patient would like someone with them | Having a family member or friend present can provide emotional support |
| Preparation | Review the case notes and test results beforehand | Nothing undermines trust faster than a professional who is visibly unprepared |
A scenario that asks about the best way to deliver bad news will almost always rate "ensuring privacy and adequate time" as a very appropriate first step. Answers that involve delivering bad news in inappropriate settings (in a corridor, over the phone when a face-to-face conversation is possible, in front of other patients) are consistently rated as inappropriate.
Before delivering bad news, you need to understand what the patient already knows and expects.
| Technique | Example |
|---|---|
| Ask what they know | "Can you tell me what you understand about why we did the tests?" |
| Assess their expectations | "What are you expecting the results to show?" |
| Note discrepancies | If the patient expects good news, you know the gap between their expectation and reality is large |
Not every patient wants full information immediately. The Invitation step involves asking the patient how much detail they want.
| What to ask | Example |
|---|---|
| Level of detail | "Some people want me to explain everything in detail; others prefer the big picture first. What would you prefer?" |
| Timing | "Would you like me to go through the results now, or would you prefer to come back with a family member?" |
| Written information | "Would you find it helpful if I gave you something to read afterwards as well?" |
In SJT, responses that respect the patient's right to control the flow of information are rated as more appropriate than those that dump all information at once. However, you should never withhold critical information that affects patient safety.
This is the step where you actually deliver the bad news. The way you do it matters enormously.
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