MRCP PACES exam stations overview

There are five MRCP PACES exam stations in each carousel. Each station lasts for twenty minutes with a five minute changeover time between stations. Overall you will be in your exam for approximately two and a half hours, so it is important to be aware that you will be need to be completely focused for that length of time.

At each of the MRCP PACES exam stations two consultant examiners will be observing your consultation, taking notes then testing you with a small number of questions at the end.

So not only do you need to have all your medical knowledge ready, but you need to concentrate for a couple of hours while you have the constant presence of two consultants judging what you do.

I mention this because I want you to remember this not just an exam that can be passed or failed on your knowledge, but how you keep your cool under pressure.

Prepare yourself for this and don’t be caught by surprise!

Clinical Skills Pro MRCP PACES exam stations

So let’s look at each of the MRCP PACES exam stations more closely and learn our top tips for passing each one!

MRCP PACES exam stations stethoscope

MRCP PACES exam stations – 1 – respiratory and abdominal examinations

Here you have two separate ten minute tests of your ability to examine these systems and correctly identify clinical signs, including a minimum four minute discussion with the examiners about your findings.

  • Top tips for passing
    • Respiratory – make sure you clearly look for extraneous signs in the face and hands for clues to the diagnosis (such as a yellow nails with bronchiectasis or a heliotropic rash in dermatomyositis and pulmonary fibrosis). Also look around the bed area for other clues like inhalers (for the far more common COPD patients).
    • Abdominal – do not to forget to palpate at every level of the abdomen i.e. on your knees; otherwise you are not properly examining and don’t forget to palpate and observe the inguinal regions in case there are any renal transplant scars – you do not want to say it is a normal abdomen and miss the most obvious diagnosis.
  • Station two – history taking skills. This consists of a single twenty minute consultation with an actor (they are usually very convincing) in which you are examined in your ability to take a history, form a differential diagnosis and make a clinical plan while addressing the patient’s concerns.
  • Top tips for passing
    • remember to let the patient or relative talk
    • remember to ask about herbal medicines and over-the-counter medications as well as recent changes in doctor prescribed medications and allergies
    • there are dozens more tips on our interactive video here —-> History & Communication revision video
MRCP PACES exam stations history taking
MRCP PACES exam stations cardiology neurology
  • Station three – cardiology and neurological examinations. Here you have two separate ten minute tests of your ability to examine these systems and correctly identify clinical signs, including a minimum four minute discussion with the examiners about your findings.
  • Top tips for passing
    • Cardiology – during the auscultation do not forget to sit the patient forward and listen in expiration in the left lateral position otherwise you might miss the regurgitation murmur.
    • Neurology – you do not have enough time to do an entire neurological examination (and you will not be expected to) so do the part of the exam that is most pertinent to your patient.
  • Station four – communication skills and ethics. This station assesses your ability to guide an interview with a patient, family member or other individual while communicating clinical information and applying your knowledge of ethical considerations to a given scenario.
  • Top tips for passing
    • Listen to your patient/relative, don’t assume anything and empathise with their situation.
    • Again have a look at our history and communications video —->History & Communication revision video
MRCP PACES exam stations communication skills
MRCP PACES exam stations brief clinical encounter
  • Station five – integrated clinical assessment. This station is the newest component of the PACES examination, and puts you under some time pressure.  You must take a brief focused history, conduct a targeted physical examination (at the same time), and identify and respond to patient concerns – all in eight minutes!  In the remaining two minutes you need to summarise your findings to the examiners and propose a plan.
  • Top tips for passing
    • You are against the clock! This is the part of PACES where you have to be the most efficient.
    • Practice your examinations until you can do them correctly without thinking. Once you start your station 5 exam you can concentrate on doing the most important parts and getting to a diagnosis without worrying about whether you are doing it right.

Top tips for the discussion

At the end of each of the MRCP PACES exam stations there is time for the examiners to ask you questions. One thing that I have observed when coaching people through their exam is that candidates do not volunteer information.

Remember:  Whatever question the examiners ask you should expand your answers and volunteer information. The worst thing you can do is wait to be asked – the examiners may assume that anything you don’t say you don’t know. For example, if you are giving a diagnosis or differential expand your answer and explain how you would exclude each of these. Besides, there is only a short amount of time for this part of the exam.  The more you talk about what you know there is less time for the examiners to potentially ask you a question that you don’t know the answer to.

