How to pass MRCP PACES

How to pass MRCP PACES exam

Many candidates wonder how to prepare for the MRCP PACES examination.  It can be hard to know where to start – after all, this is a test of clinical skill and acumen.

The first thing to recognise is that it is not possible to revise for this examination exclusively by doing online banks of MCQ’s, or from a book.  There are innumerable candidates who mistakenly conclude that because this tried and tested approach worked for their part I or part II they should stick to the same proven formula.

Wrong.  In fact, very wrong.

PACES measures a different type of knowledge.  Although some basic factual knowledge is essential, this is not really what PACES is designed to test.  If you have passed the part I and part II, you already have 80-100% of the knowledge you need under your belt.

PACES tests all those qualities of being a good doctor that just can’t be answered with a Google search or from a book.  For example:

  • The ability to elicit, interpret and contextualise clinical signs;
  • Displaying empathy;
  • Demonstrating good judgement in ethically challenging scenarios;
  • The ability to think on the spot;
  • Confidence;
  • Efficiency.

So how should you prepare?

Priority one: Practice

Then practice some more.  And then practice again.

For many PACES candidates, modern clinical medicine – with it’s ready access to CT and echo – has relegated the importance of clinical examination to a cursory afterthought.

You must put that behind you and learn to maximise the value you get from examining a patient.

Not only because it will help you pass the PACES but because you will be a much better doctor.

Examine your friends.  Examine patients who are well.  Examine patients who are ill.  Examine your relatives.  Examine your partner, or your sibling, or your parents.

Work on your examination routines until you don’t have to give a nanosecond’s thought to what you’re doing and are focusing solely on deciding whether you can identify a clinical sign or not.

PACES is tough.  You don’t want to be spending your brain power on what to do next in your clinical examination of the patient.  You need to be thinking about what you’re going to tell the examiners.

Priority two: Experience

Expose yourself to clinical signs and scenarios.

Doctors taking the MRCP PACES need to discern normal variation from abnormal pathology.  Just as modern investigations have hampered doctors’ ability to thoroughly examine a patient, they have also damaged their ability to interpret what they’re hearing through a stethoscope.

Are you a doctor (there are many) who got in the habit of hearing a potentially abnormal heart sound and just booking an echo?

You need to get over that.

You need to be able to discern aortic stenosis from mitral regurgitation with total accuracy.  But it doesn’t stop there.  To really boost your chances you need to recognise a VSD, a 3rd heart sound, a 4th heart sound and an ASD.  You need to be able to not only identify a renal transplant but be able to provide a likely explanation about why your patient had it in the first place.  And perhaps, speculate about what immunosuppressant they’re taking based on related clinical signs.

Conclusion

There are only really two vital elements to passing your PACES:  Practice, and experience.  You have the knowledge already.

We can’t practice for you.  That’s all down to you.  But we can turbocharge your ability to get the experience.

Clinical Skills Pro subscribers get access to our online HD multimedia course containing huge numbers of heart sounds, lung sounds, rare syndromes, JVP abnormalities (yes, all of them!),dermatome Dave, and much more besides.  Immerse yourself in a database of HD video recordings of clinical signs that you’d never encounter on a single traditional weekend course.  Gain access 24/7.  Rewind and revisit.

And then pass.

Most common neurological conditions that occur in MRCP PACES exams.

Each station in the PACES has cases that occur more commonly than others. This is due to a number of factors that include the number of patients with the conditions, being able to elicit decent clinical signs and create a ‘story’ out of very little history or background information.

Neurology is a much-feared station for many PACES candidates but it is also one of the most passed stations (maybe because candidates are so worried about it they revise it thoroughly).

It can be unnerving and unclear where to start revision as there are so many conditions, but one useful tip is to break down your revision of neurological conditions into the terms of their origin.

These are;

  • cranial nerve;
  • cerebellar;
  • upper limb;
  • lower limb;
  • systemic.

Not only does this instantly make your neurological revision more manageable but can help you  to work out how to examine your patient in the exam. You will never get the whole neurological system as an examination, because it is impossible to do it properly in the time allotted. You will get part of the system, for example upper limb, and even then there is not enough time to examine both motor and sensory function. It is most likely that you will need to examine motor function but do not neglect the sensory system it is something we rarely do properly in everyday practice outside of the neurological field, but one you should definitely re-learn for PACES.

A potential scenario for the neurology station is ‘examine the hand and then go on from there…’ This is typical for the systemic neurological disorders, and there are only a few that fit this area (such as Parkinson’s disease and cerebellar pathologies). So, for example in Parkinson’s, the resting pill-rolling tremor should tell you all you need to know about what to examine.

Common conditions that occur in the lower limbs include peripheral neuropathy, hereditary motor and sensory neuropathy and an abnormal gait. 

Cerebellar pathology usually comes up commonly as cerebellar syndrome, and so you should know all the potential causes.

Systemic conditions include myotonic dystrophy, Parkinson’s disease, hemiplegia, multiple sclerosis and muscular dystrophy.

