Facts last verified .
flowchart LR
S[Setting
Private, sitting, support] --> P[Perception
What do they know?]
P --> I[Invitation
How much do they want?]
I --> K[Knowledge
Warning shot, plain words]
K --> E[Emotions
Acknowledge, pause]
E --> St[Strategy
Next steps, safety net]
TL;DR
The MRCEM OSCE bad-news station almost always rewards SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, Strategy & Summary). It is a structured framework first published by Baile et al. in The Oncologist (2000) and adapted for the ED in the 2024 AEM Education and Training primer by Rivera et al.
- Sit down, fire a warning shot, then say the word. “I have some difficult news to share” — pause — then “your husband has died” or “the scan shows cancer”. Use the actual word: died, not passed; cancer, not shadow.
- Shut up after the headline. Count silently to ten. Examiners are watching whether you can tolerate the silence; candidates who fill it with filler or false reassurance lose marks.
- End with a concrete next step. Specialist nurse, social worker, viewing the body, follow-up plan, written information, and “I am here for the rest of the shift if more questions come up.”
Why does the bad-news station matter so much in the MRCEM OSCE?
Communication stations make up roughly a third of the MRCEM OSCE circuit, and breaking bad news is the single most predictable one. The RCEM blueprint examines it under SLO7 (safe and effective patient communication, end-of-life care), and the College itself signposts SPIKES as the structure to know — RCEMLearning’s 2024 module on Delivering Bad News by Charlotte Davies lists SPIKES alongside Best Case/Worst Case, PLIIIE, GRIEV_ING and SAGE & THYME, but flags SPIKES as the “helpful strategy for exams.”
For more on this, see our guide to acing OSCE communication stations.
The station hurts because the clinical content is easy and the marks are interpersonal. You are not being assessed on whether you can spell the diagnosis; you are being assessed on whether the simulated relative would feel held by you. Stations are typically eight minutes, sometimes with a two-minute reading window. Common stems include the post-arrest family, the unexpected cancer on a CT done for back pain, a child who has died from sepsis, and the diagnosis-of-life-changing-illness conversation (new T1DM, MS, motor neurone disease, miscarriage).
What framework should I use — SPIKES, BREAKS, or something else?
Use SPIKES. Examiners are trained against it, the RCEM-affiliated resources cite it, and it maps neatly onto the eight-minute station. BREAKS (Background, Rapport, Explore, Announce, Kindle, Summarise) and PLIIIE are conceptually similar — pick one, run it cleanly, and stop trying to remember the others mid-station.
One naming caveat worth knowing: Liz Crowe at St Emlyn’s argues against “breaking” or “delivering” bad news at all, preferring communicating difficult news, because the conversation is a relationship rather than a one-shot transaction. You do not need to fight the College on terminology in the exam, but Crowe’s framing — stay present, see the family more than once, do not flee after the headline — is exactly what high-scoring candidates demonstrate.
SPIKES step by step
| Step | What you do | Phrases that earn marks |
|---|---|---|
| S — Setting | Wash hands, introduce yourself by name and grade, confirm who they are, sit down, silence your bleep, offer a chaperone (specialist nurse, chaplain, the relative’s own family), close the door. | “I’m Dr Smith, one of the senior doctors in the emergency department. Can I check — you’re Mrs Khan, Tariq’s wife? Shall we sit down? I’ve asked Sarah, our senior nurse, to join us.” |
| P — Perception | Find out what they already know and how worried they already are. Calibrates how big a warning shot you need. | “What have you been told so far?” / “What was going through your mind when the ambulance crew rang?” |
| I — Invitation | Check how much detail they want. In a sudden death, the invitation is often implicit — they are there because something terrible has happened — but you still flag the shape of the conversation. | “Is it okay if I go through what happened from the moment the ambulance arrived?” / “Some people want every detail, others want the headlines — what would help you most?” |
| K — Knowledge | Fire a warning shot. Pause. Deliver the headline in one short sentence, using plain words. Died, not passed away. Cancer, not growth. Stopped breathing, not respiratory arrest. | “I’m afraid I have very difficult news.” [pause] “Despite everything the team did, Tariq’s heart could not be restarted. He has died.” [stop talking] |
| E — Empathy | Count to ten silently. Read the body language. Name the emotion. Resist the urge to rescue the silence with medical detail. | “I can see this is the worst news you could have heard.” / “Take all the time you need.” |
| S — Strategy & Summary | Once they re-engage, lay out the next concrete steps: viewing the body, the bereavement nurse, the coroner, organ donation if appropriate, follow-up phone call, written information, your name on a card. | “When you feel ready, our bereavement nurse Helen will sit with you and talk through what happens next. You can take all the time you need with Tariq. I’ll be here for the rest of the shift — please ask for me if more questions come up.” |
What does an examiner actually mark?
