4 Tips for Passing PACES

Dr Ahmed Ayuna passed PACES this summer and scored full marks in the Integrated
Clinical Assessment (Station 5). Here's how he prepared, along with his top tips for
succeeding in each station.

Hi, Im Ahmed, I passed my PACES exam from the first try in June 2015 in the UK
and it was the toughest exam in my life, so let me tell you about my experience.

Preparation
To start with, I spent about 3.5-4 months preparing for my exam by practising a
proper clinical examination with timing; attending PACES teaching groups held in
hospital where I work; reading some PACES books; attending a PACES preparation
course and subscribing to Pastest PACES Online as it contain a wide range of videos
and teaching material.

On exam day
I started with Station 1, Abdomen. It was a middle-aged lady with distended abdomen,
a tinge of jaundice and huge ascites. I couldnt feel any organomegaly, so I gave the
differential diagnosis of ascites, then was asked about management. I didnt score
very highly in this station as I forgot to lay the patient flat!

Top tip always position the patient correctly!

Next was the Respiratory Station with an elderly gentleman with mild kyphosis. It
was a normal chest exam apart from slight reduction of chest expansion. In the
question it said he had got intermittent dyspnea. On finishing my exam, I asked the
patient for permission to examine his lower back to check for sacral oedema. He told
me to be careful as it was sore; looking carefully there was a very small scar over the
sacrum from recent surgery. The examiner asked about findings and diagnosis; I gave
differential of PE following the operation to the lower back, asthma, resolving chest
infection. Both examiners were happy and I got 16/20.

Top tip always look very carefully so you dont miss any clues!

Station 2 involved a young lady with recurrent chest infection; she presented with
fever, cough, SOB and sweating. The examiner was concerned about the possibility of
HIV.

Top tip listen carefully for any clue that may be given by the patient while taking
the history. Usually 3-4 clues are provided. You need to ask about them in detail, as
you will be penalized severely if you neglect them.

In Station 3 Cardiology I saw an elderly lady with diastolic murmur in the apex and
thoracotomy scar. Pulses were present on both radials and no radio femoral delay. I
thought it was mitral valvotomy due to mitral stenosis, and I got 15/20.

For Neurology I was asked to examine upper limb and I noticed signs of upper motor
neuron. During examination I noticed he had cerebellar signs, so once I had finished
full upper limb exam I did cerebellar exam as well. I thought this gentleman had MS.
The examiner asked me about differential and management plan, and I scored full
marks.

Top tip remember that doing an extra examination related to your diagnosis will
give you extra marks.

For Station 4 I saw a young gentleman with asymptomatic high blood pressure
unresponsive to life style modification. He had a very healthy life and my consultant
asked me to talk to him to do further investigation and start oral anti-hypertensive
medications. The patient was very silent. He didnt give any information and was not
keen on doing any further tests nor taking medication. I explained to him the meaning
of high blood pressure, complications and the medications along with their possible
side effects. At the end the patient was happy to do the investigations and take the
medications. The examiners were very impressed and gave me 16/16.

In Station 5, the first case was a middle-aged lady with sudden loss of vision 3 months
ago. Her observations were fine apart from blood pressure of 170/110. In the history I
asked for more details of what happened; she said she was driving and suddenly lost
vision in the left eye. There was no eye pain, no headache and no vomiting. She
wasnt diabetic, and she is a housewife living with her husband and 2 children. On
examination I found a newspaper on the bed side, so I asked her to read one line.
Using the ophthalmoscope there was haziness of the disc and signs of grade 4
hypertensive retinopathy. The examiner asked me about the differential diagnosis,
causes of painless loss of vision and anatomy of cerebral blood circulation.

Case 2 was an elderly gentleman who collapsed while in church. The collateral
history gave feature of cardiac cause and irregular palpitation; nonetheless I excluded
other possibilities like neuro, postural hypotension, medications etc. On examination,
I found pan-systolic murmur and sinus rhythm. The diagnosis was mitral regurgitation
and atrial fibrillation. I scored 28/28 in each of these cases.

Top tip you will be given 5 minutes before this station to read the scenarios.
Analyse the scenarios very, very carefully as they always put clues in it!

In this station you should always concentrate of the social aspect of the history. This is
what examiners want, because they want to see a safe, competent doctor who puts the
patient at the centre and does his best to help and protect him. Make sure you ask who
looks after the patient and about their health.

In Royal College Exams on Thursday, 17th December, 2015

Recently-successful PACES candidate Lucy shares her top tip for passing the exam -
getting a revision buddy.