I hope this post outlining the MRCP PACES exam stations has helped.  However, always remember:

The examiners have one question that they are asking of you, the ultimate PACES question.

MRCP PACES exam stations trust

The Clinical Skills Pro course goes into each of these MRCP PACES exam stations in depth helping you to be prepared for your exam day.

The examiners meet briefly after you depart to discuss the exam progress, and may already have a clear idea about whether you have passed or failed.  However, you will have to wait a number of weeks to find out how it went while the RCP conducts a moderation exercise across centres to ensure fairness and consistency.

GOOD LUCK!

PASS MRCP PACES: Behind the scenes

A clear understanding of what goes on behind the scenes during PACES is actually very helpful for your preparation.  This post describes how the MRCP PACES exam is administered and run, providing valuable insight into how patients are picked for your exam day.

Consultants, usually from UK hospitals, act as examiners and are unpaid and often giving up their own free time.  There is usually single organising consultant from the host hospital who organises the exam on the day and ensures everything (hopefully) runs smoothly.

This consultant will often delegate certain responsibilities for the exam to a medical registrar who will organise many of the patients and some of the admin on the day.  That person is probably running around dealing with unexpected glitches, and is likely to be quite stressed.

Patient databases

Because exam centres host PACES repeatedly each year, they work from patient databases of willing volunteers with clinical signs – particularly for stations one, three and five.  What this means in practice is that patients appearing in these stations will usually fit one of the following categories:

  1. Patients with chronic illnesses and stable clinical signs who are able to attend the exam centre repeatedly;
  2. Patients with clinical signs of shorter duration who are current inpatients, but are well enough to transfer to the exam centre for several hours at a time.

For the same practical reasons, self-evidently acutely unwell patients at risk of clinical deterioration will not be present on the day.  For example, you are very unlikely to see a patient with acute left ventricular failure, pneumonia or a bleeding duodenal ulcer – even though such things are commonly seen on the general medical take!

Structured mark sheets

Examiners are quite constrained in how they can assess you.  Although horror stories may abound of people failing for having the wrong haircut or wearing their stethoscope around their neck while presenting their findings, these are fictitious.  You can download the mark sheets the examiners have to score you by here.

The ultimate PACES question

Despite the structured mark sheets, at the back of each examiner’s mind is the ultimate PACES question:

Would I trust this candidate to work as my medical registrar and run my hospital at night?

If you can persuade enough of them that you are a safe pair of hands, one way or another you’ll be OK..

Patient perspective: Cushing’s disease

Patient perspectives can be very useful learning opportunities.

We know not every patient walks through the door with a textbook set of signs and symptoms, and hearing directly from patients about the progression of their condition can give us a greater understanding of complications.  We can also use these insights to gain empathy about the frustrations and struggles different patient groups may endure – in this case a patient with Cushing’s disease (not Cushing’s syndrome!) describes how her weight gain may be assumed to being due to overeating by many health professionals without consideration of other diagnoses.

A Cushing’s disease patient perspective

My story is that in 2011 I had a few falls which was very unusual. Presumably from one of these falls I developed a prolapsed disc in my neck, and tore the tendon across my left shoulder, giving me excruciating pain. The GP just gave me more painkillers, I was taking amitriptyline, diclofenac, codeine and paracetamol and was getting little if any pain relief. I was offered acupuncture by a Chinese doctor, which at last gave me some relief.

Early the next year I went to her to get help to improve mobility in my left arm. She told me I had to see a GP that day as the oedema in my legs and feet was very bad. Unexpectedly when I told the receptionist what the problem was, she told me to come in 1/2 hour. The GP I saw just happened to be a hospital trainer and said I think you have Cushing’s disease! I did not even know I was unwell and had certainly never heard of Cushing’s Disease. However I became quite unwell quite quickly after that with many nasty physical symptoms kicking in. I have a very good endocrinologist who apparently said to himself the first time he saw me – “If this lady does not have Cushing’s disease, I am going to pack up my job and go home!!”

