20/03/2023
How PACES is marked
Before the exam starts the examiners calibrate all do cases at each station. This involves agreeing on the specific areas that a candidate needs to cover in order to be awarded a ‘satisfactory’ mark. Their criteria are based on the guidance they are provided on the marksheet and also by the expectations of how a competent trainee doctor entering higher specialist training (ST3 in the UK) should perform.
PACES is marked on seven skills, A-G. Skill B, identifying physical signs, is often considered the most challenging skill to pass.
Skill A: Physical examination (stations 1, 3 and 5)
Skill B: Identifying physical signs (stations 1, 3 and 5)
Skill C: Clinical communication (stations 2, 4 and 5)
Skill D: Differential diagnosis (stations 1, 2, 3 and 5)
Skill E: Clinical judgement (all stations)
Skill F: Managing patients’ concerns (all stations)
Skill G: Maintaining patient welfare (all stations)
General tips to help you improve
If you feel that you have done badly at one station, it is important that you try and remember this will not affect your marks at the next station and that you can still pass the exam. Use the 5 minutes to concentrate on the next station and not to reflect on what went before. This can be particularly difficult at stations 1 and 3 where you have no scenario to read. Examiners realise that you may be anxious, and that this can affect performance. The more you practice, the easier you will find it to keep your anxiety under control.
Skill A: Physical Examination
You must demonstrate good technique when examining the major clinical systems (respiratory, abdomen, cardiovascular and neurological) in a thorough and methodical manner. At stations 1 and 3, you have to complete your examination in no more than 6 minutes. In station 5, you must be able to perform a focused examination of the areas relevant to the scenario you have read and the history you have obtained from the patient in front of you. You should start the examination at the same time you obtain the history.
Reasons why you may not have passed Skill A:
not examining in a systematic way
using incorrect techniques
missing out significant parts of the examination.
Reasons for being marked down:
your examination was hesitant or lacking confidence
examining in an unprofessional way
examining the patient through their clothing.
Tips to help you improve
Examine as many patients as possible, including those without clinical abnormalities.
Have your examination technique for the various systems observed by your clinical supervisor or by other more senior colleagues who can give you critical feedback.
Use a timer when you practice to make sure you know how long you have to perform each aspect of the examination.
Skill B: Identifying physical signs
You must be able to identify the key clinical signs that are present and also, and just as importantly, you must not report clinical signs that are not present. You need to be able to present these signs in a logical and clear manner to the examiners during discussion.
Unsatisfactory performance in Skill B is one of the most common reasons for not passing PACES. The ability to identify physical signs is one of the most important skills of a physician, even in the era of relatively easy access to investigations. Confidence in this skill comes with practice.
Reasons why you may not have passed Skill B:
not identifying the physical signs that were agreed to be present by the examiners during calibration
finding physical signs that were not present.
Tips to help you improve
Examine as many patients as possible, in a systematic manner, including those without abnormal clinical signs, so that you are comfortable identifying and reporting when physical signs are not present.
Discuss with your clinical supervisor, and ask your clinical colleagues to observe you examining consenting patients with clinical signs in all of the relevant systems.
Ask colleagues from a range of specialties to observe you examine consenting patients, and discuss both your examination technique and examination findings with them.
Skill C: Clinical Communication skills
Clinical communication skills are examined in a variety of ways, depending on the station. Being able to communicate clearly is essential to get an accurate history so that the underlying medical, personal and social issues can be addressed. This skill is also important for patient safety.
In station 2, you must be able to take a systematic and thorough history, identify the patient’s concerns and agree a management plan in no more than 14 minutes.
In station 4, you must be able to explain relevant clinical information in an accurate, clear, and structured manner. You are expected to lead a structured interview, yet remain flexible enough to respond to the questions and concerns of the patient or surrogate. You should spend the full 5 minutes reading the scenario to ensure that you are clear about the task you have been asked to perform.
In station 5, you are required to take a focused history based on the scenario you have been given.
Reasons why you may not have passed Skill C:
not explaining the relevant clinical information in an accurate or clear fashion
missing out important information
giving inaccurate or unclear information
using information that includes too much specialist language that the patient did not understand, or was unprofessional.
Tips to help you improve
Reflect on the comments on your marksheets and discuss them with your educational supervisor or a senior colleague.
