Demystifying PACES - Abdominal [Station 4] (26 Jan 2024)

SPEAKER_03 0:00

Hello, my name is Kat Ralston and I'm a member of the Training and Members Committee as well as a mentor of the Elderly Registrar in Edinburgh. I'm delighted to introduce this new podcast series called Demystifying PACE. In this series, we will discuss each station in detail with an experienced PACES examiner to share top tips for success, common challenges, insights and advice. We will also have episodes exploring the exam from the candidate perspective. This series focuses on candidates sitting in the UK, and while the principles will be the same for those sitting internationally, local variation will of course be present. We hope that this will be helpful in both your preparation for PACES and your experience on the exam day itself.

SPEAKER_01 0:40

Hello, I'm Dr. Matt Thomas, Dean of Examination at the Royal College Physicians of Edinburgh. When I was chatting to successful candidates recently when they were receiving their diploma, I was pleased to hear about how they valued Edinburgh and the education that it provides from evening medical updates through to the PACES podcasts. And that was one of the reasons that they chose Edinburgh as their college of entry. Add to this the expert team in the examinations department who will try and help smooth your way through your PACES application, along with the fact that we provide PACES centers throughout the UK.

SPEAKER_04 1:20

I would encourage you to think of Edinburgh as your college of entry when doing PACES ESESESCADESCOINGES My name is Emma and I'm an internal medical trainee in the South East of Scotland and also a member of the Royal College of Physicians of Edinburgh Trainees and Members Committee. We're a group working to represent the interests of physician trainees within the Royal College. Today we're bringing to you another episode of our Demystifying Paces podcast series, and this time it's a look at the Abdominal Examination Station or Station No. With me to talk through this station today is Dr. Kerry Baker. Dr. Baker is an acute physician who also works as the Dean of Education at the Royal College of Physicians Edinburgh and is training programme director of internal medical training in South East Scotland. She's examined for PACE both in the UK and internationally. Nice to see you, Dr. Baker. Thanks for inviting me. Pleasure. So perhaps we could start off by just talking quite generally about the format of station number four and the abdominal examination component.

SPEAKER_02 2:36

Of course. So the abdominal station component is one that's not changed in PACES 2023, but previously it used to be paired with the respiratory station and this time it's paired with comms. And as you said, it won't focus on the communication one, but just the abdominal bit. So it takes up half of station four, which means it's a total 10-minute session. During that you've got six minutes to perform the examination and four minutes to talk with the examiners. And during those six minutes, the examiners will let you know when you've got one minute remaining so that you can make sure you wrap up and complete any essential bits of the exam before you go on to chatting to the examiners.

SPEAKER_04 3:14

Excellent. What might an examiner be expecting the candidate to achieve during this station?

SPEAKER_02 3:22

So the important thing is we're not expecting you to perform as a gastroenterology registrar consultant, and also that the examiners themselves shouldn't be a gastroenterology consultant. So it's always someone from a different specialty. So you're not looking for someone with massive expertise in that field or being examined by someone with massive expertise in the field. You're being examined by someone like me who's a generalist that regularly examines people's abdomens but will not be measuring the difference between three and a half and four and a half finger breadths of spleen. Both examiners will have agreed in advance what they're looking for, but generally we want to see something that looks fluent and comprehensive and confident, unlike you've examined patients before. Really just what you do in the day job. It doesn't have to be one set format. So I know there's lots of different styles of teaching and teaching classes and courses and online material, and it's easy to get worried that you have to follow their order and their way of doing things. But in reality, we just want to see that it looks fluent. It doesn't necessarily matter exactly the order of the steps as long as it looks systematic and complete.

SPEAKER_04 4:24

Yeah, totally. And you talked a bit there about how the examiners will have agreed beforehand kind of what they're looking for. I think that might be a useful insight for people just to know how you agree those signs beforehand.

SPEAKER_02 4:36

Of course. So that step is called calibration. It's one of the most important things of the exam. And we take a good time before the exam starts to go through this. And it is the process by where each examiner examines the patient and then they discuss together to agree what signs are or are not present. It's worth bearing in mind that some patients will have subtle signs that can be difficult to pick up. And sometimes these depend on how sensitive your fingertips are or how sensitive your ears are. And if those two examining consultants can't definitely agree on what's there, then we generally agree to disagree and not expect the candidate to pick it up. Or we found something but we think it was very difficult, we're unlikely to make the candidate pick that up. So we will really be looking for signs that are fairly obvious and that both of us agreed on. If we're not sure, we'll mark that out. We're also not looking for millions of signs. We're really looking for you to pick up up to three or four key signs. And that might be the presence of a sign, so for example, a hepatomegaly, or it might be the absence of a sign, so it might be no evidence of decompensation, for example. But generally we're not looking for a list for 20 things. We've picked out two, three, four key aspects that we want you to pick up on. And if it's really subtle and I wasn't sure about it, my examiner wasn't sure about it, we do not expect you to be sure about it either.