I had surgery in Wessex Neuro Unit, Southampton, for a macro adenoma in 2012, and again a week later. I was then left with 3 bits of tumour – one bit too high to get at transphenoidally (the surgeon had intended to re-operate above the eyebrow, but had to re-operate again transphenoidally, so obviously decided to leave it as I was having radiotherapy anyway). Another bit is wrapped around the carotid artery and the other one is on the pituitary stem, so I had radiotherapy in late 2012.

I therefore struggle with seeing that so many people do not get the quick diagnosis I received. I have realised that my GP’s know nothing about Cushing’s, my endocrinologist knows a bit more, but as even he only sees a Cushing’s disease patient about every 2 years I do not feel that is enough to understand the disease. I now run a patient support group and have realised that we all have different experiences and symptoms with the same illness. I am not surprised it is difficult for doctors to understand and diagnose it.

It is a dreadful disease and now 4 years later, I feel unwell a lot of the time, and am unable to do very much. I am 67 but felt I was fairly fit and healthy until hit with this. Left untreated it definitely damages our organs, so early diagnosis is very important.

You are welcome to share my story, if you wish. However, it is not at all typical as I was diagnosed before I knew I had a problem, but so many others have to wait years, getting sicker and sicker being told to go and lose weight or that it is just in their mind, there is nothing wrong! There are also many mis-diagnoses along the way, such as depression, PCOS etc.

I just wish they could find better diagnostic tools.

Cushing’s disease revision notes.

We are grateful to patient E for sharing her story about her diagnosis of Cushing’s disease with us.  Her story is not unusual.

In the revision notes below we review the pathology of Cushing’s disease:

Cushing’s disease is not the same as Cushing’s syndrome (CS). It is characterised by an abnormally high level of cortisol in blood due to an ACTH secreting pituitary tumour. Rarely ACTH producing tumours may grow elsewhere in the body, when they are called ectopic tumours.

Clinical Features

Clinical features of Cushing’s disease include the symptoms resulting from excess hormone in blood as well as compressive effects of the pituitary tumour (if large enough). Common clinical features in the disease are:

  • Change in physical appearance
  • Moon facies
  • Buffalo hump
  • Easy bruising of skin
  • Abdominal striae (purplish stretch marks)
  • Weight gain (in abdominal area only. Limbs tend to be thin)
  • Plethora (red cheeks)
  • Increased hair growth on legs, face, neck and chest
  • Generalized weakness and fatigue
  • Muscle wasting in upper thigh making getting up from chair difficult
  • Menstrual disorders
  • Reduced sex drive
  • Reduced fertility
  • Hypertension (uncontrollable)
  • Diabetes mellitus (severe)
  • Behavioral changes and mood disturbances
  • Vision loss (macroadenomas)
  • Loss of acuity
  • Color perception affected
  • Hypopituiarism (macroadenoma)
  • Reduced sex hormones, LH and FSH
  • Elevated Prolactin levels (stalk effect)

Diagnosis

Due to slow evolution of symptoms and signs it is often difficult to diagnose the disease in early stages. Furthermore, elevations in hormones occur in cycles and periods making diagnosis complicated. A detailed history, a thorough physical examination and tests are crucial to reach a diagnosis. Investigations that can be carried out include:

  • Hormone testing
  • 24 hour urine free cortisol measurement
  • Cortisol saliva testing
  • Blood ACTH
  • MRI- detects adenoma in 70% of cases
  • Inferior petrosal sinus sampling (IPSS)-if MRI fails then IPSS is conducted. It distinguishes ACTH producing tumor in pituitary from a tumor elsewhere in the body

Management

Management of Cushing’s disease requires a team of experts and treatment options available for the disease include:

  • Surgery
    • Surgical removal is a long-term solution
    • Cure rate for small tumors – 80-85%
    • Endoscopic technique is very effective
  • Medication
    • Drugs don’t lower ACTH production and don’t shrink tumor but inhibit cortisol production by adrenals
    • Necessary before surgery (ill patients)
    • Indicated if surgery fails
  • Radiation therapy
    • Effective for controlling growth if surgery fails
    • Stereotactic radiosurgery
    • Delayed pituitary failure may occur several years later as a consequence
  • Other options
    • Cortisol replacement by hydrocortisone or prednisolone after surgery.

