Breaking bad news comes up at medical school interviews in two forms: as a direct question about what you would need to consider, and as a role play, where an actor plays a patient, a relative or a customer and you have to deliver the news. The same structure answers both. Communication is fundamental to medicine, and poor communication is one of the most common causes of medical error and patient complaints, so interviewers want to see how you would actually behave in the room rather than how you would describe yourself. This article goes through why schools ask it, a framework for structuring the conversation, and an example of a strong answer.
What do you need to consider when breaking bad news to patients?
- What non-verbal cues should be avoided, and which should be used?
Why medical schools ask it
Doctors explain diagnoses, deliver bad news, counsel anxious patients, coordinate with colleagues, and navigate sensitive conversations daily. Role play stations test whether you can listen actively, respond with empathy, explain things clearly, and maintain professionalism, even when the situation is uncomfortable. They reveal how you'd actually behave with patients and colleagues, not just how you'd describe yourself.
Breaking bad news is the scenario schools return to because it combines every communication skill at once: setting the scene, finding out what the person already knows, pacing the information, tolerating silence, and leaving them with a plan. It also comes with a well-known structure, SPIKES, which interviewers expect you to know, but not to recite.
What the marking criteria reward
The marking sheet for the direct question has three content points, plus the usual mark for how clearly you communicate:
- Provides 3+ reasonable considerations, may use SPIKES framework
- Provides 2+ reasonable non-verbal cues to be avoided and used
- Reflects on the importance of breaking bad news
For the role play version the same ideas are marked as behaviours: did you introduce yourself and sit down, did you ask what they already knew, did you give a warning shot, did you avoid jargon, did you allow silence, and did you end with next steps. Scenarios involving a mistake add one more: honesty under the duty of candour.
How to structure your answer
Whether clinical or non-clinical, the SPIKES framework provides a reliable structure:
- S - Setting :
- Ensure the setting is private and comfortable, with minimal interruptions. Sit down, at the person's level.
- P - Perception :
- Ask what they already know or understand. This ensures you're on the same page and don't over- or under-explain.
- I - Invitation :
- Invite them to talk about the topic. "Would you like to talk about your results now?"
- K - Knowledge :
- Deliver a warning shot to prepare them: "Unfortunately, it isn't the news we hoped for." Then deliver the news slowly and clearly. Don't rush. Take frequent breaks to check understanding. Avoid all medical jargon.
- E - Emotions :
- Pause and give them space to process. Allow silence. Acknowledge their feelings without trying to fix them immediately.
- S - Strategy :
- When appropriate, explain next steps, follow-up, or support options. Confirm understanding: "I know it's a lot. Is there anything you'd like me to go over again?"
If the scenario involves a mistake, you're bound by the duty of candour to be honest about what happened. If you're at fault, take full responsibility. The model answer below covers these considerations, along with the non-verbal cues some schools ask about specifically:
Key considerations when breaking bad news
Breaking bad news well is crucial because it helps the patient cope, maintains trust in the healthcare team, and supports understanding of their condition and the next steps in their care.
Non-verbal communication
Non-verbal cues to avoid
Non-verbal cues to use
Example answer
A spoken answer to the direct question, about ninety seconds, with the non-verbal part at the end:
- Setting
- The first thing is the setting. I'd want somewhere private, with no interruptions, enough time, and I'd sit down with the patient rather than deliver it standing at the end of a bed. If they wanted someone with them I'd wait for that person.
- Perception and invitation
- Then I'd find out what they already understand, with an open question like "can you tell me what you've been told so far?", and ask how much they want to know. Some people want everything, some want the headline and the plan, and it's their call.
- Knowledge
- When I give the news I'd give a warning shot first, something like "I'm afraid the results aren't what we hoped", then say it plainly, in small pieces, without jargon, and stop after each piece to let it land.
- Emotions
- The part people find hardest is the silence afterwards. I'd let it happen rather than fill it, acknowledge whatever they're feeling, and not try to reassure it away.
- Strategy
- Before the end I'd make sure they know what happens next, who they can contact, and that they can come back with questions, and I'd check what they've taken in.
- Non-verbal
- Non-verbally, the things to avoid are looking at a watch or the door, crossed arms, frowning, and anything that looks rushed. The things to do are gentle eye contact, sitting at their level, open posture, nodding, a calm steady voice, and small things like offering tissues or water.
Practise this question out loud
Try answering it with the AI interviewer: it asks the question, follows up on what you say, and marks you against the points above.
Common follow-up questions
Breaking bad news is asked in many guises, and in role plays the "patient" is often not a patient at all. The structure is the same whether you are telling a family about a death or a neighbour that their cat has gone missing.
As a doctor, how will you cope with breaking bad news?
Asked at Sheffield. Acknowledge that it is difficult but essential, mention SPIKES, and talk about reflection, debriefing and self-care.
How would you tell a patient's family that the patient died as a result of your misdiagnosis?
Reported at St George's and Cardiff. SPIKES plus the duty of candour, then how you would cope and take accountability.
How would you break the news to a neighbour that their pet has gone missing?
A non-clinical role play. The same framework, and interviewers watch for whether you still allow silence when the stakes are smaller.
As a GP, explain to a patient what BMI is.
The explaining-information variant: start from what they know, plain language, check understanding, invite questions.
What is the difference between empathy and sympathy?
The quality this station is really marking. The empathetic response is the one that asks what is worrying the patient most.
Common pitfalls
Things to avoid when answering the question:
- Jumping to the news :
- Delivering it before finding out what the person knows and wants is the most common fault. Perception and invitation come first.
- No warning shot :
- "I'm afraid I have some difficult news" gives the person a second to brace. Going straight in does not.
- Using jargon :
- Even if you know medical terms, the person you're speaking to may not. Keep language simple.
- Filling the silence :
- Pausing to allow silence is a strength, not a weakness. Reassuring too quickly tells the person you cannot sit with their distress.
- Forgetting to introduce yourself :
- It's a small thing, but starting without an introduction feels abrupt and unprofessional.
- No plan at the end :
- Leaving the person with bad news and nothing else is the second most common fault. Next steps, contacts and a chance to ask questions.
- Reciting SPIKES :
- Interviewers know the acronym. Use it as the shape of your answer, not as a list of letters.
Which schools ask it
The direct question is reported at the schools below. Imperial runs a station on empathy and breaking bad news, the misdiagnosis version is reported at St George's and Cardiff, and the coping version at Sheffield. Any school with role play stations can set it.
Reported at Leeds and Manchester.
Frequently asked questions
What does SPIKES stand for?
Setting, Perception, Invitation, Knowledge, Emotions, Strategy. It was developed for oncologists telling patients about cancer, and it works for any difficult conversation.
What if the actor starts crying or gets angry?
That is the station working as intended. Stop talking, acknowledge the emotion in a sentence, and wait. Anger is usually fear; do not argue with it. When they are ready, carry on with the next step. Interviewers mark how you respond to emotion, not whether you prevent it.
Should I say "I know how you feel"?
No. You usually do not, and people notice. "I can see this is a shock" or "that sounds very hard" acknowledges the feeling without claiming it.