The thought of revising for PACES is terrifying. Part 1 and Part 2 feel like they
happened years ago. I can remember speaking to some of my senior colleagues about
their experiences and was shocked at how negative their responses were: 'it takes over
your life', 'you just have to put everything on hold for those months'. I felt they must
be exaggerating.

But they werent.

It does take over your life. And in those few months you will do little more than go to
work and revise. But it's worth it.

PACES revision is different. It involves more time, more attention to detail. However,
for me, it reignited my love for medicine. It was frightening how little knowledge I
had managed to get by on throughout my foundation years, and it was incredible to
learn how to examine in a different, more efficient way (especially neuro!)

My main advice is to get a buddy. Revision is lonely. I don't think I could have done it
without my friend.

Sarah was a friend I'd made in FY1. I knew what she was like, what her work ethic
was like and that we could work together. We were at different hospitals, but that was
fine. We set a date we were starting revision and started. When one of us was
flagging, the other one encouraged. We'd meet before nights, after nights, weekends,
any time we were free, and alternated between our hospitals. We organised teaching
from consultants at both locations. We learnt together, shared the nuggets of
knowledge we had learnt independently, and were brutally honest with one another
about each others performance. (We later found out our exams were at the same time
at the same place...and only through a last-minute change were moved from being one
after the other on the same circuit!)
There are times when you will get incredibly frustrated. Or tearful. Or just lose the
will to do more revision. Those are the times when you need someone who will stop
you giving up and tell you to get over the fact it was MR not AS, or reassure you that
no one ever really hears aortic regurg...

If you are like me, you will never feel you know enough, particularly in those last few
weeks. So we stopped trawling round the hospital for another COPD patient, and went
to the pub. There we did communication skills practice and broke bad news to each
other, to the horror of our fellow pub-goers.

Make a deal with your revision buddy about after-exam chat. Can you tolerate hearing
that that patient was not someone with polycyclic kidneys?!? Decide that youre both
going to keep quiet and stay quiet. Or do the opposite.

But one thing I promise is that it always has gone better than you think.

I had hands down failed. And so I moped around for the week after, feeling sick that I
had to repeat the whole process.

Don't do it.

Forget about it.

Enjoy your new found freedom in your evenings.

Wait till you get the email. And if you have failed, just think how much easier its
going to be to revise for it again.

And for those that have passed you've probably made a friend for life in your
revision buddy.

In Royal College Exams on Wednesday, 9th December, 2015

8 Things to Remember in Your PACES
Exam
In his second blog post, Dr Atef El Dean outlines 8 key points to follow before and
during your PACES exam that will help you to focus and achieve PACES success.

1. PACES requires sustained energy. Have some good sleep in the last few days
before your exam, and if you can relax for half a day before the test, that would be
ideal.

2. Always keep in mind that the examiners want to be satisfied that you are a safe,
competent doctor that they can depend on to look after their patients even while they
are away.

3. Be confident in front of the examiners, not arrogant.

4. Smile, and be calm. Imagine that you are presenting the cases to your consultant in
a normal working day during ward round.

5. Be nice to the patients. Respect them, ask their permission for examination, be
gentle and at the end of the examination ensure that your patient is as comfortable as
you found them. And finally don't forget to thank them.

6. If you know the diagnosis, state it then give the real the relevant supporting
findings. If you dont, present systematically and then give differentials.

7. Remember that difficult cases may be really difficult to all candidates (and even
examiners!)

8. Each station and case is marked separately, and even the same case would be
marked by two examiners and they don't share their evaluation. Try not to lose hope.
Try not to think about a case you think you did badly on, but focus on the remaining
stations. Examiners won't fail you because you didn't do well in one case. You can
still easily pass by getting the minimum score in each skill examined.

Good luck to everyone.

Dr Atef El Dean MBBCh MSc MRCP(UK)

Specialty Doctor in Gastroenterology

In Royal College Exams on Friday, 11th September, 2015

How to Prepare for PACES
Dr Atef El Dean conquered PACES this summer scoring an impressive 165/172. Here
are his tips for how to prepare for PACES.

The PACES exam is a challenge to many candidates, especially International

Graduates like myself.

I think PACES can be easily beaten if you stick to the following advice:

1. Start preparing 3-6 months before the exam.

2. Prepare, prepare, prepare.
3. Make it a part of your routine. Whilst working every day practise examining
patients as you would in the exam.
4. Get seniors to watch you, comment on your technique and then ask you questions.
5. Attend PACES teaching at your local hospital.
6. Stick to 6 minutes examination and present your patient in under 1 minute.

For your preparation I would recommend the following:

Online
I would strongly recommend the Pastest videos. All Pastest videos are very important,
especially exam techniques (I found the Neurology examination very useful) and
Communication Skills. These videos give you an idea about what the examiners
expect while dealing with different clinical and ethical dilemmas. These are crucial
for postgraduate and overseas doctors who in my experience often fail the exam
because of Communication Skills.

