1 The PACES CarouselWHY PACES?PACES is the acronym for ‘Practical Assessment of Clinical ExaminationSkills’, the practical component of the MRCP examination. It was firstheld in June 2001 replacing the previous clinical (long case and shortcases) and oral examination. The introduction of a huge revision of theexamination involved major changes for candidates, examiners,teachers, local organisers, and central administration throughout theworld.What are the Aims of the PACES Examination?The aims of the PACES examination have been clearly stated in thecurriculum (MRCP(UK) Part 2 Clinical Examination (PACES) and clinicalguidelines 2001/2). They are to:• Demonstrate the clinical skills of history taking• Examine a patient appropriately to detect the presence or absence of physical signs• Interpret physical signs• Make appropriate diagnosis• Develop and discuss emergency, immediate and long-term management plans• Communicate clinical information to colleagues, patients or their relative• Discuss ethical issues
2 Revision Notes for MRCP 2 PACESHow does the PACES Carousel Work?Five candidates rotate through five 20 minute stations, separated byupto 5 minutes for change-over and waiting (Fig. 1.1). The cycle beginswith a five minute wait which enables candidates at the two talkingstations (stations 2 and 4) to read the introductory material, whilst theother three hopefully relax. The whole cycle therefore lasts 125 minutes;it can be entered at any station and, thereafter, the five candidates followthe same sequence. Two of the clinical examination stations are doublestations; two systems, respiratory and abdominal, at station 1, andcardiovascular and central nervous, at station 3, are each examined forten minutes. Station 5 is now an assessment of a focussed clinicalproblem of the type that you might be expected to see in higher specialisttraining. Figure 1.1: Carousel of PACES stations The talking stations, stations 2 and 4, begin with an al limportantwaiting period outside the room, when the candidates read theinstructions and introductory material and should devise an action planfor what is to follow. Within the station, they will spend 14 minutestalking to the patient/subject or surrogate, followed by one minute’sreflection, during which the subject usually leaves the room and, then,a five minute discussion with one or both examiners.
The PACES Carousel 3TimeTime-keeping is a key to success for both the PACES examination andthe candidate to succeed. The traditional system of bells and verbalwarnings are used together with additional prompts, for a slowcandidate running out of time. Bells are rung at the beginning and endof the five 20 minute stations and, usually, at 10 minutes in the twodouble stations (1 and 3). The examiner will often draw the candidate’sattention to a clock, or, better still, will start a stop clock in the room. Inthe two talking stations (2 and 4), a verbal 2 minutes warning will begiven at 12 minutes. Time management is also increasingly importantin every clinician’s daily work. Although, it is not explicitly tested inPACES, it is implicit in the strict, but relevant, time limits set to undertakethe various tasks. It may occur to the candidates that if they prolong their timeexamining a patient, it may shorten the discussion time (and, of course,potential hostile questions). This is not advisable; although examinerswill award some marks for the candidate’s examination technique theyare observing, the majority of marks will go to the candidate’s correctclinical findings, the interpretation of them in a diagnosis or differentialdiagnosis, and discussion of further relevant management. As in allexaminations, the way to avoid difficult questions is for the candidateto be pro-active and try, if possible, to control the discussion by talkinggood sense. Most examiners will not interrupt them if what they aresaying is relevant. Examiners get irritated by the slow candidate who,in addition, may go back to repeat their examination, suggesting a lackof confidence in their findings. The times allocated for the tasks you are given at each station, andsubstation, are realistic by the standards that apply in everyday practice.On exception to this, which was soon appreciated by PACES examiners,is that candidates would not have time to perform a full neurologicalexamination, in the detail specified in the guidelines, in the timeallocated. The solution lay in the introduction to the case wherecandidates should be directed specifically to which part of the CNSthey would be required to examine, e.g. “the arms”, “the legs”, “thecranial nerves”, “speech” etc. Such limitation placed on the examinationof a particular system should not preclude the candidate from sayingin their presentation that he or she would investigate further. A generousexaminer would even supply the missing information! If you are uncertain about the instructions given relating to theexamination, or any other aspect of the case for that matter, please ask
