Script with golden words (Preview)

Scenario: Spinal Metastasis – Missed CT Biopsy – Daughter Now Needs Counselling

Setting:
Mr. Hamid, a 68-year-old gentleman, presented two months ago with severe lower back pain. Initial MRI spine suggested possible discitis versus metastasis. At the time, a CT-guided biopsy was recommended, but the patient refused due to fear and wanted to try antibiotics first. He was managed as discitis and initially seemed better. He has now re-presented with worsening pain, some leg weakness, and weight loss. Repeat MRI shows vertebral collapse and features highly suggestive of spinal metastasis. A review by the oncology team has advised urgent CT of the abdomen and pelvis to look for a primary source, and a repeat attempt at spinal biopsy to confirm the diagnosis before starting treatment. The patient is unable to decide now due to drowsiness from analgesia. His daughter is the next of kin and needs to understand the seriousness and help with decisions.

Task for Doctor:
 Please speak with the daughter, explain the current situation, the need for CT and biopsy, and try to obtain consent to proceed with the investigations

Dialogue Flow

Doctor Islam:
Miss Hamida, thank you for sitting with me. I understand this has been a difficult time for your father and for you as well.

Daughter:
Yes. He was doing better before. Why has it gotten worse again?

Doctor Islam:
I wish the situation were different. When he first came, we had two possibilities. One was an infection in the spine; the other was cancer spreading to the spine. Since he did not want the biopsy then, we tried treating the infection, but unfortunately, his condition has worsened.

Daughter:
So now you are saying it was not discitis?

Doctor Islam:
We are very concerned now that this is due to cancer spreading to his bones. The latest Imaging (MRI) shows damage to the vertebra that does not look like infection. To help him further, we need to find out where the cancer started and confirm it with a small chunk of tissue-called a biopsy.

Daughter:
But last time he was scared. And now he is drowsy. Why can you not just treat?

Doctor Islam:
I understand that. But treatment like chemotherapy or radiotherapy needs an accurate diagnosis. Giving the wrong treatment without confirmation could do harm. Also, if we can find where the cancer started, some treatments may improve his symptoms and slow it down.

Daughter:
What are you planning to do?

Doctor Islam:
We would do a CT scan of his abdomen and pelvis to look for where the cancer may have come from; often it is from the lungs, prostate, or bowel. And an Image (CT)- guided biopsy from the spine will tell us for sure what cells are involved.

Common Concerns & Dr Mamun’s Suggested Responses

• Concern: Why are you doing the scan now when you did not confirm it earlier?
  Dr Mamun: That is a valid concern. We always offer the least risky option first. At the time, your father did not consent to the biopsy, so we respected that and tried treatment. Now that things have worsened, it is time to re-investigate more urgently.

• Concern: Is the biopsy painful or risky?
  Dr Mamun: It is done under a local Numbing agent (anaesthetic), with an Image  (CT scan) guiding the needle. The risks are small, and most people tolerate it well. The benefits in terms of diagnosis are very important.

• Concern: Is this cancer curable?
  Dr Mamun: If it has spread to the spine, it is less likely to be cured fully. But many treatments can help control symptoms, prevent further weakness, and give a better quality of life.

• Concern: He is not in his senses now. Can I even make that decision?
  Dr Mamun: Since you are the next of kin, we want to involve you as much as possible. This is about acting in his best interest, and we think he would have wanted treatment to continue if it gives him some hope.

NICE Guideline

•  Recommends urgent imaging and biopsy for patients with unexplained spinal pain and suspicion of malignancy
• Shared Decision-Making: Involve relatives where capacity is lacking; decisions must be in the best interest
• Recognition of serious spinal pathology: When symptoms worsen despite antibiotics, malignancy must be reconsidered, and CT-guided biopsy is standard

Tips for Doctor: 

• Start by acknowledging emotional distress: I can see this is frustrating
• Avoid sounding like blame: Your father did what he felt was right at the time
• Be clear about what next steps are for: Not just diagnosis, but to guide possible treatment
• Use plain terms: Avoid words like ‘malignancy’; say cancer
• Do not rush to a prognosis; wait for her to ask
• Keep body language open, calm, and non-defensive
  

