Counselling · Intermediate · Haematology

Breaking Diagnosis of Acute Leukaemia and Discussing Treatment

Practise this PLAB 2 counselling station on Acute Lymphoblastic Leukaemia. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor working with the haematology consultant. Mr Brian Radcliffe, a 34-year-old previously fit man, has presented with fatigue, bruising, and bleeding gums. His blood tests show acute lymphoblastic leukaemia. He has been waiting for this appointment to hear his diagnosis and discuss what comes next. His wife is with him for support. Please break the diagnosis sensitively and discuss treatment options.

Background notes: PMH: Completely healthy until present illness, Childhood: measles, chicken pox, Adolescence: Glandular fever age 17 (recovered)

What this station tests

  • SPIKES framework: Perception, Invitation, Knowledge delivery, Empathy, Summary/Strategy
  • Allowing silence after delivering the diagnosis: not rushing to fill emotional space with information
  • Fertility preservation counselling: sperm banking before chemotherapy is time-critical and commonly missed
  • Providing honest, proportionate hope: ALL cure rates of 50 to 60% in young adults, not false reassurance but genuine optimism
  • Including the spouse: acknowledging Emma's distress, offering family support resources, directing information to both

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Breaking a cancer diagnosis to a young, previously healthy adult is among the most emotionally demanding PLAB 2 stations. The candidate must deliver devastating news using a structured approach (SPIKES) while maintaining the patient's trust and hope. Mr Radcliffe is 34, previously fit, presenting with fatigue, bruising, and bleeding gums. Bloods confirm acute lymphoblastic leukaemia. His wife is present. He has been googling his symptoms and suspects leukaemia. Open with: 'Mr Radcliffe, thank you for coming in with your wife. I have the results of your blood tests and I want to go through them with you. Before I do, can you tell me what you have been told so far?'

Core approach

Assess his perception first (SPIKES: Perception). He has googled his symptoms and suspects leukaemia. Knowing this allows you to gauge how to pitch the news. Ask how much he wants to know (Invitation): 'Some people want all the details, others prefer the big picture first. What would work best for you?'

Deliver the diagnosis clearly. Give a warning shot: 'I'm afraid the results show something serious.' Then state it: 'The blood tests show that you have a type of blood cancer called acute lymphoblastic leukaemia.' Stop. Allow silence. Do not rush to fill it with information. He may become very quiet, cry, or say 'I knew it.' His wife may react strongly. Respond to the emotion before continuing (SPIKES: Empathy): 'I know this is devastating news. Take the time you need.'

When he is ready, provide key information in small chunks. ALL is treatable: cure rates in adults under 40 are approximately 50 to 60% with intensive chemotherapy. He will need admission for treatment soon. Treatment involves cycles of chemotherapy over approximately 2 to 3 years. He will lose his hair (he may ask). He may need a stem cell transplant depending on response.

Address fertility immediately. He and his wife were planning to start a family. Chemotherapy is likely to affect his fertility. Sperm banking must be arranged urgently before treatment starts. This is time-critical and commonly missed.

Closing and safety netting

Summarise the next steps concretely. Admission within days for bone marrow biopsy and first cycle of chemotherapy. Sperm banking before treatment starts. Specialist haematology team will provide detailed treatment plan. He will have a named nurse and access to psychological support.

Address his wife directly: 'Emma, I know this is incredibly difficult for you too. There is support available for families as well.' Offer Macmillan Cancer Support and Leukaemia Care as immediate resources. Provide honest hope: 'ALL is one of the most treatable blood cancers, and we have very effective treatments. The next few months will be tough, but many people come through this.'

Safety net: 'If you develop high fever, severe bleeding, or feel very unwell before your admission date, come to A&E immediately and tell them you have acute leukaemia.' Arrange follow-up within 48 hours.

How examiners mark this station

Examiners will assess your ability to explain acute lymphoblastic leukaemia and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Supporting)

Scores well: Assessing his perception (what he already suspects). Checking how much he wants to know. Understanding his family context (wife, family planning).

Costs marks: Not checking his perception. Not asking about his information preferences.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Accurate diagnosis delivery. Correct prognosis (50-60% cure rate). Fertility preservation urgently arranged. Treatment outline (chemotherapy, possible transplant). Support resources named. Safety netting for neutropenic sepsis.

Costs marks: Inaccurate prognosis. Not mentioning fertility. No treatment outline. No safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Warning shot given. Silence allowed. Empathic response to emotion. Wife included. Honest hope provided. SPIKES framework applied. Practical next steps alongside emotional support.

Costs marks: No warning shot. Talking through the silence. Ignoring the wife. False reassurance or no hope.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Delivering the diagnosis without a warning shot. Saying 'you have leukaemia' without preparation causes unnecessary shock. The warning shot ('the results show something serious') prepares the patient emotionally.
  2. Not allowing silence. After delivering the news, the instinct is to immediately explain treatment options. The patient needs time to process. Silence is therapeutic. Candidates who talk through the emotional response score poorly on Domain 3.
  3. Not mentioning fertility preservation. He and his wife were planning to start a family. Chemotherapy will likely affect his fertility. Sperm banking before treatment is time-critical. Candidates who discuss treatment without mentioning fertility miss a life-altering counselling point.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

How do I open and run an acute lymphoblastic leukaemia counselling station in PLAB 2?

Breaking a cancer diagnosis to a young, previously healthy adult is among the most emotionally demanding PLAB 2 stations. The candidate must deliver devastating news using a structured approach (SPIKES) while maintaining the patient's trust and hope. Mr Radcliffe is 34, previously fit, presenting with fatigue, bruising, and bleeding gums.

What does a strong performance look like to the examiner in this station?

Strong performances show: Assessing his perception (what he already suspects). Checking how much he wants to know. Understanding his family context (wife, family planning). Weak performances: Not checking his perception. Not asking about his information preferences.

What is the biggest pitfall in this acute lymphoblastic leukaemia station?

Delivering the diagnosis without a warning shot. Saying 'you have leukaemia' without preparation causes unnecessary shock. The warning shot ('the results show something serious') prepares the patient emotionally.

How should I prepare for acute lymphoblastic leukaemia if I have never seen it in practice?

Structure beats experience here. Focus on allowing silence after delivering the diagnosis: not rushing to fill emotional space with information. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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