“What cases will come up in my MRCP PACES?” [Updated 2019]

Common questions for MRCP PACES candidates are “does anyone have any experience of XX hospital?” and “what is likely to come up in my MRCP PACES exam?”

It is completely understandable to try to find out other people’s previous experiences of a specific exam centre, or other exams.

By reading this post you’ll learn:

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Section author

Dr Edward Banham-Hall

Consultant physician

Clinical Cases (stations 1, 3 and 5)

“You can’t predict what cases are coming up, so don’t try.”

That was the advice I was given when I started out preparing for my MRCP PACES – by a very experienced examiner.

It was good advice.  But not the best advice.  And here’s why:

If you understand how MRCP PACES is organised, you gain an insight into why certain clinical cases are much more likely to come up than others.

Stick with me here.

When hospitals organise the MRCP PACES exam, they do a ton of logistical preparation:

  1. Forming a list of patients with clinical signs for each station
  2. Arranging for the patients to show up on the day
  3. Arranging transport
  4. Some form of concierge service
  5. Dealing with last minute drop-outs
  6. And so on

That’s a lot of work.  Which is why your fees are so high, even though the examiners are unpaid volunteers.

Trust, me – the preparation starts months (or even years) ahead of the day.

What organisers don’t want is:

  1. Unreliable patients who don’t show up
  2. Patients with clinical signs that come and go
  3. Patients who make a full recovery between being recruited and exam day
  4. Patients who could get sick during the exam
  5. Patients who can’t consent to participating

That tells you a lot, actually, about what’s likely to come up in your exam.

It’s called selection bias

A clear understanding of MRCP PACES selection bias will be the single most useful way to target your revision.

How selection bias influences cases in MRCP PACES

There is very significant selection bias inherent in the cases that show up on exam day.  If you have insight into this selection bias you can use it to more effectively target your revision.

In this next section I’ll give you examples of common conditions that are very unlikely to come up.

Then we’ll move onto rare conditions that are disproportionately likely to appear in the MRCP PACES exam.

Let’s get started!

 

Unreliable patients who don’t show up

If you’ve worked in hospital medicine, you’ll have very likely seen alcoholics, intravenous drug users, and other people with a history of substance abuse.

They often have incredible clinical signs of chronic liver disease, or infective endocarditis. But examiners are not likely to recruit these patients to their exams because they don’t want to deal with the hassle of a patient not showing up, or being under the influence of a substance during an exam.

 

Patients with clinical signs that come and go

I’m sure that if you’ve got as far as entering PACES you’ll have seen patients with pneumonia come into hospital.

It’s the “bread and butter” of a hospital medics daily work.

It can give rise to bronchial breathing, crepitations in the chest or even a parapneumonic effusion – all great clinical signs.

It’s also not very likely to come up.  The patient’s clinical signs would be expected to have recovered in between being recruited and the exam day.

I’m sure you can think of some more examples here.

What you could get is bronchiectasis as a complication of a previous severe pneumonia.  Even though that is less common in day to day hospital medicine, it is more likely to come up in an exam.

Another great example would be a young patient with asthma.  They come in with a widespread wheeze throughout their chest.  But come exam day their chest could easily be completely clear.

COPD, in contrast – much more common in the exam. Those patients have chronic clinical signs.  So it comes up more often.

Patients who make a full recovery before exam day

Obvious, really, when you think about it.

Acute hepatitis.  A bright yellow patient secondary, perhaps, to a drug reaction or poisoning.  Amazing clinical signs while the patient is unwell.

But it gets better.  Or it gets worse and they end up deceased or transplanted.

For sure, you could get patients brought down on the day from the ward with acute liver failure.  But it’s much more probable that you’ll get a patient brought in from home with a transplant or chronic liver disease.

Patients who could get sick during the exam

I see a ton of sepsis in my daily work.

Clammy, peripherally shut-down patients with hypotension and shock.  

Fluids, antibiotics, potentially inotropes – you know the drill.  It’s the sort of thing all medical doctors will definitely encounter repeatedly before they even get close to taking their MRCP PACES.