4 Revision Notes for MRCP 2 PACESthe examiner for clarification. Examiners will frequently ask thecandidates, after they have read the written instructions, “Do youunderstand?”MarksheetsYou must be familiar with the contents of the seven marksheets as theyare the cornerpiece of the PACES examination. They are easily accessed,either on the website, or in the Regulations (free), in the references above.More than recording the marks awarded, they contain the necessarydemographic information and detailed breakdown and checklist of thecomponent parts of each problem posed at each station. This is essentialto the fairness of the marking systems and also enables detailed feedbackto be given to candidates, as well as forming the basis of counselling onthe rare occasions that this is recommended. Each marksheet has four sections and, partly, uses boxes to be filledusing a 2B pencil, to facilitate computer scanning:1. CandidateThe candidate prints their NAME and fill in their EXAMINATIONNUMBER and the CENTRE NUMBER boxes on each of the seven pairsof sheets handed to them by the organising registrar (the sheet numberboxes corresponding to the station is already filled in).2. ExaminerThe examiners write in (a box) a brief description of the CASE followedby PRINTING and SIGNING their name, and, finally, theirEXAMINATION NUMBER.3. Conduct of CaseExcept for Station 5 (Marksheet 7), which is appreviated, there are threeparts for the four major clinical substations. At stations 1 and 3, the first part is headed “Physical examination”,followed by bullet points relevant to that system; the second part isheaded “Identification and interpretation of physical signs” with threebullet points: “Identifies abnormal physical signs correctly”, “Interpretssigns correctly”, and “Makes correct diagnosis”. The third part is headed“Discussion related to the case” with two bullet points: “Familiar withappropriate investigation and sequence” and “Famililar withappropriate further therapy and management”.
The PACES Carousel 5 These second and third parts are identified for the four majorsystems (marksheets 1, 2, 4 and 5) and examiners are expected for eachof the three parts to fill ONE of the four boxes: Clear pass, pass, fail,clear fail. Station 5 (marksheet 7) is divided into the four minor systemsexamined and each, in turn, subdivided into the three parts discussedabove (which now become bullet points as there is no room on thesheet to subdivide them further). For each of the four systems overallthe examiner is required to fill ONE of the four boxes as above. Thecrucial part of each marksheet is the bottom line – mirroring life. Thebox in the bottom right-hand corner requires the examiner to makean “overall judgment” using the same four item scale which istranslated into marks: clear fail – 1 mark, fail – 2 marks, pass – 3marks, clear pass – 4 marks. Adjacent to it is a “Comments” box whichevery examiner must complete to explain the decision to give a fail orclear fail. If the examiner is particularly concerned about some aspectof the failure which needs to be further explored with the candidate,another adjacent box, “Counselling Recommended”, is filled in. Thiswill NOT automatically lead to the candidate being counselled butwill be discussed with the other nine examiners, at the completion ofthe cycle, to decide whether further action is required. The format of the marksheets for the two talking stations, Station 2(History Taking) (Marksheet 3) and Station 4 Communication Skills(Marksheet 6) have the same tripartite structure as those for the majorclinical systems, appropriately adapted, but requiring each examinerto fill in boxes, as well as, identical to the other sheets, the overalljudgement, comments, and counselling boxes. Thus, the first part ofMarksheet 3, is “Data gathering in the interview”. The second is“Interpretation and use of information gathered”, and the third,“Discussion related to the case”, all with appropriate bullet points, andthe examiner (and candidate). Similarly, in marksheet 6, the three partsare headed “Communication skills – conduct of interview”,“Communication skills – exploration and problem negotiation” and“Ethics and law” (The bullet points are described below under the twostations). The marksheets can be downloaded from the official MRCP website:http://www.mrcpuk.org/Pages/Home.aspxMarking SystemThe overall judgement that determines each examiner’s mark is notintended to be the numerical mean of the intermediate assessments
