Delivering a New Leukemia Diagnosis to a Family in the Emergency Department
7m 10s encounter
This is a real, unedited encounter from the platform — the same read-only feedback page a learner sees after a session.
The scenario
Your role
You are the Pediatric Hematology-Oncology fellow caring for Ethan, a previously healthy 7-year-old boy with new findings concerning for leukemia.
Ethan Morales, a previously healthy 7-year-old, came to the emergency department with two weeks of fatigue, bruising, intermittent fevers, and leg pain. His bloodwork shows pancytopenia with circulating blasts, concerning for acute lymphoblastic leukemia.
The diagnosis is not yet confirmed — a bone marrow biopsy is planned for the following morning to confirm it and guide treatment. Ethan's mother, Sofia, has been told only that the results are concerning. She has been waiting for hours.
You are meeting Sofia one-on-one in a quiet consultation room off the pediatric ED to disclose the likely diagnosis, explain the admission and the bone marrow biopsy, and support her through the news.
You are speaking by voice with Sofia Morales, Ethan's mother — a warm, polite, frightened parent who has been waiting for hours and is desperate to understand what is wrong with her son.
Objectives
- Deliver a serious new diagnosis clearly and compassionately, using a warning shot and plain language.
- Assess and respond to the family's understanding and emotional state throughout the encounter.
- Explain diagnostic uncertainty and the immediate next steps, including admission and bone marrow biopsy, in understandable terms.
- Respond empathically to grief, guilt, and fear, including the question of whether the child will die.
- Organize complex information into manageable segments while preserving realistic hope.
Listen to the recording
Hear the full 7m 10s encounter
▶Transcript25
Thank you for waiting, doctor. They keep telling me his bloodwork is concerning but nobody will tell me what that means. Please, just tell me what is going on with my son.
Hi, Sophia. This is Dr. Rissman. I am a pediatric hematology oncology fellow taking care of Ethan. Um, before I share with you a bit about what I know now, I would love to hear a bit about what you've been seeing and what you understand.
Of course, doctor... thank you for coming in. Um, for about two weeks now Ethan has been so tired, not himself at all. He's had these bruises showing up that I couldn't explain, and fevers that come and go, and he keeps complaining his legs hurt. I thought... I thought it was a virus, maybe growing pains... I feel terrible I didn't bring him in sooner.
Um, for about two weeks...
...
So... Sophia, I wanna share with you that you've done everything right. Um, you brought him in at absolutely the right time.
Thank you, doctor... I've been sitting here for hours just going over and over it in my head, wondering if I missed something. That... that helps to hear. So please... what is happening with him?
So what I wanna share with you is that his blood work showed that all of his blood counts are low, and I know that that's a new term for you. And so what I wanna do is take a moment to explain what this means, um, and, you know, why this is important for, for us to know.
Okay... yes, please explain it to me. I know what white blood cells are from my work, but... all of them being low, I don't know what that means.
So, the cells that your body makes, some are called white cells, some are called red cells, some are called platelets. And the white cells are the cells that help fight infectio- infections. The, um, red blood cells, um, are hemoglobin, and they carry oxygen to the rest of the body. And the platelets help so that your body is able to clot, so when you get a cut, then your cut forms into a scab because you have platelets to be able to do so. I just explained a lot of sci-ence, and I wanted to see what questions you have about that.
No, that... that makes sense, doctor. So his white cells, red cells, and platelets are all low... that's why the bruising, then, isn't it? Because of the platelets? But... what would make all three of them be low at once?
So we don't have a confirmation yet, but all of these things, from his symptoms and his counts, are concerning for something called leukemia, which is a cancer of the blood.
Leukemia... oh god... cancer? My mijo... I'm sorry, I... I need a moment. My mother had cancer, doctor, and... are you sure? Is he... is he going to die?
So, I know you have lots of questions and lots of concerns, and those are completely understandable. Um, and what I want to share with you is that I will not have a lot of answers for you until we get something called a bone marrow biopsy. So, tomorrow morning, what we're gonna do is we're gonna make him really comfortable and a little bit sleepy, and we're gonna take a piece of his bone marrow to look at it under a microscope to see exactly what his bone marrow, which is where the cells are made, what they looklike. And so, once we have those results, then we can talk about Ethan's future.
Okay... okay. A bone marrow biopsy... so they make him sleepy, he won't feel it? I'm just... I'm scared of him hurting. And you still haven't... please, doctor, I need to know... can children survive this? Is my son going to die?
Children can absolutely survive this. Um, it is my hope that he lives a long, beautiful, healthy life, and that this is, I'm gonna say, just in quotations, just a little bit of a roller coaster that you'll be able to get off of very soon.
Thank you... thank you for saying that, doctor. I needed to hear that there's hope. Okay... so tomorrow is the biopsy. What about tonight? Does he stay here? And... can I call my husband? Daniel is at home with our older son, and I don't want to do any of this without him.
