Breaking bad news in the SCA, at a human pace

What makes these cases hard

Breaking bad news tests everything at once. You have to be clinically accurate, you have to be honest, and you have to do it in a way the patient can take in. Twelve minutes is not long. Most candidates either rush to the plan because silence feels uncomfortable, or spend so long on feelings that the patient leaves without knowing what happens next.

The task is not to deliver a speech. It is to find out what the patient already knows and wants to know, give the news clearly, stay with the reaction, and then agree the next step together. In general practice that next step is often a referral, a further test or a follow-up call, and the patient needs to leave knowing who will contact them and when.

How the RCGP domains apply

These summaries are ours. The domain names are the RCGP's; read its own descriptors on the marking and results page and in the SCA consultation toolkit. See how the SCA is marked for the grades and pass mark.

A practical structure

This is our suggested shape, not an RCGP template. Real cases rarely split so neatly.

1. Set up (about 1 minute). Introduce yourself, check identity, and on video or phone check they can talk privately. Ask whether they would like anyone with them.
2. Find out what they know (1 to 2 minutes). “What has the hospital told you so far?” and “What have you been thinking it might be?” Their answer tells you where to start and how far apart you are.
3. Warning shot, then the news (1 minute). A short warning, then the news in one or two plain sentences. Avoid jargon and avoid hedging so heavily that the message is lost.
4. Silence and emotion (2 to 3 minutes). Stop talking. Let the reaction happen and name it. Answer the question they ask, not the one you prepared for.
5. What happens next (3 to 4 minutes). Explain the next step, the timescale and who will be in touch. Check their priorities and worries, including practical ones.
6. Support and safety-netting (1 to 2 minutes). Agree a follow-up, give a way back in, and check what they will tell family. Summarise in a sentence.

Common pitfalls

• Filling the silence. A pause after bad news is not a gap to fix. Talking straight into it tells the patient you are uncomfortable, and they stop asking questions.
• Leading with statistics. Survival figures and staging detail rarely help in the first conversation, and you often do not have them. Say what you know and what will be found out next.
• False reassurance. “I’m sure it’ll be fine” is not honest when you do not know. Hope can sit with honesty: “There are treatments, and the team will talk you through them.”
• Running out of time for the plan. Good rapport with no clear next step fails clinical management. Keep an eye on the clock from the halfway point.
• Ignoring the person in the room. If a relative is present, acknowledge them, but keep the patient at the centre and check what they want shared.

Natural phrases

• “Before I go through the results, can I check what you’ve been told so far?”
• “I’m afraid it isn’t the news we were hoping for.”
• “The scan shows a growth in the bowel that looks like it could be a cancer.”
• “That’s a lot to take in. Take your time.”
• “What’s going through your mind right now?”
• “What matters most to you over the next few weeks?”

More in our explaining phrase bank and safety-netting phrase bank.

Practice cases with difficult news

Each of these cases involves news that is serious, uncertain or unwelcome. Some are results conversations, some are about the end of life, and one is with a bereaved relative.

• “The hospital hasn’t rung me — have my scan results come through to you?” · Video
• Back pain that isn’t mechanical · Telephone
• "My routine blood test showed raised lymphocytes and the word ‘leukaemia’ — I’m terrified, but I feel completely well" · Video
• "It’s just the tail end of that chest infection, isn’t it, doc?" · Video
• "My smear came back abnormal — do I have cancer? I’m terrified and I don’t understand the letter" · Video
• "My calcium’s high — my friend said that means cancer" · Video
• "The scan found a bulge on my aorta — is it about to burst?" · Video
• "My dad died young of bowel cancer and the hospital said it ran in the family — do I need testing? I’m only 22" · Video
• "I’ve got a terminal diagnosis and I want help to end my life when the time comes — will you help me, doctor?" · Video
• "I don’t want to end up on a machine — but I’m frightened every time I can’t catch my breath" · Video
• The pain and the envelope · Telephone
• “Why does Dad’s certificate say heart failure — and why can’t we bury him yet?” · Telephone

Each case page shows the candidate brief you would read in the 3-minute window. The learning points sit behind a spoiler, so read the brief, practise, then look. The full case, with the role-player script and examiner checkpoints, is in The Hot Seat.

How to practise

Read a case brief, set a 12-minute timer and run it with a partner, the AI patient or out loud on your own. The Hot Seat holds the full case bank with a scorecard for each case. The Consultation Conversation Lab drills the Relating to others skills (cues, ideas and concerns, shared plans), and Worked Example Consultations show what a passing consultation sounds like from start to finish. If English is not your first language, the IMG Track has plain-English explaining drills that suit these cases. Then put a few of these cases into your next mock exam.

Frequently asked questions

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