The main advice for revising and taking the neurological station is break it down into manageable pieces, don’t try and cover everything in the exam (there isn’t time) but do what you need to get the correct diagnosis

Most common cardiovascular conditions that occur in MRCP PACES exams.

stethoscope on ecg

Each station in the PACES has cases that occur more commonly than others. This is due to a number of factors that include the number of patients with the conditions, being able to elicit decent clinical signs and create a ‘story’ out of very little history or background information.

Many candidates worry about the weird and wonderful of cardiac murmurs, and there is a discrepancy between what appears commonly in everyday practice versus the MRCP PACES exam. There are, however, some common conditions that do recur, and you will far more likely encounter a prosthetic valve or aortic stenosis as opposed to Tetralogy of Fallot with a Blalock shunt. In countries that still have rheumatic heart disease then the patient might be younger with complications from this.

Prosthetic valves, especially mechanical ones, appear commonly and often you can hear these at the end of the bed with a characteristic metallic click.  This makes your job easy – all you then need to do is determine whether the prosthetic valve click coincides with S1 or S2 to figure out of the valve is likely to be an aortic or mitral replacement.

Mitral valve disease and aortic valve disease are as common in the exam as they are in everyday practice. Both stenosis and incompetence occur reasonably commonly in both valves so do not forget to listen in all areas and to conduct all manouvres necessary to elicit more subtle murmurs, such as aortic regurgitation.

Atrial fibrillation is also a common finding, and you should look for associated features, such as medication (the side effects of amiodarone) or heart failure.

Mixed valve disease is also common so do not assume simply because you’re confident that you’ve heard mitral regurgitation, for example, that there is nothing else to be found. It happens, unfortunately. In reality, everyone’s cardiac auscultation improves after the echocardiogram has been done(!) but in the PACES it’s just you, the patient and your stethoscope.

5 mistakes doctors make when revising for MRCP PACES

With so much to learn for your MRCP PACES exam it is easy to make some mistakes in planning your revision. Avoid these and you will be better prepared on the day of your exam.

1. Avoiding the neurology station
Neurology to many medical students and young doctors can appear to be a ‘dark art’ and one that is to be avoided at all costs. Unless you want to become a neurologist, then for many, it is a subject that can appear, initially to be quite difficult. However, do not let this put you off. Not only is neurology a fascinating subject, but once you have learnt a few techniques for understanding how to classify the neurological system, it does not become that hard. So do not avoid it, embrace it!
2. Not practicing history station because you do it everyday and know how to take a medical history
This is a common issue (see the next top tip to fail as well). You are a doctor, you take a medical history everyday, so why do you need to practice it? Well, the simple answer is, (and I can tell you this from experience in training many doctors to go through PACES,) that you have bad habits and you do not take a proper medical history. The PACES is a performance where everything is done ‘by the book’ and this includes the history. So practice it as much as any other station, because you do not want to fail because you took a bad history.
3. Not practicing communications skills because that is also something you do everyday and know how to do, right?
Wrong. Again, you get into bad habits, and once you start practicing, you will find that you do a lot of the following: talk over the patient; not allow enough time for them to digest the information and generally be too fast. A lot of this comes from doctors having heard most of the responses and trying to reassure the patient. Let the patient talk, give them time, and PRACTICE. Again, failing because of the communications station is not pleasant.
4. Focusing on the complicated, rare conditions
Focusing on primarily the rare conditions is a sure-fire way to fail. You have to know about some rare conditions, but also, do not forget that common conditions happen commonly. In a later blog post we will go over the top conditions covered in the MRCP PACES exams.
5. Not practicing presentation skills
Presentation of your findings is an important part of your PACES exam and verbal diarrhoea is common with nervousness. Again I will go over some presentation tips in a later blog post but in the meantime practice your presentation skills with a friend and get them to (honestly) give you feedback.

 

The main thing to remember is practice everything, repeatedly and don’t leave anything to chance. Even the aspects of your clinical examinations that you find easy or feel confident about.

What you need to know about the MRCP PACES examiners.

There are 11 of them and only one of you, and they determine your success or failure.  But who are they?

For candidates sitting MRCP PACES in the UK (and most other places around the world) the examiners are a collection of senior hospital consultants.  Their motivation is seeing the next cadre of hospital doctors trained to an adequate standard – and that includes being able to competently examine a patient.

As a minimum, PACES examiners have held a CCT in a medical specialty for at least two years prior to starting as an examiner, and be working in a substantive post.  They need to be active clinically and involved in general medicine.

The other requirements include clinical supervision of core medical trainees in general medicine and having undertaken equality and diversity training in the last three years.

Your examiners will all have completed a day-long training course to ensure reproducibility and fairness, and are encouraged to examine at least 30 candidates per year – a process that will usually take two or three days.

For each station you will have two examiners, who will take it in turns to lead with asking you questions or observing and taking notes.  Each examiner marks candidates independently, without knowledge of what scores the other examiner is assigning.

So what does the 11th examiner do?  You are likely to not even meet them – their role is to troubleshoot during the examination cycle, collate and check marksheets and compile the candidate performance summaries.  In most cases, the host examiner acts as the 11th examiner.