Pearls in PACES- Introduction

Adel Hasanin

1

INTRODUCTION TO PACES

AIMS OF PACES

MRCP Part 2 Clinical Examination or the Practical Assessment Clinical Examination Skills (PACES) will

test ability to:

•••• demonstrate the clinical skills of history taking

•••• examine a patient appropriately to detect the presence of absence of physical signs

•••• interpret physical signs

•••• make appropriate diagnoses

•••• develop and discuss emergency, immediate and long-term management plans

•••• communicate clinical information to colleagues, patients or their relatives

•••• appreciate the ethical issues that relate to day-to-day clinical practice

EXAM CONTENTS

PACES consist of five stations, each assessed by two independent examiners. Candidates will start at any

one of the five stations, and then move around the carousel of stations at 20 minute intervals, until they

have completed the cycle.

•••• Station 1 (respiratory 10 min, abdominal 10 min) → 5 min interval →

•••• Station 2 (history taking 20 min) → 5 min interval →

•••• Station 3 (cardiovascular 10 min, neurological 10 min) → 5 min interval →

•••• Station 4 (communication skills and ethics 20 min) → 5 min interval →

•••• Station 5 (skin 5 min, locomotor 5 min, eyes 5 min, endocrine 5 min)

Pearls in PACES- Introduction

Adel Hasanin

2

PACES STATIONS

Station Number of

examiners Case Time

Distribution of

time

Number

of mark

sheets

Total

score

Respiratory 10

minutes

� 5 minutes for

examination

� 5 minutes for

discussion

2 mark

sheets

8

points

Station

1

Same 2 examiners

for both respiratory

case and abdomen

case

Abdomen 10

minutes

� 5 minutes for

examination

� 5 minutes for

discussion

2 mark

sheets

8

points

Station

2

2 examiners History taking 20

minutes

� 14 minutes for

history taking

� 1 minute for

“gathering

thoughts”

� 5 minutes for

discussion

2 mark

sheets

8

points

CVS 10

minutes

� 5 minutes for

examination

� 5 minutes for

discussion

2 mark

sheets

8

points

Station

3

Same 2 examiners

for both CVS case

and CNS case

CNS 10

minutes

� 5 minutes for

examination

� 5 minutes for

discussion

2 mark

sheets

8

points

Station

4

2 examiners Ethics, legal and

Communication

skills

20

minutes

� 14 minutes for

history taking

� 1 minute for

“gathering

thoughts”

� 5 minutes for

discussion

2 mark

sheets

8

points

Endocrine 5

minutes

Examination and

discussion

simultaneously in

the 5 minutes

Rheumatology 5

minutes

Examination and

discussion

simultaneously in

the 5 minutes

Skin 5

minutes

Examination and

discussion

simultaneously in

the 5 minutes

Station

5

Same 2 examiners

for endocrine,

rheumatology, skin

and eye cases

Eye 5

minutes

Examination and

discussion

simultaneously in

the 5 minutes

2 mark

sheets

8

points

Total 10 examiners 100

minutes

14 mark

sheets

56

points

PASSING SCORE: A candidate will pass if they score a total mark of 41 or greater out of 56

Pearls in PACES- Introduction

Adel Hasanin

3

PACES MARKING SCHEME

Clear Pass

(Scores 4)

Pass

(Scores 3)

Fail

(Scores 2)

Clear Fail

(Scores 1)

System of

Examination

Examines

thoroughly and

systematically

Examines

systematically

Examines inadequately,

either by omission or by

lack of system

Examines badly

and

unsystematically

Language and

Communication

Skills

Talks to patient in

a structured but

flexible manner,

using intelligible

language and

avoiding jargon.

Talks to patient

in a mainly

structured

manner

Uses unstructured

language and is unaware

of communication

problems with the

patient

Talks to the

patient in a

completely

unstructured way

and uses technical

jargon.

Confidence and

Rapport

Displays

confidence, rapport

and empathy

Demonstrates

correct

approach to the

patient

May appear

inappropriately

confident, or

unconfident/hesitant.