RCEM marksheets for communication stations are typically a global rating (clear pass / pass / borderline / fail / clear fail) plus a structured domain score. The domains that come up consistently across the published OSCE guides and the RCEMLearning material are:
For more on this, see our guide to common OSCE station fails.
- Structure — did you follow a recognisable framework? Did setting and warning shot precede the headline?
- Language — were you jargon-free? Did you say the actual word (died, cancer, stillbirth)?
- Empathy and non-verbal communication — eye contact, body position at eye level, tolerating silence, no false reassurance (“I’m sure it will all be fine”), no premature problem-solving.
- Safety — did you check capacity, mention safeguarding where relevant, identify suicidal ideation in life-changing-diagnosis stations, flag DVLA implications for new epilepsy or first faint?
- Closure — concrete next step, named follow-up, written information, offer of chaplain / specialist nurse / bereavement service, summary, invitation to ask more.
The fastest way to fail is the opposite of each of these: blurting the diagnosis before the warning shot, using medical jargon, false reassurance, filling the silence, and ending without a plan.
Sample script: post-arrest in the resus room
Stem: a 58-year-old man brought in with witnessed VF arrest, downtime 35 minutes, brief ROSC, re-arrested, asystolic; resuscitation stopped after 50 minutes. You speak to his wife.
Setting. “Mrs Khan, I’m Dr Smith, one of the senior doctors in the emergency department. This is Sarah, our senior nurse. Shall we go through to the family room? Please, have a seat.”
Perception. “Can I start by asking — what have you been told so far?” (She says: paramedics rang to say his heart had stopped.)
Warning shot. “I’m afraid I have very difficult news.” (Pause.)
Knowledge. “When the ambulance crew arrived, Tariq’s heart had stopped. They started CPR straight away and continued all the way to hospital. Our team carried on the moment he arrived — we put a breathing tube in, gave adrenaline, and shocked his heart several times. For a short period his heart restarted, but it stopped again and despite another 30 minutes of resuscitation we were not able to get it going. I am so sorry — Tariq has died.”
Empathy. [Silence. Count to ten.] “There are no words for how awful this is. Take all the time you need.”
(She asks: did he suffer?) “The paramedics said he collapsed without any warning and was unconscious within seconds. He would not have been aware of what was happening.”
Strategy and summary. “When you are ready you can spend as long with Tariq as you want. Sarah will stay with you. Because this was a sudden death it has to be reported to the coroner — that’s routine, not because anyone has done anything wrong. Our bereavement nurse Helen will talk you through the paperwork tomorrow. Is there anyone we can call for you now? Any faith representative you would like us to contact?”
Sample script: child death from sepsis
Stem: a four-year-old with three days of fever, presenting moribund, meningococcal septicaemia, dies despite aggressive resuscitation.
This station is brutal. Marks come from acknowledging the unimaginable, naming the diagnosis honestly, and resisting the urge to explain too much. Lead with the headline; explain mechanism only if asked.
“I’m Dr Smith, the senior doctor in the emergency department. I am so sorry — this is the worst news. Despite everything the team did, Amal’s heart stopped and we were not able to get it started again. Amal has died.”
[Silence. Allow whatever comes — collapse, anger, denial, stillness. Do not move on until they do.]
If they ask what happened: “Amal had an overwhelming infection in her blood — we think meningococcal sepsis. It can move from a child being a bit unwell to critically ill within hours, and that is what happened today. The team gave her antibiotics and fluids the moment she arrived, but the infection had already affected her heart and circulation too severely.”
