Top Tips for PACES Success: An Examiner Speaks
I have been an examiner for the Practical Assessment of Clinical Examination Skills (PACES) since dinosaurs walked the earth (or at least since the exam started). The following views are entirely my own and based on my observations of hundreds of candidates I have seen during that time.
•The cases are usually straightforward with clear-cut physical signs.
Centres are actively discouraged from selecting rare or esoteric conditions. Patients with physical signs sometimes come to the exam on an annual basis, and occasionally their physical signs may become less obvious over time. If this is the case, an allowance will be made during ‘ calibration’ ; a process prior to the exam where the two examiners at that station examine the patient independently, compare findings and make an assessment of the abnormalities a candidate might be reasonably expected to find.
•I am often asked, ‘ What is the standard required to pass PACES?’
There are of course strict marking criteria for each station, but the majority of examiners are ‘ jobbing’ physicians; we don’ t expect super specialist levels of knowledge. For most of the time, we are examining cases outside our own speciality. For me, the overall benchmark is, ‘ Would I feel comfortable with this doctor running the general medical take in my hospital?’
•Practise, practise, practise!
I am afraid it’ s all too easy to spot a candidate who isn’ t wholly comfortable doing a physical examination. Get a senior colleague to critique your exam technique: it is important that you have a structured approach that you could do almost automatically.
•You will not pass unless you can identify physical signs.
Part of this is pattern recognition: once you have felt polycystic kidneys, you are likely to correctly identify them in the future. The longer and more diverse your clinical experience is, the more likely you will be to detect physical signs because you have seen them before. When you think about it, the types of physical sign you are likely to come across in each station are fairly limited, so when preparing for PACES, sit down and make a list of your deficiencies and make sure you have seen all the common abnormalities at least once, even if that means visiting other hospitals. I am not generally a fan of commercial courses, but this may be an area where they can help if your exposure to abnormal physical signs is limited. The other common problem is candidates who ‘ look but do not see’ ; in other words, they go through the motions of the examination almost by rote but do not find the abnormalities they are ostensibly looking for.
•Not every patient in the exam will have something to find.
So don’ t make things up! Abdominal and chest cases particularly may only have a scar to find. In general, if you can’ t find anything wrong, then you are probably correct.
Station 5 carries a lot of marks, and the time available is limited. You have to be able to talk and examine at the same time; the good news is that the tasks you are given and any examination findings are usually pretty straightforward. Don’ t try to examine too many systems at once; read the introductory statement and allow that to focus your history/discussion and examination. The examiners realise you will not be able to do everything, so concentrate on what you think is important.
•Timing is everything.
When practising, make sure that you take 6 minutes to complete your abdominal, respiratory, cardiology and focused neurological examinations. Finish too early and you are likely to have missed something and exposed yourself to extra questioning. Too late and you will have failed to pick up the appropriate signs. In general, in the talking stations you should have plenty of time to complete the required task, so go through the history or the communication issue in a steady, structured way, clarifying things where necessary and avoiding repetition. Try not to finish early; if you do, you are very likely to have missed something. When you are sitting outside the station in the 5 minutes after reading the clinical information, list your structured approach to problem, questions to cover in the history-taking station and important issues that need to be addressed (and questions to be answered) in communications skills.
•Don’ t waste time.
Especially on unnecessary ‘ peripheral’ examinations; spending 3 minutes examining for a collapsing pulse will not give you time to palpate the precordium and listen to the heart properly. If you discover a displaced apex and a diastolic murmur, you can go back and do it later.
•Honesty is the best policy.
Don’ t make up physical signs because you think they should be there or you think that’ s what the examiner wants. In the talking stations, if you don’ t know the answer to the surrogate’ s question, say so, but explain why and how you will obtain the information.
•Don’ t beat about the bush.
Candidates who are not confident about things will sometimes be deliberately vague when describing their findings; this is unlikely to help. The examiners will press you to clarify things, so it’ s best to come clean early on, describing what you have found, what it could be and why.
•Always answer the question.
In the talking station, the surrogate will have been primed with questions or concerns. A good candidate may answer most of these during the consultation. But if asked a direct question by the surrogate, you should usually try to answer it there and then. Occasionally, you may feel you have not gathered enough information to do so, in which case you can say so and return to the question later, but do not forget that failure to address the ‘ patient’ concerns is a common cause of poor marks in Stations 2 and 4.
•Create an impression.
Wear comfortable but smart clothing; it’ s not a fashion show, but you should look professional – so no jeans or short skirts. Don’ t weigh yourself down with equipment; all you need is a stethoscope. Everything else will be provided, and bringing more stuff just means a greater chance of dropping it or leaving it behind at one of the stations.
•Read the introductory statement carefully.
Particularly in the neurological station, it should tell you which area to focus on; it is impossible to do a complete neurological examination in 6 minutes. In the other stations, it is likely to guide questioning, particularly when assembling the list of possible causes of the physical findings.
•Be kind to the patient and try to look as though you are enjoying yourself.
Not an easy thing to do, but handling the patient with courtesy and good humour will set you in good stead with the examiners and show that you are an experienced clinician.
•Finally, the examiners genuinely want you to pass.
You may not believe it or feel like it at the time, but it’ s true. We have been in your position ourselves at some stage and realise how nerve racking it is. You will need to meet the required standard, but we will give you every opportunity to demonstrate that you can, given the confines of the examination structure. During questioning, the examiner may try to lead you towards a diagnosis; this is not a plot to try to trick you into saying the wrong thing but is usually a genuine attempt to make you clarify your views on a clinical problem.
Anonymous reviewer