Poor rapport with the

patient.

Causes the patient

visible physical or

mental distress

and is oblivious to

it.

Clinical Method Demonstrates

correct and

comprehensive

clinical method and

skills, eliciting the

correct physical

signs.

Demonstrates

majority of

clinical skills

correctly and

elicits the

majority of

physical signs

correctly.

Misses important or

obvious physical signs,

resulting in poor or

incorrect formulation of

differential diagnosis.

Misses or invents

the majority of

physical signs and

is unable to

appreciate their

significance in

solving clinical

problems.

Discussion and

Appreciation of

Patient’s

Concerns

Discusses clinical

issues sensibly,

spontaneously and

with confidence,

whilst able to

negotiate and

acknowledge areas

of doubt/ignorance.

Shows awareness

of patient’s

concerns

Majority of

discussion

sensible and

correct, with no

important

errors of fact or

interpretation.

Inadequate appreciation

of patient’s problems

and concerns. Large

part of discussion

incorrect through

inadequate clinical

skills or underlying

ignorance. Is unaware

of patient’s concerns or

deals wit them

inappropriately

Demonstrates an

inability to

discuss, or most of

the discussion is

incorrect, despite

examiner’s

attempts at

assistance. Lacks

insight

Clinical

Thinking

Clear, appropriate

and professional.

Able to solve the

problem posed by

the patient.

Reasonable

clinical

thinking.

Muddled

clinical

thinking.

Examiner has to work

hard to give assistance.

Poor grasp of

clinical concepts

and may be

argumentative.

Pearls in PACES- Introduction

Adel Hasanin

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GENERAL HINTS

PREPARATION FOR THE EXAM:

•••• There are eight clinical examination stations. For each system, be sure to have your own well-

rehearsed technique of examination, so that during the examination you do not have to think about

what to do but to concentrate on the abnormal physical signs.

•••• Frequently practice examining normal subjects just to master your technique of examination. Be sure

to have single method of examination for each system (do not hesitate between two methods of

examination)

•••• Physical findings that appear in the PACES examination are so clear that it is difficult to miss it. Most

of candidates have enough clinical experience to identify the abnormal clinical findings in the PACES

without further practice, however, it is strongly advised to attend at least one preparatory clinical

course for PACES (preferably one that is held in the same territory in which you plan to take the

examination so that you get into contact with the medical conditions common in that place)

•••• Try to formulate a modifiable scheme for presentation of each system and practice it frequently in

front of your colleagues.

AT THE EXAM:

•••• Always read the instructions carefully for clues, and recall it during the examination (sometimes the

first question is related to the complaint mentioned in the instructions)

•••• When examining or discussing the patient (or the surrogate), do so in an interested and kind manner

•••• Keep asking the patient if he (she) has any pain or tenderness before you put hands on

•••• Do your thinking and summarizes your findings in your head while you are examining the patient,

in order to be ready for the discussion once you finish examination.

•••• Do not forget to thank the patient and cover him after finishing your examination

•••• Approach the examiner in friendly and confident but polite manner.

•••• Eye contact should be appropriately maintained with the examiner. Do not look back to your patient

during the discussion.

•••• A common advice is to keep your hands by your sides or behind your back. This may make you feel

under pressure. It is better to keep your hands in the position that make you feel comfortable as far as it

does not make you look arrogant.

•••• Think for a while before you answer

•••• Say headings whenever possible, e.g. autoimmune profile, thyroid profile…

•••• If your examiner challenges, do not assume it means you are wrong. However, if there is uncertainty,

state it, and proceed to say how you would resolve the uncertainty (be certain in both your certainty

and uncertainty)

•••• The common question “how do you mange this patient?” may be answered in the following sequence:

� I would first review the history, in particular…

� A full examination might provide other clues such as …

� Simple investigations may be helpful such as …

� The crucial investigation is …

�� Management might be divided into:

1. Management of the underlying disease process

2. Symptomatic treatment

3. Rehabilitation including physiotherapy and occupational therapy

4. Social support

5. Patient and family education