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Practice case P2-01 · Face-to-face · simulated patient

Breaking bad news — the abnormal chest X-ray

A 55-year-old smoker returns for a chest X-ray result. The report describes a mass.

Reviewed and kept current

Station family: Breaking bad news / explanation · 8-minute station · 1 min 30 s reading · Last editorial review: 19 September 2026 · Next scheduled refresh: 11 April 2027.

Candidate instructions

Read this as you would outside the room

You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.

Information
Your roleFoundation Year 2 doctor in a general practice
PatientMr John Edwards, 55, office manager
BackgroundSeen two weeks ago by a colleague with a three-month cough, about 5 kg of weight loss and occasional streaks of blood in his sputum. A chest X-ray was arranged.
Result in front of youChest X-ray report: “Right upper lobe mass, suspicious for malignancy. Urgent CT and respiratory referral advised.”
RecordsHypertension, on amlodipine 5 mg. Smoker. No known allergies.

Your task

•
Explain the result to Mr Edwards.
•
Discuss what happens next.
•
Address his concerns.
•
You are not required to examine the patient.
Folded away

For the actor and the examiner

1 · Actor script — role player only

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 “a few times”.

Only if asked

  • You smoke 20 a day and have done since you were 20. You have tried to stop twice.
  • No chest pain. A little 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.
  • The blood: only if asked how much or how often — this last week it has been most days, about a teaspoonful. Otherwise keep it until you are invited to add anything.

Impact on daily life — home and work (only if asked)

  • The cough wakes you and Carol most nights; you have moved into the spare room so she can sleep.
  • You get breathless carrying files up the stairs at work and have stopped playing five-a-side with your son.
  • You have told nobody at work. You are the main earner.

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?”
  • If you have not been told the result by minute 3: “Please — just tell me what it shows.”
  • 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.”

If the doctor summarises and asks whether you want to add anything

  • “There is one thing. I told the other doctor it was a few streaks — but this last week I’ve been bringing up blood most days. About a teaspoonful. I didn’t want to make a fuss.”
  • If this has already come out: “Only that Carol doesn’t know about the blood. How do I tell her?”

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.
  • If the doctor has not said what to do if things get worse, ask near the end: “And if I cough up more blood before I’m seen?”

Do not

  • Volunteer your father’s lung cancer or the fear of chemotherapy before minute 4 unless asked what worries you.
  • Volunteer that the bleeding is now daily unless you are asked how much and how often, or invited to add anything.
  • Ask about treatment details (surgery, chemotherapy regimens) — accept “the specialists will go through that once the tests are back”.
2 · Examiner mark sheet — generic scheme plus the key facts for this case

Domain marks — with the key facts that earn a 4 at this station

Domain (GMC wording) · key facts for this case1234Score
1 · Data gathering, technical and assessment skills
  • Finds out what he already knows and expects before giving the result
  • ICE: idea (infection), concern (cancer, dying, his family; his father’s death), expectation (antibiotics)
  • Impact on home and work — sleep, stairs, five-a-side; smoking quantified; who is at home
  • Red flags that change urgency: how much blood and how often, breathlessness, chest pain
☐☐☐☐/4
2 · Clinical management skills
  • Brief recap and check for anything to add, then the result in plain words — a shadow that could be a cancer
  • Working diagnosis: possible lung cancer (35 pack-years, blood, weight loss); infection, TB or scarring possible — an X-ray alone cannot say
  • Urgent suspected-cancer referral today — CT within days, answer in about 28 days; acts on the heavier bleeding; supervising GP; stop-smoking support
  • Safety-net: a tablespoonful of blood at once, increasing bleeding, worsening breathlessness or chest pain → 999/ED · Follow-up: FY2 or supervising GP within a week; rings us if no hospital contact in 7 days
☐☐☐☐/4
3 · Interpersonal skills
  • Unhurried; signposts that the news is serious; small chunks, checks after each
  • Tolerates silence; names the emotion; responds to the father and chemotherapy cue
  • No jargon and no false reassurance — realistic hope
  • Summarises, checks understanding, asks what he will tell Carol
☐☐☐☐/4
Station total/12

Domain score (educational construct):

ScoreDescriptor
1Unsatisfactory (did not achieve safe FY2 standard)
2Borderline (just achieving minimum safe FY2 standard)
3Satisfactory (competent and safe FY2 standard)
4Good (exceeds FY2 standard)

This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4.