Practice information gathering and information giving as often as possible; ask patients for their feedback as well as being observed by senior colleagues.
If English is not your first language, practice speaking English as often as possible, including the use of medical terms which you should try and convey in easy to understand terms in order to avoid the use of confusing specialist language.
Practice using the sample station 2 and 4 scenarios on the MRCP(UK) website. These are very similar to those you will encounter in the examination and are an excellent source of practice material.
Ask one of your senior colleagues to watch you taking a history or communicating with a patient or surrogate.
Skill D: Differential diagnosis
Differential diagnosis is a ‘linked’ skill, this means that if you failed to identify the physical signs present (Skill B), you will also be marked down on differential diagnosis. You must include the correct diagnosis and indicate an appropriate differential diagnosis for the patient in front of you. You should mention the most likely diagnosis first. A good differential diagnosis for the wrong signs will not be regarded as satisfactory.
Reasons why you may not have passed Skill D:
giving a poor differential diagnosis
failing to consider the right diagnosis
giving a ‘textbook’ list, rather than a list of likely diagnoses that are relevant for the patient you have just seen.
Tips to help you improve
Practice discussing the differential diagnosis for all patients you see, and ask for feedback from your colleagues.
Discuss with your clinical or educational supervisor, or with a senior colleague, and practice case-based discussions of patients.
Arrange to be observed examining patients and formulating a differential diagnosis.
Skill E: Clinical judgement
Clinical judgement is a ‘linked’ skill. If you failed to identify the physical signs (Skill B) and particularly if you fail to consider the correct diagnosis (Skill D), you will also be marked down on clinical judgement. You must be able to suggest appropriate investigations and discuss a sensible management plan for the patient you have just seen. Good management of the wrong condition will not be regarded as satisfactory.
Reasons why you may not have passed Skill E:
not seeming familiar with the correct management plan
suggesting inappropriate investigations or management for the patient
failing to identify the correct clinical signs, or to reaching the correct diagnosis which led to suggesting an incorrect management plan.
Tips to help you improve
Reflect on any feedback on the marksheets and discuss it with your clinical and educational supervisors, or with a senior colleague.
Ask senior colleagues to observe you examining as broad a range of medical patients as possible, and follow this by discussion of differential diagnosis, appropriate investigations and management.
If you feel the exam exposed some knowledge gaps, review the areas you covered in the written exams.
Skill F: Managing patient concerns
The ability to identify the patient’s main concerns is important to ensure a satisfactory consultation. All scenarios for stations 2, 4 and 5 have specific questions for the patient or surrogate to ask of the candidate. You must demonstrate that you have asked the patient/surrogate if they have any questions and then answer them accurately and sympathetically. You should ensure that the patient has understood your explanation and discussion.
Reasons why you may not have passed Skill F:
not exploring the patients’ concerns in enough detail or not addressing the concerns in a satisfactory manner
not really listening to the patient/relative
talking over the patient/relative
not checking that the patient/relative understood what you had discussed
appearing unconcerned and failing to build a rapport with the patient
running out of time to ask the patient/relative if they have any questions and to answer them.
Tips to help you improve
Review any comments on the marksheets to help you identify areas of weakness.
Reflect on where things might have gone wrong during each scenario and discuss this with your educational supervisor or a senior colleague.
When you are interacting with patients, focus on identifying their concerns, and ask for feedback on your performance.
If English is not your first language, use every opportunity to practice potential scenarios.
Use a timer during practice to ensure that you leave sufficient time to specifically ask the patient/relative if they have any questions or concerns.
Skill G: Maintaining patient welfare
Ensuring that the patient is treated with dignity and sensitivity is an essential part of safe practice, and is crucial to the doctor-patient relationship. If you have failed on Skill G, the examiners have felt you did not treat the patient with sufficient respect and sensitivity, or have failed to ensure their comfort or safety. You may have caused the patient emotional or physical discomfort that concerned the examiners. You may have been felt to make decisions that jeopardised the patient’s safety. Your marksheets may tell you the specific areas of concern.
Tips to help you improve
Reflect on any comments on the marksheet and discuss it with your educational supervisor, or with a senior colleague.
Think about how you would like your relatives to be examined or cared for.
