If you’re planning to sit the PACES exam over the next few months, it’s really important to get in as much practise as possible beforehand. Get out there on the wards and see as many patients as possible, and even though you might feel foolish, presenting cases to yourself in a mirror and to colleagues will really help you to improve and refine your presentation skills. 

Our PACES subscription features a huge range of filmed patient cases to give you just the type of practice you need to succeed in the exam, and we’ve also put together the following ‘Breaking Bad News’ scenario which you can use to see how you’d fare if presented with a similar case in the exam. 

Breaking Bad News: Multiple Sclerosis

A 33-year old woman has a consultation with you to discuss the results of her recent MRI, which you had organised at her previous neurology appointment. She has a 3-year-old daughter but is actively trying for a second child. For the last 3 months she has noticed several episodes of visual disturbance and intermittent weakness of her legs. Her MRI is consistent with the diagnosis of multiple sclerosis.

Please discuss this result with her.

Preliminary thoughts

• The course of multiple sclerosis (MS) and its variable nature
• Morbidity and mortality of MS
• Implications with regard to pregnancy
• Treatment options including interferon and the NICE guidelines
• Inheritance of MS

A good candidate

• Will explore the patient’s knowledge of why she had the tests and MS
• Will not take all hope away and will explain the variable nature of MS

Goals for consultation

For her to understand:
• The diagnosis and its implications
• The need for a multidisciplinary approach
• The variable nature of progression of the disease; few patients progress rapidly
• Treatment options

Key points in the consultation:

• Introduction and establish a good rapport
• Ask if she wishes for anyone else to be present
• Explore the patient’s understanding of her condition and expectations/ suspicions of what may be wrong: ‘Did the previous doctors tell you why they were doing the MRI or what they thought was causing the weakness?’

Directions of the consultation:

Scenario A
The patient has never heard of MS and has no idea of its implications.
• The patient should be given small pieces of information in a logical manner; pauses are essential and give the opportunity for questions
• Patients can be given too much information in one consultation after receiving bad news. It is preferable to establish one or two key points
• Further consultations can address more detailed information. They may choose to bring a friend or relative

Scenario B
The patient is suspicious that MS is the cause and knows a great deal about it.
• A discussion about exactly what she understands and expects is important
• The Press tend to report the more disabling end of the disease spectrum, heightening patient anxiety
• Emphasise the variable progression of the disease. Often remitting/relapsing. There can be long periods with few symptoms. Few patients progress rapidly
• Discuss available treatment options such as steroids and interferon (in outline only)
• Discuss the implications for pregnancy and whether this should be pursued
– MS has no effect on fertility and does not affect pregnancy outcome
• Reassure her that it is not hereditary

Finishing

• Summarise what has been discussed
• Ask if there is anything that she would like repeated or if she has any questions
• Arrange follow-up and put her in touch with relevant support groups

Discussion

• Patients do not absorb masses of information from consultations. This is worse in stressful, anxious situations. For this reason it is preferable to give and repeat a little information well, to write it down if possible and to arrange to discuss issues further at the next appointment. Having a relative or friend present is reassuring and helps in the amount of information recalled
• It is best to give a little information well rather than a lot badly
• It is not necessary to discuss all of the details of MS in the first consultation