These patients are not coming to your exam.  Get real.  There is no way an acutely unwell patient who could deteriorate at any time is being brought into your PACES exam to be prodded and poked.

So don’t be diagnosing septic shock in your exam – the examiners would call time on the test long before things reached this point.

Patients who can’t consent

The final category of conditions you’re not likely to see contains those patients who lack the capacity to consent to participate in the exam.

  • Delirium
  • Dementia
  • Persistent vegetative state
  • Previous head injury

And so on.

You’ve certainly encountered at least some of those patients in your daily clinical practice.  Guaranteed.

They’re not likely to come to your exam.

Mini-summary: Cases that are unlikely to come up

Let’s recap.

There are a bunch of things that are common in real life, but uncommon in MRCP PACES due to selection bias.  Here’s the list, plus two examples for each one:

  1. Unreliable patients (alcoholics, intravenous drug users)
  2. Clinical signs that come and go (wheeze in asthma, bronchial breathing in pneumonia)
  3. Clinical problems that recover fully (acute hepatitis, transient ischaemic attack)
  4. Patients who could get sick in the exam (any cause of sepsis, acute left ventricular failure)
  5. Patients who can’t consent (delirium, previous severe head injury)

Cases more likely to come up

You can take the same considerations, and use it to devise a list of clinical conditions that are more likely to come up.

The sort of patients examiners want to recruit are the opposite of the sort of patients in the list above. They want:

  • Reliable patients
  • Stable clinical signs over periods of weeks and months and years
  • Patients who won’t suddenly become unwell in the exam
  • Patients who can consent to participate

That brings selection bias back into the picture.

There are a bunch of clinical conditions which are super-stable over time.  They’re often quite uncommon or rare in clinical practice, but over-representated in the MRCP PACES exam.

Here are some examples:

  • Dextrocardia
  • Acromegaly
  • Post-polio syndrome
  • Neurofibromatosis
  • Tuberous sclerosis

These are examples of conditions that you simply won’t see often while working on the wards. 

 

In fact, there’s a good chance none of these things will present on your wards at all between you applying for MRCP PACES and turning up for your exam. 

 

That’s why the advice to “just spend time on the wards” has shortcomings.

You’ll need to familiarise yourself with this kind of thing before exam day.  That’s ultimately why MRCP PACES courses might have a role to play in your exam preparation – they provide you with access to the same sort of patients that you might not see on the wards.

Our subscribers get to watch 302 HD video cases of all of these cases (and more besides), curated by elite NHS consultants.

The commonest clinical stations in MRCP PACES

We’ve dredged every corner of the internet, every MRCP PACES book, and gotten feedback from all our previous students to form the most comprehensive meta-analysis of what commonly comes up in MRCP PACES.

Read on to learn more…

Methodology

We wanted to create the most accurate summary in existence of what cases can come up in MRCP PACES.

Of course, we can’t tell you will come up in your exam.  

But we can tell you exactly which cases come up most commonly in MRCP PACES, based on the most comprehensive survey ever conducted of previous candidates.

Our sources

To create this “bird’s eye view” of cases that come up in MRCP PACES, we have scoured:

  • All MRCP PACES books we can get our hands on
  • Every account we can find in over a hundred different internet discussion groups
  • The responses of our previous student surveys

We have found over 3,000 different accounts of MRCP PACES exams, and what cases came up for various candidates.

And we’ve tallied and aggregated them for you here to provide the ultimate overview of MRCP PACES cases.

Stations one and three

We’ve listed the ten most common cases for all of respiratory, abdominal, neurology and cardiology.

Cover all these “Top Ten’s” in detail and you’ll have covered a disproportionately large chunk of the curriculum.  There’s a decent chance that if you have a sound ability to diagnose these conditions then you’ll clear PACES entirely..

We can’t promise that these will come up – but know these conditions inside out and you’ll have taken the most rational approach possible to your preparation and placed the odds on your side.