3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here

The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

MarkDomain 1 · Data gathering, technical and assessment skillsDomain 2 · Clinical management skillsDomain 3 · Interpersonal skills
4
  • Checks identity and that he is happy to discuss the result now; offers to have someone with him
  • Establishes what he already knows and expects from the X-ray before giving the result
  • Brief, relevant update rather than a repeat history: cough, weight loss, breathlessness; smoking quantified
  • Red flags that change urgency: how much blood and how often (now most days, about a teaspoonful), breathlessness, chest pain
  • ICE: the idea (infection), the concern (cancer, death, his family) and the expectation (antibiotics); elicits his father’s death from lung cancer
  • Impact on daily living (credit before or after the news): sleep and the spare room, stairs at work, five-a-side with his son; who is at home and what support he has
  • Gives a brief recap of why the X-ray was done and checks whether he wants to add anything before hearing the result
  • Gives the result in plain words: “a shadow on the right lung that could be a cancer — we cannot tell from an X-ray alone”
  • Working diagnosis with justified differentials: lung cancer is the main concern because of his age, 35 pack-years of smoking, blood in the sputum and weight loss; infection (including tuberculosis or an abscess), scarring from an old infection or a benign growth are possible, but at 55 with 35 pack-years a mass with blood and weight loss is treated as cancer until proved otherwise — which is why this needs urgent tests rather than antibiotics and a repeat film
  • Next steps: urgent suspected-cancer referral to the lung clinic today — a contrast CT of the chest usually within days (he should keep the next four weeks free for tests), possibly a camera test or biopsy; bloods today; tells the supervising GP today
  • Acts on the heavier bleeding he has just disclosed: notes the amount and frequency, says his pulse, blood pressure and oxygen level will be checked before he leaves, includes it in the referral and discusses it with the supervising GP today
  • Explains that the aim is a diagnosis, one way or the other, within about four weeks of referral
  • Offers stop-smoking support as something that helps whatever the diagnosis; declines to speculate about treatment before the tests
  • Safety-net: coughing up a tablespoonful or more of blood at one time, bleeding that is heavier or more frequent than now, sudden or worsening breathlessness, chest pain, or feeling faint or acutely unwell → 999 or the emergency department; any new symptom before the clinic date → ring the practice the same day.
  • Follow-up: an appointment (telephone or face-to-face) with the FY2 or the supervising GP within the week to check the referral has gone through and to answer the questions he and Carol will have; written information and the practice number; if he has heard nothing from the hospital within seven days he rings the practice.
  • Setting: unhurried, sits forward, signposts that the news is serious
  • Delivers information in small pieces; checks after each
  • Tolerates silence; names and acknowledges the emotion (“this is a shock”)
  • Responds to the father cue and the fear of chemotherapy
  • No jargon; no false reassurance; offers realistic hope (“if it is a cancer, finding it quickly gives us the most options”)
  • Summarises, checks understanding, asks what he will tell Carol
3Perception checked and ICE largely elicited; one element thin — for example the amount of bleeding not quantified, or the impact on home and work not explored.Accurate explanation and urgent referral arranged; one of stop-smoking support, the specific safety-net or the follow-up missing.Empathic and clear; one missed cue or a rushed ending.
2Either the patient’s starting point or his concerns explored, not both; red flags not screened; or re-takes a full history and runs short of time.Referral mentioned but timescale or tests vague; no differential or reasoning offered; drifts into treatment detail; safety-net generic (“come back if worse”).Kind but formulaic — stock phrases, talks through the silence, or over-explains clinically while under-responding emotionally.
1Goes straight to the result; no exploration of understanding, concerns, impact or support. Or unsafe: no data gathered at all, or wrong patient / result not checked.States a definite diagnosis or prognosis from the X-ray, or the plan is routine rather than urgent; no safety-net and no follow-up. Or unsafe: false reassurance, or antibiotics and a repeat X-ray with no urgent referral; or no plan.Abrupt delivery, jargon, or the patient’s distress ignored. Or unsafe: dismissive, blaming (“well, you do smoke”) or dishonest.
4 · GMC feedback statements — where underperformance was identified — with case-specific examples

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. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