Examiner-cued mentions for this scenario: the Sudden Unexpected Death in Childhood (SUDC) process, the coroner, paediatric pathology, possible post-mortem, police involvement (routine for any unexpected child death — say that out loud), bereavement team, chaplain, and mementos (hand and footprints, lock of hair, photographs).
Sample script: unexpected cancer on imaging
Stem: a 45-year-old man attended with back pain. CT shows widespread liver and bone metastases, likely pancreatic primary.
“Mr Williams, I’m Dr Smith, one of the senior emergency doctors. Can I ask — what have you been told about the scan?”
“You’ve had a lot of investigations today. I’m afraid I have some difficult news about the CT.” [Pause.] “The scan has shown a number of growths in the liver and on the spine. We think these are most likely cancer, and that the original site is somewhere in the pancreas.” [Stop. Allow the silence.]
Avoid prognostic numbers, treatment plans, and false hope. You do not have histology and the oncology team will lead that conversation. Name what the scan shows, acknowledge the shock, hand over cleanly. End with: “I’ll ask the medical team to come and see you. They will admit you so we can plan the next tests. Is there someone I can call to come in?”
How do I handle the silence without panicking?
Three concrete tricks from the candidates who pass cleanly:
- Count to ten in your head. St Emlyn’s chapter 4 says it explicitly: “Silence is golden (but feels uncomfortable — count to 10 before speaking after breaking bad news).”
- Breathe out slowly. Your nervous system will calm and your body language will read as steady rather than fidgety.
- Watch their hands and eyes. When they look up and meet your gaze, or speak, the silence is over — not before. If they keep crying, the silence is not over. “I am so sorry” is the only acceptable filler.
What about angry relatives, conflict and denial?
Bad-news stations sometimes morph into conflict stations halfway through. The simulated relative may push back: “Why didn’t anyone listen when I said he was worse?” or “You should have done more.” The marks here are for staying calm, not getting defensive, and acknowledging the underlying feeling.
A reliable de-escalation script: acknowledge, apologise for the feeling (not necessarily for fault), explore, and offer a next step. “I can hear how angry you are, and I am so sorry that you feel let down. Can you tell me what specifically you are worried we got wrong? Whatever you tell me, I will make sure it is looked at properly — I can ask the matron to come and speak with you, and I will complete an incident form so it is investigated formally.”
Crucially: do not argue clinical detail in the moment, do not blame colleagues, and do not promise specific outcomes. Acknowledge, signpost (PALS, formal complaint, duty of candour), close.
What language should I never use?
- “Passed away” or “lost” — say died. Euphemisms cost marks and create ambiguity.
- “I know how you feel” — you don’t.
- “At least…” — there is no at least in a death conversation.
- “Everything will be okay” / “Don’t worry” — false reassurance is an automatic fail in the empathy domain.
- “We did everything we could” — only if you can specify what you did, otherwise it sounds defensive.
- Acronyms and jargon — no PEA, no STEMI, no SAH, no DNACPR (say “decision not to attempt resuscitation”), no “metastases” without “growths that have spread”.
Practical things I should do in the two-minute reading window
- Read the stem twice. Underline who you are, who they are, and the specific bad news.
- Decide your warning-shot sentence in your head. Rehearse the actual headline you will say.
- Plan one named next step (bereavement nurse, two-week-wait, paediatric ICU, social worker).
- Take a breath. Drop your shoulders. Walk in slowly.
Common candidate failure modes
- Talking too much. The bad news should be one short sentence after a one-sentence warning shot. Anything else delays the silence the examiner is waiting for.
- Reaching for tissues too fast. Liz Crowe at St Emlyn’s notes that pre-emptive tissues can read as “your grief is making me uncomfortable.” Have them visible, hand them over if asked.
- Trying to fix it. Strategy comes last, not first. Resist the reflex to jump to “the good news is the oncology team has lots of options” before the relative has even taken the headline in.