Station five

The number of conditions here is far more varied, as anything can come up (including with actors rather than patients).  We still want you to have a great chance to clear your exam, though – so we’re proud to present a “Top Twenty” conditions to ensure you get adequate curriculum coverage.

Grasp these conditions, and their systemic complications, and you’ll be supremely well prepared.

Station one: respiratory cases

%

Top ten respiratory cases (% of total candidate reports)

  • Interstitial lung disease 21.4% 21.4%
  • Lobectomy 11.1% 11.1%
  • Bronchiectasis 11.1% 11.1%
  • COPD 7.7% 7.7%
  • Pleural effusion 7.5% 7.5%
  • Pneumonectomy 7.1% 7.1%
  • Kyphoscoliosis 6.7% 6.7%
  • Asthma 6.3% 6.3%
  • Rheumatoid lung 5.9% 5.9%
  • Lung transplant 5.0% 5.0%

Station one: abdominal cases

%

Top ten abdominal cases (% of total candidate reports)

  • Transplanted kidney 20.3% 20.3%
  • Chronic liver disease 11.1% 11.1%
  • Hepatosplenomegaly 8.9% 8.9%
  • Hepatomegaly 8.5% 8.5%
  • Splenomegaly 8.2% 8.2%
  • Transplanted liver 7.0% 7.0%
  • Polycystic kidney disease 6.7% 6.7%
  • Ascites 6.1% 6.1%
  • Inflammatory bowel disease 5.9% 5.9%
  • Abdominal mass 5.5% 5.5%

Station three: cardiology cases

%

Top ten cardiology cases (% of total candidate reports)

  • Prosthetic aortic valve 17.2% 17.2%
  • Aortic stenosis 12.0% 12.0%
  • Mitral regurgitation 8.1% 8.1%
  • Aortic regurgitation 6.9% 6.9%
  • Mitral valve replacement 6.4% 6.4%
  • Mitral stenosis 6.1% 6.1%
  • Atrial fibrillation 5.8% 5.8%
  • MItral prolapse 5.0% 5.0%
  • Mixed aortic valve disease 4.9% 4.9%
  • Ventricular septal defect 4.3% 4.3%

Station three: neurology cases

%

Top ten neurology cases (% of total candidate reports)

  • Peripheral neuropathy 14.0% 14.0%
  • Parkinson’s disease 11.1% 11.1%
  • Charcot-Marie-Tooth disease 9.3% 9.3%
  • Abnormal gait 8.8% 8.8%
  • Spastic paraparesis 7.6% 7.6%
  • Cerebellar syndrome 6.8% 6.8%
  • Myotonic dystrophy 6.5% 6.5%
  • Myasthenia gravis 4.6% 4.6%
  • Post-polio syndrome 3.6% 3.6%
  • Acromegaly 3.2% 3.2%

Station five: clinical cases*

*Excludes station five scenarios using an actor rather than a patient.

%

Top twenty station five cases (% of total candidate reports)

  • Rheumatoid hands 7.2% 7.2%
  • Thyroid eye disease 6.4% 6.4%
  • Erythema nodosum 5.7% 5.7%
  • Cushing syndrome 5.1% 5.1%
  • Goitre 4.9% 4.9%
  • Pyoderma gandrenosum 4.6% 4.6%
  • Acromegaly 4.5% 4.5%
  • Neurofibromatosis 4.3% 4.3%
  • Scleroderma 4.1% 4.1%
  • Osler-Weber-Rendu 4.0% 4.0%
  • Ankylosing spondylitis 4.0% 4.0%
  • Psoriatic arthropathy 3.8% 3.8%
  • Lupus pernio 3.7% 3.7%
  • Dermatomyositis 3.5% 3.5%
  • Tophaceous gout 3.3% 3.3%
  • Tuberous sclerosis 3.3% 3.3%
  • Vitiligo 3.0% 3.0%
  • Osteoarthritis 3.0% 3.0%
  • Marfan syndrome 2.8% 2.8%
  • Sturge-Weber syndrome 2.8% 2.8%

Section author

Dr Nidhi Gupta

Consultant physician

What comes up at specific hospitals

It’s super-common for candidates to find out their exam location and date, and immediately try to figure out what cases have come up at that hospital previously.