GMC feedback statementUnderperformance it signals (generic)Case-specific examples
1 · ConsultationDisorganised or unstructured consultationRe-takes the whole respiratory history, reaches the result at minute five and delivers the next steps in a rush — no recognisable shape of setting → what he knows → warning → news → emotion → plan.
2 · IssuesKey issues or priorities not recognisedRuns the station as a smoking-cessation or chest-infection consultation; does not recognise that the priority is an honest explanation of a possible cancer and an urgent referral.
3 · TimePoor time managementFour minutes on history already in the notes; the 28-day pathway, the safety-net and the follow-up never reached.
4 · FindingsAbnormal findings or results, or their implications, not identifiedReads the report aloud without interpreting it; does not register that the bleeding is now most days, or that “mass, suspicious for malignancy” with haemoptysis at 55 mandates a suspected-cancer referral.
5 · ExaminationPhysical examination or use of instruments not competentNot tested here — no examination is required. A candidate who stops to listen to his chest spends time the station does not have.
6 · DiagnosisWorking diagnosis or differential diagnoses not correctTells him it is “definitely cancer” or “probably just an infection”; cannot say why cancer is the leading possibility or what else it could be.
7 · ManagementManagement plan not reflecting current best practiceAntibiotics and a repeat X-ray in six weeks; routine rather than urgent referral; nothing about what to do if he coughs up more blood; no follow-up appointment.
8 · RapportRapport and sensitivity to the patient’s feelings and concerns not shown“I understand how you feel” and “try not to worry”, said to the screen; no acknowledgement of his shock, his father’s death or what this means for Carol and the children.
9 · ListeningVerbal and non-verbal cues not used; poor active listeningMisses “My dad had this”; talks through the silence after the word cancer; does not notice he has stopped taking anything in.
10 · LanguageLanguage or explanations not understandable; understanding not checked“The radiograph shows a lesion suspicious for malignancy so I’ll put you on the urgent suspected cancer pathway for CT and bronchoscopy” — and never checks what he has understood.
5 · Examiner points of fact and guidelines

Points of fact the examiner should have to hand

  1. A chest X-ray suggesting lung cancer warrants a suspected cancer pathway referral, which NICE now defines by the 28-day Faster Diagnosis Standard — cancer diagnosed or ruled out within 28 days of urgent referral (the separate two-week-wait standard ended in England in October 2023). The NHS England timed lung pathway expects CT within 72 hours of an abnormal X-ray. Unexplained haemoptysis at 40 or over is itself a referral criterion (NICE NG12).
  2. A chest X-ray cannot diagnose cancer. The honest position is “this could be cancer and needs urgent tests”. Diagnosis rests on contrast-enhanced CT and tissue sampling (NICE NG122).
  3. Differentials for a lung mass on X-ray: primary lung cancer, metastasis, pneumonia or abscess, tuberculosis, old scarring, benign tumour. Smoking history, haemoptysis and weight loss together make cancer the leading possibility.
  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. There is no agreed UK volume threshold for haemoptysis. A stable patient with small-volume bleeding is referred on the urgent suspected cancer pathway; increasing volume (a tablespoonful or more at once), new or worsening breathlessness, chest pain or abnormal observations need same-day assessment, and large-volume haemoptysis is an emergency. NHS advice to the public is more cautious still — 999 or A&E for more than a few spots or streaks. His observations should be checked before he leaves today.
  6. Strictly, NICE NG12 supported a suspected-cancer referral at the first visit (unexplained haemoptysis at 40 or over). If he asks why he was not referred then: be honest, do not criticise a colleague, apologise for any delay and tell the supervising GP.
  7. An FY2 in general practice would tell the supervising GP the same day. Saying so earns credit; it is not a weakness.
  8. 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 four weeks.
  • Ending without saying what to do if the bleeding gets worse.

Guidelines for this station

6 · MLA content map tags for this case
MLA content mapThis station
Domain 1 · Areas of clinical practiceCancer · Respiratory · Clinical imaging
Domain 3 · Clinical and professional capabilitiesCommunication with patients, relatives and carers · Investigations: request, interpret, act · Complexity, uncertainty and prioritisation
Domain 5 · Patient presentationsCough · Haemoptysis · Weight loss
Domain 6 · ConditionsLung cancer
Appendix A · Body systemLungs, pleura and airways
Interpersonal skill (GMC PLAB 2 guide)Breaking bad news · Explaining diagnosis, investigation and treatment · Dealing with anxious patients or relatives
Station familyExplanation, counselling and breaking bad news — Breaking bad news / explanation
7 · My marks and reflection — practice log form

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

Revision link for this case: mdacumen.com/plab-2-osce/case-01-breaking-bad-news-chest-x-ray

All practice cases P2-02 →

Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional. This course never provides, and will never ask you to share, real GMC exam content — full regulatory statement: Legal & Regulatory.

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