Test Stations

Surgery / General Surgery: Breaking bad news


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a junior doctor on medical ward cover. You have been called by the nursing team to come explain the results of a patients CT scan that has now been reported. He is very anxious and does not want to wait until the day team comes in tomorrow.   

Patient: 55 year old has been admitted with a cough and has been coughing up bits of blood for the past six months, has had a chest x-ray in A&E and as a consequence a CT scan.

CT scan report = large upper mass in the right lung with 6 smaller lesions throughout the lung. There is evidence of underlying emphysema. There is lymphadenopathy present in the lungs. There is evidence of metastasis present in bone, liver and adrenal glands. Probable advanced primary lung cancer with metastatic spread. Recommend lung MDT input.

Task:

  • Gather the reason for admission
  • Communicate these results to the patient
  • Answer any questions the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers may be required.

You are in hospital by yourself, your partner is at home and you do not want to worry them by calling them into hospital until you know what is going on.

You are a 55 year old patient who has come into hospital because you have had a cough, bringing up specs of red in your phlegm over the past 6 months. You were not particularly worried about this but your partner has been, so you went to the GP and he sent you immediately to the hospital for a chest x-ray. You have lost a lot of weight, have no appetite and have very little energy. If asked you have smoked 40 a day for the past 40 years. Otherwise you are fit and well.

You had a CT scan earlier on today to “exclude” cancer as the doctors in A&E had seen something unusual on the chest x-ray. You are worried what this could be and you hope this is not lung cancer.

Your bother died of lung cancer just over a year ago. He had a lot of treatment  that made him very sick and he passed away very quickly after being diagnosed. You are worried that the same thing will happen to you.

You still work as a self employed builder and are the sole provider for your partner. You are concerned that you wont be able to continue working and how will you be able to provide for yourself and your partner.

Overall role = you are a concerned patient, you need everything explaining. You do not understand any medical jargon and require it to be explained if said by the candidate. You need to specifically know what the CT scan shows, a “mass” is not enough, the focus of this station for you is to know if this is cancer or not. You need to give the candidate opportunity to break down this station, you are required to give very long pauses in order to make the station uncomfortable. Make use of non-verbal cues to show you are upset e.g hands on face covering eyes, shaking of head, ect.

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

CategoryQuestion
Done
Excellent
IntroductionCandidate appropriately introduced themselves with:
Full name
Role
Clarifies who they are talking to
Asks patient for preferred name


IntroductionIntroduction
Gains consent for consultation
Mentions confidentiality
Explains context of consultation
Asks if patient has brought anyone else along to the consultation


Pre-knowledge Assesses what the patient already knows
Asks for events leading up to now
Determines what patient already knows or expects
Covers any ideas, concerns and expectations for consultation
Candidate summarises the situation so far


InvitationCandidates checks
If patient would like to know the result now
Are there any family members they would like to be present


Delivery of information 1
‘Warning shot’ - e.g, “we have looked at your results and unfortunately, it is not good news"


Delivery of information 2
Provides information in a sensitive but clear manner - e.g “Unfortunately it is a tumour”


Delivery of information 3
‘Chunks’ information to check patient has understood


Delivery of information 4
Avoids medical jargon


Delivery of information 5
Provides patient with time to process information / does not try to fill the silences


When delivering information:
Candidate allows patient to lead consultation (does not talk endlessly to fill silence)
Does not attempt to solve problems
Listens and responds appropriately to cues


Following the information
Responds appropriately to non-verbal cues - e.g, “you have been very quiet, what are you thinking about”
Displays appropriate empathy


Candidate explores:
Emotions related to hearing news
Recognises and validates concerns


Closing consultation
Provides pamphlets to take away regarding condition or support available
Makes appropriate arrangements for follow up


Patient score
Good rapport with patient
Active listening skills
Appropriate use of body language
Avoids medical jargon
Logical structure / does not jump around topics in consultation
Summarises and checks patient understanding



Score


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