6 Revision Notes for MRCP 2 PACESmade in the various sections of marksheets 1 – 6, or, even, of theseparate marking of the four minor systems in marksheet 7. This isbecause each box filled does not carry equal weight. The value of themultiple judgements is primarily in providing feedback to candidatesbut also enhances broad objective marking by the examiners. It mayhelp to avoid that they be not overimpressed by one thing the candidatehas done well, ignoring several things not well done, or vice versa. Afurther aid to the examiners, available to candidates at the same sourcesas the marksheets, are the anchor statements. Thse try to givesubstance to the four gradings in assessment, under six headings:“System of examination”, “Language and communication skills” (inpatient encounters when examining clinical systems as well as thetarking stations”, “Confidence and rapport”, “Clinical method”,“Discussion and appreciation of patient’s concerns” and “Clinicalthinking”. When writing comments on a candidate who is being givenan overall fail or clear fail, examiners are encouraged to selectappropriate statements that define the mark; evenn if the patientachieves an overall pass or clear pass, it can still be helpful to pointout deficiencies (along the way) as an individual examiner will knownothing of the assessment by the other nine examiners until afterwards. The pass mark for each of the three diets of PACES held annually isagreed by the Clinical Examining Board at end of the examination. Themaximum mark attainable by a candidate is to receive a clear pass fromeach examiner at every station or substation: 14 × 4 = 56. The minimummark would be 14 × 1 = 14. An “ideal” cut off would be that the candidateshould get a pass from each examiner: 14 × 3 = 42. Often the pass markis simply 41.ExaminersExaminers are widely recruited. There is no lower age limit but theywill usually have been consultant physicians, or equivalent, for atleast4 years, and have been elected FRCP of one of the UK colleges. Theymust have some acute general medicine content in their workingpractice; therefore, superspecialists may not be eligible but cancontribute to question-setting. Examiners usually retire within 1 to 2years after retirement from active clinical practice. Increasing emphasisis placed on examiner training at regular sessions and briefing beforeeach examination. Observation of an examination, before actuallyexamining, is mandatory. Others with an interest in the examination(teachers, course organisers, examiners from other colleges, and
The PACES Carousel 7disciplines) may also observe and their non-participatory role will bemade clear to the candidate. The performance of examiners is remarkably consistent. Before eachcarousel, the paired examiners will see the patients or role players(surrogates) together and assess the ease or difficulty of a case. Theywill agree the criteria they will use in independently awarding the fourgrades/marks available. When the candidate has left the examinationroom each examiner completes the marksheet and puts it into acollecting box before finding out the co-examiner’s mark. There is exactconcurrence within one mark in over 95% of candidate-examinerencounters and exact concurrence in 60%. If necessary, a brief discussionof any discrepancy within a pair takes place before the next candidateenters.PatientsIt is a privilege that patients help with the examination, and it is thereforeit is vital that you are as courteous and kind as possible to the patients.Failure to introduce yourself to and respect these patients – a pointwhich will be repeated in this text – is unacceptable. Many patients arenervous about participating, and also are concerned about sayingsomething that we fail you. Please be courteous to them. Many patientsask afterwards how successful you have been and are genuinelyconcerned you do well!Aseptic TechniquesIt would be a disaster for the Royal Colleges if patients attended theexamination and then developed some form of transferred infectionsuch as MRSA which can be tracked back to the examination. Aqueousgel or hand-washing facilities should be available, and should be usedbetween all patients.REFERENCE MRCP(UK) Part 2 Clinical Examination (PACES): A review of the first four diets (June 2001 – June 2002). J Dacre, GM Besser and P White on behalf of the MRCP(UK) Clinical Examining Board. J R Coll Edinb 2003;33:285-92.