Breaking bad news — the abnormal chest X-ray

Candidates: do not open until you have consulted.

Persona and manner

• John Edwards, 55, office manager for a haulage firm. Married to Carol; two teenagers, 14 and 17.
• Friendly, slightly jokey on the surface; underneath you are anxious. You have been telling yourself it is “just a smoker’s cough”.

Opening line — say this verbatim

• “Doc, have you got my results? Tell me I’m all right.”

Volunteer freely if given the space

• The cough has been there about three months and is not shifting.
• You have lost weight — your belt is two notches tighter — without trying.
• You have seen streaks of blood in your phlegm four or five times.

Only if asked

• You smoke 20 a day and have done since you were 20 (about 35 pack-years). You have tried to stop twice.
• No chest pain. Slightly more breathless on the stairs. No hoarse voice, no swallowing problems, no bone pain, no headaches.
• Hypertension only; amlodipine; no allergies.
• Your father died of lung cancer at 62. You watched him go through chemotherapy and “it was the treatment that finished him”.
• Carol does not know you have been coughing blood.

Ideas, concerns and expectations

• Idea: a chest infection that needs stronger antibiotics.
• Concern (only if the doctor asks what is worrying you, or after the news): “Is it cancer? Am I going to die?” — and what happens to Carol and the children. You are frightened of chemotherapy because of your father.
• Expectation: antibiotics and reassurance.

Cues to deliver, timed

• Around minute 1–2, if the doctor launches straight into the result without checking what you know: look confused and say “hang on — what are you saying?”
• When you hear “mass”, “shadow” or “growth”: go silent for several seconds, look down, then ask quietly “Is it cancer?”
• Around minute 5: “My dad had this. I watched what the chemo did to him.”

How to respond to the doctor

• If the doctor gives a warning shot, goes slowly, tolerates your silence and is honest that cancer is a possibility that must be checked urgently: you are upset but you trust them — “Right. So what happens now?”
• If the doctor says it is definitely cancer, or definitely not: challenge — “How can you know that from an X-ray?”
• If the doctor gives false reassurance (“I’m sure it’s nothing”): brighten — “So I don’t need to worry then?” — and do not raise your fears again.
• If the doctor uses jargon (“malignancy”, “lesion”, “two-week wait”): “What does that mean?”
• If asked whether you would like someone with you or to be phoned: you would like Carol told, but you want to do it yourself tonight.
• If smoking is raised kindly: “I suppose I’ve got a reason now.” If it is raised as blame: go quiet and defensive.

Do not

• Volunteer your father’s lung cancer or the fear of chemotherapy before minute 4 unless asked what worries you.
• Ask about treatment details (surgery, chemotherapy regimens) — accept “the specialists will go through that once the tests are back”.

Domain marks

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory   ☐ Borderline   ☐ Satisfactory   ☐ Good

What each mark means

GMC feedback statements — where underperformance was identified

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. Tick every statement that applied; leave all blank if none did.

Timing checkpoints (observer)

Full explanation: the mark scheme and how PLAB 2 is passed · anatomy of the 8-minute station.

Use with the generic sheet. The top row lists what a competent F2 would do at this station; lower rows describe how performance falls away. Acumen training standard — the GMC does not publish station mark sheets.

Points of fact the examiner should have to hand

1. A chest X-ray suggesting lung cancer in an adult warrants a suspected cancer pathway referral (appointment within two weeks). Unexplained haemoptysis at 40 or over is itself a referral criterion (NICE NG12).
2. In England the Faster Diagnosis Standard aims for cancer to be diagnosed or ruled out within 28 days of urgent referral.
3. A chest X-ray cannot diagnose cancer. The honest position is “this could be cancer and needs urgent tests”. Diagnosis rests on contrast CT and tissue sampling (NICE NG122).
4. He is 35 pack-years (20 a day × 35 years ÷ 20). Stopping smoking improves outcomes whatever the diagnosis; offer behavioural support plus pharmacotherapy (NICE NG209).
5. An F2 in general practice would tell the supervising GP the same day. Saying so earns credit; it is not a weakness.
6. SPIKES is a scaffold, not a script: Setting · Perception · Invitation · Knowledge · Emotions · Strategy and summary.

Where candidates lose marks at this station

• Re-taking the whole history and reaching the result at minute 5.
• “I’m sure it’s nothing to worry about.”
• Filling the silence after the word “cancer”.
• Explaining chemotherapy instead of the next fortnight.

Guidelines for this station

• NICE NG12 — Suspected cancer: recognition and referral
• NICE NG122 — Lung cancer: diagnosis and management
• NICE NG209 — Tobacco: preventing uptake, promoting quitting and treating dependence
• GMC — Decision making and consent

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-01