How do I deliver a 'warning shot' in SPIKES?

A warning shot is a short signalling phrase that prepares the patient for difficult news, such as 'I'm afraid the results are not what we were hoping for.' It gives the patient a moment to brace before details arrive.

What empathic statements work in the Emotions step?

Use NURSE statements: Name the emotion, Understand it, Respect it, Support, Explore. Examples include 'I can see this is overwhelming' and 'Anyone in your position would feel shocked.'

How long should a SPIKES consultation take in AMC Handbook AI RolePlay?

AMC Handbook AI RolePlay stations are around 8 minutes. Aim to spend roughly one minute on Setup and Perception combined, two minutes on Knowledge, three minutes on Emotions, and the remaining time on Strategy and Summary.

Can SPIKES be used outside of cancer diagnoses?

Yes. SPIKES applies to any difficult conversation — pregnancy loss, genetic disease, treatment failure, end-of-life discussions, unexpected death notification, and even disclosing medical errors.

AMC Handbook AI RolePlay Frameworks · Updated 2026

SPIKES Protocol: Breaking Bad News in AMC Handbook AI RolePlay Stations

A six-step communication framework every IMG should drill before the AMC clinical exam. Learn each step with example phrases an examinee can deliver under pressure in eight minutes.

Why SPIKES matters in AMC Handbook AI RolePlay

In AMC Handbook AI RolePlay counselling stations, you will routinely be asked to break bad news — a new cancer diagnosis, a miscarriage, a positive HIV test, a terminal prognosis, or news of an unexpected death. Examiners assess communication and professionalism as much as clinical content. A structured framework prevents you from rushing facts before the patient is ready, which is the most common reason candidates fail counselling stations.

SPIKES, developed by Baile and Buckman in 2000, is the most widely taught protocol for these conversations and maps cleanly to AMC marking domains.

The six steps of SPIKES

S — Setup. Arrange the environment before talking. Sit at eye level, ensure privacy, silence your pager, and offer tissues. Ask if the patient would like a support person present.
"Before we begin, would you like your husband to join us? I want to make sure we have privacy and time."
P — Perception. Find out what the patient already knows or suspects. This calibrates your language and avoids repeating or contradicting earlier clinicians.
"What have you been told about why we ordered the biopsy?"
I — Invitation. Ask permission to share results and check how much information they want.
"Are you the kind of person who likes all the medical detail, or would you prefer the broad picture first?"
K — Knowledge. Deliver a warning shot, then share the news in small chunks of plain English. Pause frequently. Avoid jargon.
"I'm afraid the news is not what we were hoping for. The biopsy has shown cancer cells in the breast tissue."
E — Emotions. Respond to feelings before facts. Use NURSE statements (Name, Understand, Respect, Support, Explore). Allow silence.
"I can see this is a huge shock. Take whatever time you need. I'm here."
S — Strategy and Summary. Agree clear next steps once the patient is ready. Summarise, offer written information, and arrange follow-up.
"Our next step is a referral to the breast surgeon this week. I'll write everything down and we'll meet again in three days. What questions do you have right now?"

Timing inside an 8-minute station

Step	Approximate time	Key examiner cue
Setup & Perception	1 minute	Privacy, sitting, opens with patient's understanding
Invitation	30 seconds	Asks permission before sharing
Knowledge	2 minutes	Warning shot, plain English, chunks
Emotions	2–3 minutes	Names emotion, allows silence, validates
Strategy & Summary	1–2 minutes	Concrete next step, written info, follow-up

Common mistakes IMGs make

Rushing into Knowledge before assessing perception or invitation.
Using jargon ("malignancy", "metastasis") without translation.
Filling silence with facts when the patient needs space.
Forgetting to arrange follow-up — examiners explicitly mark for safety-netting.
Closing too early without checking understanding.

Practise SPIKES with AI feedback

Mostly Medicine offers AI-powered counselling roleplays where you speak the consultation aloud and receive examiner-style feedback mapped to AMC domains. SPIKES is built into the marking rubric.

Start practising free →

Frequently asked questions

What does SPIKES stand for?

Setup, Perception, Invitation, Knowledge, Emotions, and Strategy/Summary — a six-step protocol developed by Baile and Buckman in 2000.

Is SPIKES tested in the AMC Handbook AI RolePlay exam?

Yes. Counselling stations involving bad news are a standard AMC Handbook AI RolePlay station type, and a SPIKES-style structure is the safest approach.

How do I deliver a warning shot?

Use a short signalling phrase that prepares the patient: "I'm afraid the results are not what we were hoping for." Pause briefly before details.

Which empathic statements work best?

NURSE statements — Naming the emotion, Understanding it, Respecting it, Supporting, Exploring. Combine with deliberate silence.

How do I close a SPIKES consultation in 8 minutes?

Summarise in two sentences, agree one concrete next step, offer written information, and confirm a follow-up time. Then ask "What questions do you have right now?"