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.


Patient perspective | Cushing’s – patient no.2

Clinical Skills Pro Free PACES revision

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.

My journey started in 2012 when I visited my ENT consultant complaining about compromised taste and smell, and as I’d had previous sinus surgery he ordered an MRI. The result of this showed clear sinuses but a 1mm pituitary adenoma. I was referred to an Endocrinologist who ordered various tests which claimed that the pituitary wasn’t secreting excessive hormones. I would be reviewed on a yearly basis.

In February 2014 I had a total knee replacement; the other one had been replaced previously. I had already been diagnosed with osteoarthritis & rheumatoid arthritis was confirmed by a hand ultra sound scan although blood results were negative for the RA factor.

Following my knee surgery it was noted that my BP was elevated. I had been diagnosed with hypertension several years previous and was already on hypotensives. For several months my BP was monitored by my GP and more medication introduced however the BP was fairly resistant to medication. I frequently stated that this wasn’t normal for me; I ate healthily, (my husband being an insulin dependent diabetic) exercised, didn’t smoke and drank little alcohol. Eventually I was referred back to my endocrinologist who at that time was slow to respond. In the end it was my rheumatologist who felt that I exhibited signs of Cushing’s . She started the process of testing. My weight had increased but I felt that was due to not being able to exercise so much since the knee replacement. I have always been fit, walking the dogs for an hour plus each day; holidays were hill walking and swimming.

My endocrinologist took over the testing process and Cushing’s was confirmed in November 14. However it took a while to see the neurosurgeon who required more testing; he also wanted to do the surgery with an ENT surgeon due to my previous sinus surgery. Eventually it was scheduled for September 15, the surgeons were only allocated 2 days a month for theatre time.

I had gained nearly 2 stone in weight, not as much as some people. My muscles had become very weak and I had to resort to using a mobility scooter to get out as I couldn’t walk very far. I was on four different medications for my BP, I was being investigated for sleep apnoea prior to the surgery. I was diagnosed with sleep apnoea in November 15, stopping breathing 72 times an hour; I now use a CPAP machine.

Surgery went well although initially my cortisol levels were still quite high so they weren’t convinced that the surgery had been successful, however the levels did come down. Recovery is very slow, you’re not given enough information about the recovery, initially I had thought that the tumour would be removed and I would recover quickly. This hasn’t been the case. I am now nearly a year post op,  my BP is still elevated, I haven’t lost weight either. I am still struggling with muscle weakness even though I am actively trying to exercise with hydrotherapy. I take 20mgs of replacement hydrocortisone, taking it trying to mimic the circadian cycle.  A day curve showed that I needed replacement HC. I am due to have more tests soon to see what is going on, he plans to do saliva tests throughout the day.

Although my endocrinologist is good (he thinks outside of the box) I have had the greatest support via the internet community, learning far more there than from any doctor. Most of the groups are US based but the UK based Facebook group has 103 members which just goes to show that it isn’t as rare as we’re led to believe and that people are looking for support!  

We have another perspective on Cushing’s disease here written by another patient. On this post we have included some notes on the condition that you will find useful for you revision.

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.

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..

Communication skills: Informal resolution of a complaint.

A clear understanding of the NHS complaints procedure is vital for the MRCP PACES.

The first line of defence against any potential complaint is always, always to attempt informal resolution as soon as possible.  This process of attempting informal resolution is one of the commonest scenarios encountered in the MRCP PACES, and vital in your working career.  Sensible doctors recognise that a few minutes invested in formal complaint prevention through informal resolution saves vast amounts of time, effort and hassle later – not to mention having the potential to leave complainants feeling better treated and more satisfied.

It is hard to overestimate the importance of doing this well.  For this reason, attempting informal resolution of a complaint is one of the most common MRCP PACES scenarios.

The key steps involve:

  1. Establishing the facts, as the complainant sees them;
  2. Listening and demonstrating empathy;
  3. Expressing regret (if the complaint is not reasonable or down to a misunderstanding rather than a complaint) that the complainant feels dissatisfied, or apologising if the complaint is legitimate – in most cases an apology is the best course of action;
  4. Enquiring about any other concerns;
  5. Setting out a proposed course of action to avoid similar problems if you can identify one;
  6. Signposting the complainant to the PALS office if they wish to make a formal complaint.

Things to avoid include getting cross yourself, interrupting, failing to apologise when this is appropriate, and not listening to the complainant.

The full process for handling complaints is set out in the NHS Constitution. This describes expected response times, the PALS process in detail and how patients can pursue matters with the ombudsman if still dissatisfied.