- Forgetting yourself. The closing minute of the station is the time to mention your own follow-up: “I’ll come back in twenty minutes to check on you” or “I am here for the rest of the shift, please ask the nurse if you want me back.”
- No safety net. Always: written information, named contact, follow-up clinic, bereavement service, GP letter, safeguarding referral if applicable.
FAQ
Is SPIKES really the only framework I need for the MRCEM OSCE bad news station?
Yes, for exam purposes. RCEMLearning explicitly recommends SPIKES “as a helpful strategy for exams” even though Charlotte Davies notes she does not always use it in clinical practice. BREAKS, PLIIIE and GRIEV_ING all map onto the same six functions; running one cleanly beats hybridising three.
How long should I spend on each SPIKES step in an 8-minute station?
Roughly: Setting and Perception 90 seconds, Invitation 30 seconds, Knowledge (warning shot, headline, silence) 90 seconds, Empathy 90 seconds, Strategy and Summary 2 minutes, closure and questions 1 minute. The Empathy section can and should expand if the relative needs it — sacrifice some Strategy detail rather than rush the silence.
Should I really say the word “died” rather than “passed away”?
Yes. The 2024 AEM Education and Training paper by Rivera et al. on SPIKES in the ED is explicit: “Instead of ‘passed away’ use the word ‘died’ when sharing the loss of a loved one.” Euphemisms create genuine confusion (some relatives do not initially register “passed” as final) and lose you marks for clarity.
What do I do if the relative becomes hysterical?
Stay. Do not leave the room, do not try to talk over them, and do not call for backup unless there is a safety concern. The St Emlyn’s guidance from Liz Crowe is to maintain engaged body language, stay quiet, and wait. When their grief subsides, offer to call someone for them. Hysterical grief is normal and expected — the examiner is watching you sit with it, not solve it.
How do I handle a language barrier in the station?
Insist on a professional interpreter, not a family member, for the actual headline. Say it out loud: “Before we go any further, I would like a professional interpreter — this is too important for any misunderstanding.” Marks are available for recognising the issue even if you cannot literally produce one in the room.
Do I break bad news in front of children?
If the stem puts children in the room, yes. Liz Crowe’s St Emlyn’s guidance is explicit: “there will be no protecting the children from this news.” Ask the surviving parent what they want, support that decision, and use simple, honest language. Never “gone to sleep” — that wording is harmful.
What if I am asked a clinical question I do not know?
“I don’t know, but I will find out.” Honesty scores. Do not invent prognostic figures or histology — offer to come back, or to bring the specialty team.
Should I mention organ donation?
Only if the stem signposts it (young patient, brain injury, ITU implied), and only after the family has absorbed the headline. Liz Crowe’s phrasing: “do you know if Mr X wanted to be considered for organ donation?” Marks are for raising it and signposting the Specialist Nurse for Organ Donation, not for taking consent.
How do I close cleanly?
Three-part close: summarise in one sentence, check understanding (“Is there anything you’d like me to go over again?”), and offer a concrete next contact (“I’m here until 8pm — ask Sarah if you want me back. The bereavement nurse will call tomorrow morning.”). Stand only when they do.
Is there a difference between the MRCEM OSCE and FRCEM OSCE bad-news stations?
The structure is the same. The FRCEM stations skew slightly more towards conflict, complaint, and difficult-referral scenarios; the MRCEM station is more commonly a clean breaking-bad-news scenario (death, new cancer diagnosis, child death). The SPIKES framework holds for both.
Where can I practise these stations realistically?
Pair up with another candidate and run timed eight-minute stations using the scenarios above, swap and feedback. Record yourself if you can stomach watching it back — Bridge Medical Courses specifically recommend this for hearing the robotic tones we all default to under pressure. RCEM Learning has free open scenarios, and the major commercial MRCEM OSCE courses (Bromley, Bridge, EM Skills Academy, Doctors Academy) all run dedicated communication days.
Next step
If you are sitting MRCEM OSCE in the next sitting, the highest-yield use of your remaining time is timed practice with a partner — not more reading. For structured walkthroughs of every other MRCEM OSCE station, browse the full pillar library at emfinalexams.com.
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