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MRCP PACES Communication Scenario

Case: Congenital Myotonic Dystrophy

Scenario:

You are asked to meet Mrs Sultana, a 27-year-old mother, whose newborn baby girl is in the neonatal unit. The baby was born at term but was noted to be very floppy and had difficulty with feeding and breathing. She required oxygen support soon after birth. The neonatal team performed several tests; blood sugar and infection markers were normal. A genetic test sent urgently confirmed the diagnosis of Congenital Myotonic Dystrophy. This condition is usually inherited from a parent and affects the muscle function of the baby. The consultant has asked you to explain the diagnosis to the mother, discuss the immediate plan of care, and address her concerns. The baby’s grandmother is also present in the room for support. Both appear tearful and anxious.

Task for Doctor:
Your task is to explain the diagnosis in clear and simple words, outline the treatment and follow-up plan, and respond empathetically to the mother’s worries, while being honest about the condition’s seriousness.

Dialogue Flow:

Doctor Islam:
Good afternoon Mrs Sultana. I am Doctor Islam, one of the children’s doctors. I know this has been a very difficult time for you and your family. I would like to explain what we have found and how we plan to support your baby.

Mrs Sultana:
Doctor, why is my baby so weak? Did I do something wrong?

Doctor Islam:
I understand how upsetting this is. From the tests, we found that your baby has a condition called Congenital Myotonic Dystrophy. In simple words, the muscles are weaker and floppier than normal, which makes breathing and feeding more difficult. This happens because of a defect/change in the genes that control muscle strength. It is not caused by anything you did in pregnancy.

Mrs Sultana:
Is this condition treatable?

Doctor Islam:
We cannot cure the condition, but we can support your baby. Right now, the team is helping with breathing and feeding. As your baby grows, we will involve physiotherapists, speech and feeding specialists, and sometimes breathing support if needed. We will also refer you to a genetics team, as this condition can run in families.

Mrs Sultana:
Will my baby survive?

Doctor Islam:
Some babies do face serious difficulties in the first few months. However, many with good medical care live into adulthood, though they often need extra support. We will continue to update you daily and make sure you are involved in all decisions.

Anticipated Concerns and Dr Mamun’s Suggested Responses

• Concern: Did I cause this problem by something I did during pregnancy?
  • Dr Mamun: No, you did not cause this. It is due to a genetic change that is passed in families. Pregnancy actions or diet do not cause it.

• Concern: Could my next child also have this?
  • Dr Mamun: Yes, there is a risk. That is why we refer you to genetic counselling, where you will be given clear advice about future pregnancies.

• Concern: Will my baby ever be normal like others?
  • Dr Mamun: Children with this condition often have challenges with muscle strength and development. But with support from specialists, many improve and achieve milestones, though at a slower pace.

• Concern: How long will my baby need to stay in the hospital?
  • Dr Mamun: It depends on how quickly the baby learns to feed and breathe safely. Some need weeks, others longer. We will keep you updated every day.

• Concern: Are we alone in this?
  • Dr Mamun: You are not alone. We will link you with support groups and families with similar experiences. Our genetics and children’s teams will support you throughout.

 Team Plan:

• Neonatal supportive care: oxygen, feeding tube as needed
• Referral to physiotherapy, speech, and feeding support
• Cardiac and respiratory monitoring for complications
• Genetic counselling for parents and family screening
• Social work and psychology input for emotional support
• Regular follow-up with paediatric neurology

Tips for Doctor:

• Begin with empathy; acknowledge the mother’s guilt and fear before details
• Use plain words; say weak and floppy muscles instead of hypotonia
• Involve the grandmother; relatives are often equally anxious
• Avoid overloading with prognosis; focus on current support and safety
• Offer both verbal explanations and written information
• Emphasise daily updates from the neonatal team
• Mention referral to genetics early, as guideline  highlights its importance

