Presenting the Diagnosis in MRCP PACES

I spoke to a candidate who had failed the MRCP PACES at his last attempt. We discussed presentation of findings to the examiners and in particular how to present one’s diagnosis.
I asked him how he had presented the diagnosis of the cases he had seen at the examination and the information he gave me was inadequate. He gave basic information but left out very important facts concerning function of the system concerned and aetiology.
This led us to discuss diagnosis in detail.
I realised that this candidate had not analysed what is meant by diagnosis and had not studied this in depth.
When coming to a diagnosis it is important to make this as complete as possible and find out about the organ or system concerned, the pathology affecting the organ or system, the aetiology of the illness and the function of the organ or system
In other words it is important to elucidate the four components of a diagnosis:
Anatomical diagnosis (where is the lesion)
Pathological diagnosis (what is the pathological process)
Aetiological diagnosis (what is the cause of the lesion)
Physiological diagnosis (what is the function of the organ or system concerned)
If one presents one’s diagnosis in this manner it will demonstrate to the examiner that one is thinking clearly and this is likely to influence the marks obtained.
For an analysis of diagnosis, the four components of diagnosis and checklists for use in situations where it is difficult to come to a diagnosis; see chapter 3 of ACES for PACES

MRCP PACES Respiratory Station

I spoke to a candidate who failed the MRCP PACES. We discussed the case he had at the respiratory station.
He had a case of fibrosing alveolitis (interstitial lung disease). He said he easily made the diagnosis and knew everything about fibrosing alveolitis and was waiting for the examiners to ask him about fibrosing alveolitis so he could display his knowledge.
Unfortunately for him this was the MRCP PACES and what was being assessed was demonstration of practical examination and evaluation skills not, encyclopaedic knowledge of theory.
He was asked how he would demonstrate clubbing (see ACES for PACES pages 107,126) and he was then asked about the causes of clubbing (see ACES for PACES pages 126,254)
He was also asked about cyanosis and the types of cyanosis (see ACES for PACES page 116)
He made crucial mistakes in these basics and did not satisfy the examiners.
This is quite a common error. Many candidates prepare for PACES by studying all the details of likely cases rather than going through the basics. The examiners are looking to see if the candidate demonstrates ability to examine a patient correctly and then interpret the signs obtained.
Theory knowledge has already been assessed in parts 1 and 2 and will not be assessed here.

Fail MRCP PACES physical examination stations

I had discussions with several examiners for the MRCP PACES. I asked them how they would decide on passing or failing a candidate at the physical examination stations.
They all said the first thing they look at is how well the candidate examines the patient. If the candidate does not demonstrate correct technique or if they do not examine with ease then they would fail the candidate.
If the candidate passes this first hurdle the next step is whether they detect the physical signs present. With regard to physical signs they would not mind if a difficult sign was missed but they all said they would definitely fail the candidate if they “ made up physical signs”. That is if the candidate tells the examiner that the patient has a physical sign that is not there then, the examiners will definitely fail them. I asked several candidates how they prepare for the exam and they said they memorise the physical signs of the likely cases in the exam.
This technique of exam preparation is incorrect.
This is the reason why a lot of candidates fail the exam despite examining correctly and making the correct diagnosis. Memorising the physical signs and repeating this at the exam instead of telling the examiners the findings that are present in the case in question is why most candidates fail.
So in summary the main reasons for failing the MRCP PACES physical examination stations are:
1) Incorrect technique
2) Making up physical signs