Why This Station Is Tested
Breaking bad news by telephone is an increasingly common clinical scenario — results calls, abnormal imaging notifications, and urgent review requests all happen by phone. This station tests your ability to adapt your communication skills to a medium where you cannot see the patient's face, assess body language, or be physically present to support them.
The Limitations of Telephone Bad News
Before starting, acknowledge the inherent challenges:
- You cannot assess non-verbal cues
- The patient may be in a public place or not alone
- There is no chaperone, no tissue, no physical presence
- Confidentiality must be established immediately
SPIKES — Adapted for Telephone
| Step | Telephone Adaptation |
|---|---|
| S — Setting | Confirm identity, check they are somewhere private, ensure they have someone with them if possible |
| P — Perception | Ask what they've been told to expect: "Do you know why I'm calling today?" |
| I — Invitation | "Would it be alright to speak with you now about your results?" |
| K — Knowledge | Fire a warning shot: "I'm afraid the results have come back and the news is not straightforward" — then pause |
| E — Emotions | Listen for verbal cues: silence, crying, sharp intake of breath. Acknowledge: "I can hear this is very hard to take in" |
| S — Strategy | Agree next steps; arrange face-to-face follow-up as soon as possible |
Preparation Before the Call
- Review the results and patient notes thoroughly beforehand
- Confirm the right number and best time to call
- Ensure you have a colleague or senior available if needed
- Have the patient's details in front of you
- Block out enough time — never call between clinics with 3 minutes to spare
💡 Tip
Never give a cancer diagnosis without arranging immediate follow-up. The purpose of the telephone call may be to inform the patient of an abnormality and to arrange an urgent face-to-face appointment — not necessarily to give the full diagnosis over the phone.
Opening the Call
- 1Introduce yourself: name, role, organisation
- 2Confirm patient identity: name, date of birth, address (one identifier is insufficient)
- 3Privacy check: "Are you somewhere private where you're comfortable to talk?" / "Is there anyone with you?"
- 4Consent to proceed: "Is it a convenient time to speak with you about some results we have back?"
Warning Shot and Information Giving
*"I'm calling about your recent [test/scan/biopsy] results. I'm afraid the news isn't straightforward — are you sitting down?"*
Pause. Allow silence. Give the core information in one clear sentence then stop:
*"The results show that there is a growth/abnormality/cancer present and we need to discuss the next steps with you."*
Pause again. Do not continue until you have acknowledged their response.
Responding to Emotions on the Phone
Listen for verbal cues (silences, crying, questions, anger). Respond with:
- Empathy: *"I'm so sorry. This must be very hard to hear."*
- Normalisation: *"It's completely understandable to feel overwhelmed right now."*
- Silence: allow it — do not fill every pause
- Practical: *"Would you like me to call back when you have someone with you?"*
Closing the Call
- Summarise what was said: *"So to summarise, the results show X and the next step is Y."*
- Arrange follow-up: *"I'd like to see you in person as soon as possible — can you come in [date]?"*
- Safety-net: *"If anything comes up before then, or you have any questions, please call us on [number]."*
- Ask if they have someone with them: *"Is there someone at home with you?"*
- Document: time, content, who was informed, follow-up arranged
Frequently Asked Questions
"What are the most important differences between breaking bad news in person vs by telephone?"
The core differences are: you cannot observe non-verbal cues (facial expression, posture, tears) so you must listen more carefully to tone of voice, breathing, and pauses; you cannot provide physical comfort or ensure the patient is safe; you cannot guarantee privacy; and you have no chaperone. These limitations mean telephone bad news should be reserved for situations where an in-person appointment cannot be arranged in a timely way, or where the patient has explicitly requested results by phone. In an OSCE telephone station, demonstrating awareness of these limitations by asking about privacy and support before delivering news scores heavily on the global communication domain.
"How do you confirm patient identity before giving results by phone?"
You must confirm identity using at least two identifiers before disclosing any clinical information. Ask for: full name, date of birth, and ideally a third identifier (address or NHS number). Never rely on the caller knowing the patient's name alone — relatives, friends, or carers may have called from the patient's phone. If the person answering cannot confirm their identity, politely decline to give the result and arrange an alternative time to call when the patient is available. In an OSCE, the examiner is specifically marking whether you check identity before proceeding — skipping this loses marks for patient safety.
"When is it acceptable to give bad news by telephone?"
Telephone bad news is acceptable when: an urgent face-to-face appointment cannot be arranged quickly enough (e.g., high-risk biopsy result requiring same-day action), the patient has explicitly consented to receiving results by phone, or the news is concerning but not a confirmed cancer diagnosis (e.g., "Your scan shows an abnormality and I'd like you to come in urgently to discuss it — I can't go into full detail over the phone"). It is generally not acceptable to give a new cancer diagnosis over the phone without a planned face-to-face follow-up arranged immediately after. In an OSCE, if asked whether it is appropriate to call, demonstrate your awareness of the clinical context.
"What should you do if the patient becomes very distressed during a telephone bad news call?"
First, stop talking and allow silence — do not rush to fill it with information. Acknowledge the emotion directly: "I can hear how distressing this is. Take your time." Ask if they are alone and whether they'd like someone with them before continuing. Offer to call back in 10 minutes once they've had a chance to compose themselves, or offer to arrange for a family member to call in on them. Check for immediate safety: "Are you feeling safe at the moment?" If there is any concern about self-harm, escalate immediately — contact a colleague, consider contacting their GP, or advise them to call 999. Document everything meticulously, including the time, who was spoken to, and what was said.
"What safety-netting must you always provide at the end of a bad news telephone call?"
Safety-netting must include: the specific follow-up plan with date, time, and location ("I'd like you to come and see me on [date] at [time] at [clinic]"); a contact number to call if questions arise before then or if they feel unable to cope; signposting to support services (Macmillan Cancer Support, Samaritans 116 123, their own GP); and checking whether they have someone at home to be with them that evening. If the patient will be driving home after the call or is alone, consider whether a welfare check is appropriate. Document the safety-netting provided in the medical notes, including the patient's response to the news.
"How do you handle it if the patient refuses to come in for a face-to-face appointment after bad news?"
Explore the reasons behind refusal — it may be fear, practical barriers (transport, work), or disbelief. Acknowledge their concern: "It sounds like you might be worried about what we'd say in person." Explain the importance clearly without pressuring: "I want to make sure you have all the information and support you need, which is much easier to do together in the same room." Offer flexibility — can you see them at home, at a different time, with a family member present? If they still decline after thorough exploration, respect their autonomy, document the conversation, and arrange a further call. Inform your senior and consider safeguarding implications if there is a risk to their health from delayed treatment.
Related guides: Breaking Bad News OSCE Guide · Telephone Consultation OSCE · Angry or Distressed Patient OSCE · Consent and Capacity OSCE · Explaining a Diagnosis OSCE