SPEAKER_04 5:58

Yeah, I think that's very reassuring to hear, isn't it, that sort of two people who are generalists have examined and it'll be the same findings that they found that you'll be expected as a candidate to find as well. That's it. So if we move on to talk to you a bit about the examination, that six-minute examination component of this station. So with regards to the examination technique, is there any things you can highlight that you think look particularly good for a candidate to do, or any things that you think are less strong or kind of red flag for you as an examiner?

SPEAKER_02 6:27

Of course. So I think the most important thing is to remember that you're examining a real patient and not an abdomen. Sometimes people get so sucked into the worry of the exam that they're very focused on the belly in front of them, forget it's attached to a human being, maybe accidentally get a bit rough or not be very attentive to whether that person's in distress. So what we want to see is that you are treating them like a real patient, that you are watching their face for discomfort and that you're not hurting them. And if people are causing discomfort and that patient, for example, is grimacing during palpation, and that's a red flag, and that may be enough to fail you in patient welfare. So the best way to do that is during palpation, make it clear that you're watching the patient's face. Otherwise, we're looking for a systematic approach without too much dithering on irrelevant areas. And where I sometimes see people lose time is spending a lot of time on general inspection and not having enough time left. Realistically, most commonly the signs are going to be in the abdomen. So if you spend five or six minutes examining the hands and the neck and mouth, you're probably going to miss the key things. So whilst you need to do a general inspection, make it focused and quick. Sometimes we'll see people spend a whole minute umming and awing over the hands, really just a quick look showing that I've looked for clubbing, maybe stroke the palm to show you've looked for juperrens, move on. So a quick and focused one. But as soon as possible, you want to be getting to the belly. In most of the abdominal stations, there's probably going to be something to feel. So you want to make sure that you give yourself long enough to palpate. And if you have a little bit of extra time left at the end, instead of rushing into questioning, I would suggest using the rest of the time to have a good feel for the belly. Can I feel a mass? Can I feel organomegly? Have I missed a scar in a skin fold that could be a transplantant kidney, for example? And while you're doing that, you really need to note to yourself the signs that you have found along the way. And I know that sounds silly, but again, I think in the pressure of the exam, people are so focused on working through each step of what must I perform next that they don't mentally note what they find and they forget it by the end. And that can be really apparent because while we're watching your examine, I can see that you felt something. I see that moment when you think, oh, I think I felt a spleen and you're feeling around it. And then at the end the candidate says, no splenomegley. And you don't understand how it happened because you saw them find it. And I think people just forget about it in the panic. So my tip would be if you think you find a sign, then you just pause for a minute. You could say it out loud if you want, but certainly in your mind, say, Splenomegley, I found some splenomegley. So then you remember to bring that up later on.

SPEAKER_04 9:03

Yeah, definitely. I think the one minute from the end timing can be a good moment to just pause and think, what do I have left to do? Or what have I found that I need to understand more about, or what could I look more for? So I think that's really important. Are there any particular parts of the abdominal examination that you've seen people struggle with or get very tied down in, as it were?

SPEAKER_02 9:24

Sometimes people rush it a bit because there's not much time and you're trying to see a logical approach to them feeling for organomegaly, and that might go out the window. So making sure you've got enough time so that you're clearly demonstrating working your way up the abdomen for a liver edge and for the spleen. Sometimes people spend a lot of time percussing. If you have the misfortune of wearing gloves during paces, then you're not going to get any information from percussing. But realistically, a lot of signs aren't that relevant. So I wouldn't spend a lot of time percussing. If it's going to be organomegly, you'll feel it with your hands. People sometimes get very wrapped up in repeating shifting dullness over and over because they're not sure. But again, in real life, we know that shifting dullness is not a sensitive sign. So I would show that you know how to look for it, but not spend a lot of time on it. The key things probably really are giving yourself enough time to show that you felt for all of the organs really carefully. I did mention doing a kind of quick general inspection, but something where people miss a gift of a diagnosis is they fail to look for fistulae or dialysis lines. So always have a quick feel up at the anticubital fossa and a quick look for scars around the neck. Because if you see signs that that person has an active fistula, or even better, past fistula that's no longer buzzing, or previous tunneled line, that's an absolute gift. You know that patient is going to have a renal transplant. And so often people miss that because the patient has a long sleeve jumper on, no one rolled up the sleeves, and it's actually really sad because you barely need to examine the abdomen to know that you're going to find that. So that's definitely a tip. Look for lines, look for fistula.

SPEAKER_04 11:00

Yeah, those are real giveaways outside the abdomen that can be useful. In terms of abdominal examination as a station, kind of thinking of what you might see or what kind of patients might come up. Have you got experience of the kind of typical patients that might come up on this station? Obviously, this not being an exhaustive list.