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MRCP PACES Communication Scenario

Case: Parkinson’s Disease patient with swallowing difficulty

Scenario:

You are asked to meet Mr Rahman’s son. Mr Rahman is a 79-year-old gentleman with advanced Parkinson’s disease. He has been in the hospital for 10 days with repeated choking episodes and weight loss due to difficulty swallowing. A speech and language therapist assessment confirmed severe swallowing impairment, and he has been receiving a modified diet and careful feeding support. The son is very distressed and has requested a PEG tube (feeding tube through the stomach). The treatment team, including the consultant and palliative care,  feel that a PEG tube would not improve his quality of life or survival given the advanced stage of Parkinson’s and risk of complications. They have asked you to explain the situation to Mr Rahman’s son and address his concerns. Mr Rahman is sitting quietly in the room with his son, appearing frail but alert.

Task for Doctor:
Your task is to explain the reasons behind the team’s decision not to insert a PEG, discuss alternative care and feeding approaches, and support the son emotionally while involving the patient.

Dialogue Flow

Doctor Islam:
Good afternoon, Mr Rahman, Mr Rahman junior. I am Doctor Islam, part of the team looking after you. I know this has been a very difficult time for both of you. I would like to talk about your father’s feeding difficulties and the options we have discussed as a team.

Son:
Doctor, my father keeps choking. I want a PEG tube so he can eat safely.

Doctor Islam:
I understand how worrying it is to see your father struggle. We asked the speech and language specialist to assess him, and they found that his swallowing muscles are very weak because of his Parkinson’s disease. We considered a PEG tube carefully. The concern is that in advanced Parkinson’s, a PEG does not stop aspiration; food and liquid can still go into the lungs. It also carries risks such as infection and discomfort, without improving quality of life.

Mr Rahman:
I do not want to suffer more.

Doctor Islam:
We want to keep you comfortable and safe. That is why we are recommending careful hand feeding with modified food textures and close monitoring. We will also involve the palliative care team to support you with nutrition, comfort, and dignity.

Son:
So you are refusing to do the PEG?

Doctor Islam:
It is not about refusing, but about what is safest and kindest for your father. The whole team agrees that a PEG would not help him and may even cause harm. We want to focus on keeping him as comfortable and dignified as possible.

Anticipated Concerns and Dr Mamun’s Suggested Responses

• Concern: Without a PEG, will he starve to death?
  • Dr Mamun: No, he will not be left hungry. We will continue careful hand feeding, using textures he can manage, and ensure comfort. The goal is dignity and quality of life.

• Concern: Are you giving up on him?
  • Dr Mamun: Not at all. We are focusing on the best care for him. Sometimes adding procedures does not help but increases suffering. We are not giving up; we are supporting him differently.

• Concern: Could a PEG prolong his life?
  • Dr Mamun: In advanced Parkinson’s, PEG often does not prolong life meaningfully because the underlying problem is the disease progression. It also does not prevent aspiration pneumonia.

• Concern: My father wants to live longer. Should we not do everything possible?
  • Dr Mamun: We respect that. But our duty is also to avoid treatments that bring more harm than benefit. PEG here may cause more complications without helping.

• Concern: Will he suffer from thirst or hunger?
  • Dr Mamun: We will ensure good mouth care, offer sips safely, and adjust his diet to what he can tolerate. Comfort is our priority.

Team Plan:

• Continue modified diet and careful hand feeding
• Involve speech and language therapy and dietitian support
• Engage palliative care for comfort, symptom relief, and family support
• Regular review of swallowing ability and nutritional status
• Emotional and psychological support for the patient and family

Tips for the Doctor:

• Start with empathy; acknowledge the son’s distress before medical details
• Use plain words; say feeding tube into tummy (stomach) instead of PEG
• Involve the patient, even if frail, to respect autonomy
• Emphasise quality of life and dignity as guiding principles
• Be calm and compassionate; relatives often feel guilt or helplessness
• Offer written information and support services
• Reinforce that the team’s decision is based on guidance and best interest