Saturday, June 23, 2007


I spoke to two MRCP PACES examiners last week. One was a senior examiner who had been involved in the PACES exam since its inception and the other was one who examined for the first time this diet. Both had the same views when it came to marking candidates.
They stressed that what was most important was correct method. They observed the candidates going through history taking, clinical examination and communication and noted whether they appeared competent in the skill they were demonstrating. If they demonstrated competence they were most likely to pass.
If the candidate failed to demonstrate competence at history taking, clinical examination and communication then they would fail even if they got the findings right.
One of the examiners gave me two examples of candidates who examined the abdomen and the respiratory system. Both had what he described as appalling technique but both were able to give all the findings when asked. However, both failed, as the exam is a judge of the ability of the candidate to demonstrate or show competence in clinical method rather than an ability to memorise the findings in a given condition.
The secret of passing the PACES examination is practising clinical methods (history taking, physical examination and communication) over and over again until you can do it without even thinking about what comes next. Then you will pass with ease

Saturday, June 02, 2007

History Taking, Communication and Ethics for MRCP PACES

We had a discussion regarding these two stations. Every medical student begins learning clinical skills by learning how to take a history. By the time a doctor takes the MRCP PACES examination these skills should be second nature to him or her. Then why are so many failing in this station?
We discussed this further using examples of scenarios.
The first thing to remember is that most of the stations involve simulated patients or relatives. They have been told what to say regarding a certain condition or situation. If one asks a question they will answer according to the instructions given. If they are not sure, they will give you the answer rather than risk hiding an important fact and prejudicing the candidate’s chances.
What are the questions one should ask?
The questions to be asked in history taking are standard and these should not present a problem. (Presenting complaint, past illnesses, drug history etc)
The questions that one should ask to make the history more relevant and display maturity on the part of the clinician are the extra questions that are not yet considered standard.
These questions are regarding the beliefs, expectations, anxieties or concerns of the patient. If they are not asked very important information is missed out and this is usually the cause of failure especially in the communications and ethics station.
If one does not take into account the thoughts and views of the patient or the concerned party, then the explanation will lack focus on the situation in and will simply be a general explanation which may not suffice in that particular situation.
To make sure that you take into account these additional parts of the history, use the mnemonic:
I PASSED By Employing ACES (see ACES for PACES chapter 4, chapter 18)
The second part of these stations is delivering an explanation to the patient or concerned party regarding the situation. This explanation is best given by telling them in simple language what one’s own beliefs, expectations and concerns are regarding the situation (ACES for PACES chapter 18)
By having such a framework for assessing and explaining, the whole process becomes methodical and thus simplified.
We went through several scenarios using this method.
A scenario concerning a pregnant woman who has a deep vein thrombosis; the concern of the patient is that the treatment will cause harm to the foetus. If this concern is not elicited and addressed the explanation would be deemed unsatisfactory.
Similarly, a patient with a stroke and the scenario is regarding feeding, the relation may be concerned that not feeding and starving the patient may cause distress or on the other hand the concern may be that feeding would prolong the patient’s suffering. Hence it is important to elicit these thought and views and address these anxieties.