We are going to publish more patient perspectives with revision notes soon so please follow our blog or sign up to our newsletter to keep up to date with new posts. If you or anyone you know would like to contribute their story then please email us at [email protected] to find out more. All information is treated confidentially.

Tips for if you fail PACES

How to pass MRCP PACES exam

PACES is a difficult exam and it is not uncommon to fail the first time you sit it. The important thing to do is analyse your MRCP PACES preparation and performance and work out where you went wrong. You can then use this information to be better prepared for the next time you sit the exam.

1. Analyse what happened.

After you fail the exam, do not just jump headlong back into revising, take a step back and review your revision.

Firstly how did you revise? Were you systematic or did you jump around between subjects in your revision? It is tempting to just revise what you saw on the ward that day but it might mean you missed something. Try and stick to a systematic revision plan.

Did you see enough patients? It can be hard to go out of your way to see patients sat at the other end of the hospital especially when you have so much work to do but the extra legwork is worth it.

Did you focus on one station too much? A simple mistake is to focus on the station you are most worried about and spend less time on the one you are confident on. Many friends of mine who failed their MRCP PACES exam passed the station they were most worried about (because of the excellent preparation they put in,) and failed on the one they thought they could do without studying too much.

Did you have a study buddy? These can help you to identify gaps but more importantly watch your presentation technique and help you hone it.

These are some common issues for failing, but everyone is different and you will have your own issues – think about them, talk them though with a colleague and rectify them.

2. PACES will take over your life – just accept it.

You need to plan when  you want/can sit your exam with no distractions. It does take over your life. Did you try and fit in your exam while planning a holiday, taking extra shifts to pay for the holiday or when you just wanted to spend some time on your social life or hobbies? This could be a reason you failed.

To give yourself the best chance of success plan your PACES revision and exam for time when it can take over your life for a few weeks. Accept you might not see your friends for a few weeks – but then this is the next 30-40 years of your professional life for a few weeks of pain. Of course, I recommend planning a holiday or a treat once you have finished – you will have earned it.

3. You are a better doctor for having taken the exam.

Failing anything is not pleasant but the PACES is an exam that works, and doctors are better for having gone through the process. You may have failed at an attempt, but you are a better doctor for having gone through it and as such your are better for your patients.

4. Stay positive

Stay positive! Yes you have failed, and most doctors are not used to failing at pretty much anything academic. However, failure comes to all of us at some points in our lives, and how you deal with it is more important. So, if you have failed then do not despair and work your way through it.  Learn from your errors and mistakes and make sure the next time you do the exam, you give yourself the best chance of success.

MRCP(UK) PACES Success Rates for 2015

In 2015, 4484 doctors sat the MRCP (UK) PACES examination and around half were in training schemes in the UK at the time of sitting the exam.

Of the UK trainees:

Pass at first attemp
t 61.6% (1004/1629)

Pass at 2+ attempts 52.0%

So if you have previously failed you PACES exam take heart that you are not alone.

Of the ‘other candidates’ (i.e. did not state to be in an UK training scheme at the time of sitting the exam):

Pass at first attempt 36.4% (526/1446)

Pass at 2+ attempts 33.2%

Pass rates per category 2015:

CT1

CT2

OTHER

Physical examination

97%

95%

88%

Identifying physical signs

79%

68%

53%

Clinical communication

96%

92%

72%

Differential diagnosis

88%

80%

66%

Clinical judgement

92%

89%

70%

Managing patients’ concerns

95%

93%

70%

Managing patients’ welfare

100%

100%

96%

The percentages are averaged as appropriate

Scores by station:

CT1

CT2

OTHER

Respiratory

16

16

15

Abdominal

17

16

16

History

17

16

15

Cardiovascular

16

15

14

Nervous system

16

15

14

Communications & Ethics

14

14

12

Brief Clinical Encounters

25

23

22

The scores are averaged to whole numbers as appropriate.

Maximum score for Respiratory, Abdominal, History, Cardiovascular and Nervous System is 20. For Communications and Ethics it is 17 and for Brief Clinical Encounters it is 27.

 

Source: MRCP(UK) Part 2 Clinical Examination performance report 2015. For the full report visit MRCP(UK) Part 2 Clinical Examination performance report 2015.