Third Edition
This edition first published 2015 © 2015 by John Wiley & Sons, Ltd.
Previous editions: 2010, 2003 © Stephen Hoole, Andrew Fry, Daniel Hodson & Rachel Davies
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Library of Congress Cataloging-in-Publication Data
Hoole, Stephen, author.
Cases for PACES / Stephen Hoole, Andrew Fry, Rachel Davies. – Third edition.
p. ; cm.
Preceded by Cases for PACES / Stephen Hoole … [et al.]. 2nd ed. 2010.
Includes index.
ISBN 978-1-118-98357-7 (pbk.)
I. Fry, Andrew (Nephrologist), author. II. Davies, Rachel, active 2015, author. III. Title.[DNLM: 1. Physical Examination–Examination Questions. 2. Ethics, Clinical–Examination Questions. WB 18.2]
RC66
616.07′5–dc23
2014049398
A catalogue record for this book is available from the British Library.
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We are – as always – in a time of flux, with medical careers and the organization of hospitals needing to adjust to meet changing demands. But the fundamental essentials of the practice of clinical medicine have not changed at all. The doctor needs to be able to take a history from a patient, examine them and decide whether investigations and/or treatment are required. They then need to be able to discuss the various options with the patient in an appropriate manner, hopefully reaching a sensible mutual understanding about how best to proceed. The doctor may need to give difficult and distressing information, and must learn how to do it in a way that is clear and does not duck the issues, but also does not increase the pain. And all of these things must be done in a reasonable time frame: the next patient is waiting.
The MRCP PACES examination remains the measure that is most generally respected as indicating that a doctor has developed a fair degree of the knowledge, skills and behaviours that are necessary to do the things detailed above. They are not yet the finished article (beware of anyone, including any consultant, who thinks they are), but they can proceed from core to specialist training. The examination is not easy, with a pass rate of around 40%. Those preparing for it need to immerse themselves in clinical work. There is no substitute for seeing a lot of cases and taking histories and performing examinations, but – and here is where books such as Cases for PACES come in – endless repetition of sloppy practice isn’t helpful. The physician examining you in the PACES examination is thinking: ‘Is this doctor ready to be my SpR now? Can they sort things out in a reasonably efficient and sensible way? Would I get a lot of people wanting to see me because problems had been explained or dealt with poorly?’
What comes over in Cases for PACES is a pragmatic and sensible approach that sorts the wood from the trees and cuts pretty rapidly to the chase. I recommend it to you: if you do what it says you will stand a better chance of passing the examination than if you do not.
Consultant Physician, Addenbrooke’s Hospital, Cambridge
PACES Examiner
PACES (Practical Assessment of Clinical Examination Skills) was initiated in June 2001 by the Royal College of Physicians as the final stage of the MRCP examination. The initial examination consisted of five stations in a carousel: Station 1, Respiratory and Abdominal (10 minutes each); Station 2, History Taking (20 minutes); Station 3, Cardiology and Neurology (10 minutes each); Station 4, Communication Skills and Ethics (20 minutes) and Station 5, Short Cases (Skin, Locomotor, Eyes and Endocrine; 5 minutes each). The format was refined in October 2009 by restructuring Station 5. This station now has two 10-minute ‘Brief Clinical Consultations’ that encompass the whole exam and draw on the key skills required to be a competent registrar: the ability to extract a succinct and relevant history, elicit the key physical signs, construct a sensible management plan and communicate this to the patient.
Cases for PACES, 3rd edition, prepares candidates for the current PACES examination. It mimics the examination format and is designed for use in an interactive way. The 3rd edition has a completely revised text that has been informed by recent successful candidate feedback. It now has useful advice for the day of the exam and provides updated information on ethical and medicolegal issues. There is plenty of history-taking advice with new examples and mock questions for candidates to practise themselves. Station 5, the newest and perhaps the most challenging of stations, receives more attention than in previous editions.
Avoid further factual cramming at this stage – you know enough! Go and see medical patients on a busy acute medicine unit or outpatient department. This has always been the best way to prepare for PACES and this book will assist you to do this. We now include mock ‘mark sheets’, designed to enable groups of candidates to practise ‘under examination conditions’ at the bedside.
Common cases that regularly appear in the exam, rather than rarities, have been deliberately chosen. We assume candidates will be familiar in examination techniques and the appropriate order in which to elicit the various signs. We provide discussion topics on which a candidate could be expected to comment at the end of the case. Examiners are monitoring specifically for knowledge of the differential diagnosis and organized clinical judgement, while managing the patients’ concerns and maintaining patient welfare. The detail is not exhaustive but rather what is reasonably needed to pass. There is additional room to make further notes if you wish.