Of course. So if you want, um, me too, I'm happy to get on the phone with both you and Daniel together so that you don't have to share the news and the burden by yourself.
Oh... thank you, doctor. That would mean so much. I don't think I could find the words right now to explain this to him... I can barely hold them myself. Yes, please... can we call him together?
Yes, we can do that together. Um, lip smack and yes, just to answer your question, Ethan is gonna stay here until we have a good idea about what's happening in his body and a good plan in place for the future.
Okay... so he's admitted tonight, biopsy tomorrow, and then we'll know more. I think... I think I understand. Um, one more thing, doctor... how do I tell him? He's seven. All he keeps asking me is when he can go home. What do I even say to him?
So I want you to know that none of this is gonna be done on your own. So you will have a team to support you through talking with him. You'll have social workers and our child life supporters, and I will be there as well. It's important that we share what's going on in his body because he's smart and he'll have lots of questions.
Okay... thank you. Knowing I won't have to find those words alone... that helps. Alright, doctor... I think I understand for now. Ethan most likely has leukemia, the biopsy tomorrow will tell us for sure, and we'll go from there together. Can we call Daniel now, and then can I go be with my mijo?
Absolutely.
Thank you, Doctor Rissman... truly. Let's call Daniel, and then I want to go hold Ethan's hand.
Feedback
How to read this feedback
Every score is written as value / max, so you can see both the points earned and the points available. A spoken simulation can’t surface everything a real visit would, so when something couldn’t be judged fairly, the feedback labels it instead of holding it against you. Here’s what each label means.
(simulation limitation)The voice/text modality physically can't reveal it
e.g. eye contact, body language, facial affect, physical exam, EHR documentation
(no opportunity)The scenario never created the occasion
e.g. conversation ended before this step; situation never arose
(not applicable)Out of scope for this case
e.g. a domain that doesn't apply here
“Not assessable” never lowers your score. It just means the format didn’t give you a fair chance to show that skill, so it sits to the side rather than counting against you. That’s different from “Not demonstrated,” where the moment was there and the skill didn’t come through. Only the second one reflects on how the encounter went.
For ACGME milestones, some scenarios can only assess a competency up to a certain level — the higher levels turn on behaviors a single spoken encounter can’t surface. When a scenario’s ceiling is below Level 4, that milestone is still shown for its formative value but is “Not in overall grade” — it doesn’t count toward the overall grade, so a case that can’t fully exercise a competency never reads as a shortfall.
Overall impression
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Strengths — Dr. Rissman demonstrates a genuinely patient-centered approach throughout. The perception check is well-placed and open-ended; the blood-count explanation is chunked, plain-language, and followed by a comprehension check; the proactive reassurance about Sophia's guilt ("you've done everything right") is emotionally intelligent and well-timed. The strategy and summary step is exemplary: the plan is concrete, hope is framed realistically, family support is woven in, and the offer to join the call to Daniel is a standout moment of compassionate, adaptive care. The overall tone is warm, unhurried, and trustworthy.
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Priority gaps — The two most important gaps are in the emotional response and the setup. When Sophia breaks down invoking her mother's cancer death and asks "Is he going to die?", the learner's response is validating but moves too quickly to the biopsy plan without dwelling in the emotion, naming it, or connecting it to its source (prior loss). This is the highest-stakes empathic moment in the encounter and it was only partially met. Second, the interview was not explicitly set up: no privacy check, no inquiry about support persons at the outset, and no explicit invitation about information preferences — all of which are verbal behaviors fully available in this format.
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Top action items
- At moments of peak distress, stop and name the emotion before any clinical content. When Sophia says "My mother had cancer… is he going to die?" respond first with: "I can hear how terrifying this is — especially knowing what cancer took from your mother. I'm so sorry." Only then move forward.
- Open every bad-news conversation with an explicit verbal setup: confirm privacy, ask who the patient wants present, and signal that you have time — all before eliciting perception.
- Add an explicit warning shot immediately before naming the diagnosis: "I want to prepare you — what I'm about to share is serious news" — then pause before saying "leukemia."
- Ask an explicit invitation question early: "Some people want every detail; others prefer the big picture. What would help you most right now?" This respects autonomy and tailors the disclosure.
References
- Baile WF et al. SPIKES: a six-step protocol for delivering bad news. The Oncologist. 2000;5(4):302-311.
- Sisk BA et al. Prognostic disclosures to children: a historical perspective. Pediatrics. 2016;138(Suppl 1):S33-S39.
- Back AL et al. Training clinicians with communication skills needed to match medical treatments to patient values. J Am Geriatr Soc. 2019;67(S2):S435-S441.
- October TW et al. The parent perspective: being a good parent when making critical decisions in the PICU. Pediatr Crit Care Med. 2014.