Facebook is full of such questions – you really don’t need to look far on the discussion groups there to find examples of this.

In this section we discuss what you should and should not be able to infer from your exam location.

 

Examiners

The examiners will be different each time at the centre as they are brought in from other hospitals, so a previous candidate’s experience will not be the same as yours. MRCP PACES examiners are always brought in externally from around the country in the UK exam centres in order to ensure that the exam is examined impartially and objectively.

The examiners will change from one exam diet to the next and hence one candidate’s experience of the exam in the previous diet will not be directly relevant to future experiences.

Specialist centres

There might be some marginal benefit if you look up the hospital online to find out if they are a specialist centre for a specific condition. For example, St. Thomas’s Hospital in Central London is the national centre for post-polio syndrome.  As a result in the neurology station you are more likely to have a patient who has had a previous polio infection compared to other UK centres.

It might be a good idea to look at the hospital online and see if they have specialist clinics or are a centre of excellence for a certain condition.

However it is also useful to remember that common conditions occur commonly.  Your time is best spent familiarising yourself with the common conditions in our meta-analysis above.

Regional accents

If you are not a UK native, then you should watch some videos online to familiarise yourself with the regional accents. A lot of non-UK born candidates struggle with the regional accents that are within the UK.

Glasgow, for example, is notorious among doctors from the Middle East and the Indian subcontinent due to patients’ regional Scottish accent. However they are not the only region with a distinctive accent and other regions such as Newcastle, Liverpool, Manchester, and the South-West of England have very different accents.

This is not an exhaustive list but when you receive your centre information it is a good idea to search on YouTube for accents related to that region so that you can listen to the speech and get a feeling and understanding if English is not your first language and if you have not been brought up in the UK and hence have not experienced these accents on a regular basis.

Exam day practicalities

Another feature of a hospital exam centre is not only the exam but the practicalities travel and accommodation. Before you book your accommodation and travel it is a good idea to look through website such as TripAdvisor and Lonely Planet which can give you local advice about accommodation and travel.

Also remember that hospitals have their own accommodation and they might be able to provide you with a room on the hospital site for a fee.  Each hospital will have their own resources and their own fees but you can easily contact the hospital by searching their phone number on their website and going through initially the switchboard and then asking for the ‘Postgraduate Medical Centre’.

Each hospital in the UK has a dedicated postgraduate education unit and the MRCP PACES exam at that centre will be organised locally through this department. As such they will be able to inform you whether they can provide you with accommodation and how much it would cost or otherwise give you local advice about hotels that are nearby and travelling options.

When researching your exam centre it is important to make sure that there is at least 3-4 hours after the official end of your exam before you travel away from the exam centre.  If there are delays in the exam you do not want to be worrying about travelling afterwards and only want to be focusing on the exam.

By having a few hours afterwards the worst that will happen is that you have to find a local cafe and have a cup of tea and cake whilst you wait for your bus or train.

What not to worry about

Finally, it is important to realise that spending your time trying to find out about people’s experiences of a specific centre is not going to improve your chances of passing the MRCP PACES.

You are better off spending your time practising your examination skills,  practising history and communication scenarios and making sure that you have covered the entire curriculum.

If you spend your time trying to find out information about a specific centre that is time spent away from practising your clinical skills. Trying to find out other candidates’ experiences from two years ago will be extremely unlikely to help you pass.

Focus on being a better doctor.

Conclusion

We really hope you’ve found this guide to what comes up in the MRCP PACES exam useful.

Do you think we’ve missed something?  Just click the “Feedback” tab on the side of your screen or drop me an email.

If you suggest something sensible, we’ll add it.

Like it?  Love it?  Why not help out your colleagues by sharing this post?  Just use the share buttons in the popup or on the side of your screen.

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Until next time!

Ed and Nidhi

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