The aim of this book is to put the information that is frequently tested in the clinical PACES examination in a succinct format that will enable capable candidates to practice and pass with ease on the day.
We wish you the best of luck.
We acknowledge the help of Dr Daniel Hodson in the previous two editions. We thank the doctors who taught us for our own PACES examination, and above all the patients who allow us to refine our examination techniques and teach the next generation of MRCP PACES candidates.
Practice makes perfect; it makes the art of eliciting clinical signs second nature and allows you to concentrate on what the physical signs actually mean. Practice makes you fluent and professional and this will give you confidence under pressure. We strongly encourage you to see as many patients as possible in the weeks leading up to the exam. Practice under exam conditions with your peers, taking it in turns to be the examiner. This is often very instructive and an occasionally amusing way to revise! It also maintains your motivation as you see your performance improve. We also encourage you to seek as much help as possible from senior colleagues; many remember their MRCP exam vividly and are keen to assist you in gaining those four precious letters after your name.
Check that you have your examination paperwork in order with your examination number as well as knowing where and what time you are needed: you don’t want to get lost or be late! Also ensure that you have packed some identification (e.g. a passport) as you will need this to register on the day. Remember to take with you vital equipment with which you are familiar, particularly your stethoscope, although avoid weighing yourself down with cotton wool, pins, otoscope, etc. The necessary equipment will be provided for you on the day. Punctuality is important and reduces stress so we advise that you travel to your exam the day before, unless your exam centre is on your doorstep. Avoid last minute revision and try and relax: you will certainly know enough by now. Spend the evening doing something other than medicine and get an early night!
Think carefully about your attire: first impressions count with both the examiners and – more importantly – the patients. Broadly speaking, exam dress policy is similar to that required of NHS employees. You should look smart and professional, but above all wear something that is comfortable! Shirts should be open collar (not low cut) and short sleeved to enable bare-below-the-elbow and effective hand sanitation. Remove watches/jewellery (wedding bands are permitted) and dangling necklaces/chains that could be distracting. Facial piercings other than ear studs are not recommended.
Use the preparatory time before each case wisely. When you enter the station remember to ‘HIT’ it off with the examiners and patient:
Remember to HIT it off and your nerves will settle, you’ll be underway and the rest will follow fluently if you are well practised.
Rather like a driving test when looking in the rear-view mirror, be sure to convey to your examiner what you are doing. Similarly, your examiner will be expecting to see you do things in a certain order. Stick to this and examiner ‘alarm bells’ will remain silent. However, if you do forget to do something half way through the examination, or you have to go back to check a physical finding, do so. It’s more important to be comprehensive and sure of the clinical findings, than simply being ‘slick’.
Spend the last few moments of your examination time working out what is going on, what the diagnosis is and what you are going to say to the examiner. There’s still time to check again. Most examinations can be completed by standing up and stating to the examiners a phrase like: ‘To complete my examination I would like to check…’ and then listing a few things you may have omitted and/or are important to the case.
Eye contact and direct, unambiguous presentation of the case conveys confidence and reassures examiners that you are on top of things. Avoid the phrases ‘I’m not sure if it is…’ and ‘I think it is…’. Be definitive and avoid sitting on the fence but above all be honest. Don’t make up clinical signs to fit a specific diagnosis but do not present clinical signs that are inconsistent with the diagnosis or differential diagnosis.
There are two ways to present the case:
Where possible, a comment on the disease severity or disease activity should be made. Consider complications of the diagnosis and mention if these are present or not. Know when to stop presenting. Brevity can be an asset. It avoids you making mistakes and digging a hole for yourself! Wait for the examiners to ask a question; do not be preemptive – the examiners may follow up on what you say.
Prior to you examining the patient the examiners will have individually ‘calibrated the case’ to ensure that the clinical signs are present. This maintains the fairness and robustness of the exam and makes sure consistency exists between exam centre marking. There will be two examiners for every carousel station and usually one will lead the discussion with you. Both will have mark sheets and will mark you individually without collaboration. Contrary to popular belief they both want you to pass. They are there because they support the college training and progression of talented physicians of the future.
If you do make a mistake and realize it, do not be afraid to correct yourself. To err is human and the examiners may overlook a minor faux pas if the rest of the case has gone well. It is not uncommon to think you have failed a case half way round the carousel and that your chances of passing PACES has been dealt a fatal blow. We are often our own harshest critics! Do not write yourself off. Frequently, all is not lost. Don’t let your performance dip on the next cases because you are still reeling from the last. Put mistakes behind you, keep calm and carry on!