I also found the extensive variety of videos extremely useful. They cover many
clinical cases in different specialties, including rare syndromes. Neurology and
Station 5 were the most useful to me. You can see patients from other specialties
during your work at the hospital, but you rarely see a good case for Station 5, even in
big teaching hospitals.

I found the Neurology videos very constructive and beneficial as well, especially as
Neurology is one of the weakest points for trainees. This is because Neurology is not
one of the main specialties that trainees rotate in during the Core Medical Training,
hence most trainees haven't done any Neurology rotation/job during their medical
career. Furthermore, the Neurology station is never straightforward in the PACES
exam, even for doctors who had Neurology training.

Books
Cases for PACES by Stephen Hoole this is a must.
An Aid to the MRCP PACES (History Taking and Communication Skills) by Ryder
Clinical Medicine for the MRCP PACES (Oxford Specialty Training) by Gautam
Mehta and Bilal Iqbal (especially Station 5).

Course
I would recommend attending a PACES course, and also try to do a mock near to
PACES to get a feeling of the real exam. These may already be planned in the hospital
where you work. I would recommend the mock at Kings College Hospital London
and St. George's Hospital.

In my next post, I will cover the essential points to remember during your PACES
exam.

Dr Atef El Dean MBBCh MSc MRCP(UK)

Specialty Doctor in Gastroenterology
Member of the Royal College of Physicians of London

In Royal College Exams on Friday, 7th August, 2015

5 Tips for PACES in Practice
How should you prepare for the ever-difficult PACES exam? Dr Jez Hunter passed
PACES only a few weeks ago - here are his top 5 tips for exam success.

One of
my PACES buddies described the exam akin to running down a wet track trying to
avoid puddles, only the puddles are those of your own making. My PACES
experience was stressful, uncomfortable but ultimately successful. I hope the
following tips help to keep your own track a little drier!

1. Pick your core texts

Whoever you speak to will have their favourite. I lost count of the amount of times I
was told all you need to do is learn the green book!

In truth, most of the popular PACES texts these days are really high quality. There is a
tendency to throw serious money into PACES thinking it will offset the need to work
quite so hard. In this case, the reverse is true. I had about 3 texts on the go at any one
time, until I realised that this was both confusing and inefficient.

Have a look at the core texts early, decide which you want to use for each type of
station and stick to it.

2. Exploit your down time

I commute an hour each way into work. I was able to fill this time with PACES
podcasts which made me feel better when working 13 hour days with no time, energy
or inclination to revise at the end of each shift. I found them especially useful for the
communications and ethics stations. Many of the nuanced questions I remembered to
ask my patients were not down to my mental dexterity but simply because Id heard a
similar consultation on a podcast a few weeks before. Counselling a patients relatives
on brain stem death does not feature heavily in core medical training, so I found this
experience by proxy invaluable.

3. Station 5 prep is crucial

With over 1/3 of the whole exams marks crammed into a single station, it makes
sense to practise this and yet its the most difficult to prepare for. One colleague of
mine suggested that you have to think like a GP to get through this station, and there
is much truth in this.

This is where I found the Pastest videos so useful. They provided both aural and
visual prompts on how to deal with typical Station 5 problems. Whilst this structure
seems obvious in the comfort of routine clinical practice, this common sense approach
seems to implode when under a ticking 8 minute clock and hawkish examiners. The
videos spiced up the dullness of book work, enabling me to switch between learning
mediums when interest was flagging.

4. Invest in a course
I cannot recommend this highly enough. It is incredibly inefficient to stalk the wards
looking for typical PACES patients. When you find the perfect fit they are either
sleeping, unwilling or too ill to examine. When you find one, these untrained
PACES patients often tell you their diagnosis mid-flight, or the tight timings that are
crucial in order to replicate the real thing go out the window. Spending 2 - 4 days on a
course, seeing up to 30 typical patients with rare chronic stable conditions per day
under near exam conditions is revision rocket fuel.

I know a few who have passed without the hint of structured PACES training;
however I know far more who have struggled with multiple exam retakes until they
did a course.

5. Prepare to be disappointed
On the day you will only remember the things you missed or the mistakes you made.
You are not a good judge of performance at this stage so dont torture yourself
unpicking each thread of the experience. I do not know many who left the exam
feeling it had been positive career highpoint. That is to come. The real gem from
PACES is it refines the way you think. It teaches you the value of being really present
during clinical encounters. It trains a higher level of cognitive athleticism. It makes
you a better doctor.

Good luck.

In Royal College Exams on Thursday, 9th July, 2015