SPEAKER_02 11:18

Absolutely. So this is really important to consider, and this is part of exam technique, because in real life, in the acute medical unit, for example, most patients that need their abdomen specifically examined have a nondescript presentation and they might just have a bit of abdominal tenderness. In cases we're not going to put someone with a sore abdomen in, it's not fair to the patient. We are going to put in a patient who has stable clinical signs. So it's worth thinking about what are stable patients who can come in with predictable signs on an outpatient basis. So classically, you will see things that you don't commonly see in the acute medical take. So you will see the transplanted kidney, you will be able to blot very large kidneys that are from adult polycystic kidney disease. You may feel a liver andor spleen from a fairly stable, well patient with a myeloproliferative or lymph proliferator disorder. And in some areas of countries you'll see spleens due to hereditary spherocytosis. These are the really common ones. You might see a patient with decompensated liver disease because that's common. And if a planned outpatient fails to attend the exam, then the organizers might have a rush to find a patient in the hospital that they can put into the exam at last minute. So often that will be a patient with stigmative chronic liver disease, for example. But what we won't put in are sore and unstable people. So I've had people before find masses and say they think the patient's got pancreatitis. We also don't put surgical things in, really. So it's worth remembering it's a physician exam, we should be looking for a medical condition and it should be someone fairly stable.

SPEAKER_04 12:52

Yeah, I think that's really, really useful to remember when you're preparing your differentials and having a think about what might come up. That's very useful. During the last four minutes of this examination station, candidates are first be asked to present their findings from the examination and then posed a few questions by the examiners. And I think this is certainly an area which lots of candidates feel nervous about. Do you have any tips on how to present an abdominal case or what examiners might be expecting in this section? Absolutely.

SPEAKER_02 13:22

So my first step is to treat it like you are the medical SHO registrar, IMT, whatever country working in on call, and you're just discussing a patient with your consultant because that's what we're really looking for is in real life, what would you do next? We're not looking for a trap, we're not looking for any magic, we're looking for basically what would you do when you meet this patient for real. Bear in mind that four minutes isn't much, and the examiners are going to try and score in a number of domains in that area. So try not to waste time. So a lot of people are trained into the same kind of common introduction where they say, I examined Mr. X. Well, yes, I know I saw you. Mr. X is a 55-year-old man who is comfortable at rest. Yes, I know that, and we're only going to put comfortable patients in. All of that is wasteful and it loses time. So I would suggest you go straight into it and you say, on examination, here are the relevant clinical findings. Don't list every single one that you didn't find. So you don't need to say there was no Palmar erythema, there was no clubbing, there was no flap, really just skip to the key ones and get through those early as possible. And then there's plenty of time for the examiner to ask you questions. The examiner is definitely going to want the differential diagnosis from you. They're going to want to know your approach to investigating and managing the patient. So those are key things that are going to come up. And depending on how comprehensively or quickly you've answered them, then there may be further time for further discussion. You might find that the examiner interrupts you, and sometimes that worries candidates because you think the examiner's become grumpy, you've done something to annoy them. Realistically, if we interrupt someone, it could be because we're trying to redirect them down a better line. But often it's because the candidate has already scored full points in that domain. So if you've already told me enough information for me to give you a clear pass, a satisfactory score for your differential diagnosis, for example, I don't need to hear you talk about it for another minute, and I'll stop you and ask you another question. So don't worry if you're interrupted. That might be a really positive sign that the examiners are happy, that you've done everything and they can move you on. Similarly, if you've covered a lot of information and the questions start to become more unusual and esoteric, that's sometimes because you've already said everything we're looking for. And as an examiner, we're running out of material, but we have to keep talking. So again, if you get asked a really strange question about 2020 guidelines for something, it's unlikely that they're trying to catch you out. It's much more likely that you've performed really well. So don't panic, stay calm, be honest. If you don't know the answer to things, just say, I don't know, but this is what I'd do. That's my next tip is the honesty. So don't make up signs, whatever you do. And if you're not sure of the answer, do what you would do in real life. In real life, you wouldn't say to me on the wardround, I don't know, you would say, Well, I don't know, I'm not sure. I could feel a mask, but I wasn't totally sure whether it was kidney or liver, so I'm going to organize an ultrasound. So say that in the exam. I'm not expecting you to have x-ray vision, but I am expecting you to know what you would do next with a patient. And many good candidates will recoup scores by explaining that they're not sure about what they would do next.

SPEAKER_04 16:27

Yeah, definitely. I think it's important to remember that during this section, the examiners are trying to help you get those marks for differential diagnosis and to let them guide you through that process and help you move through the mark scheme a little bit. One question I did want to ask, because I think this worries a lot of candidates, is if you get to the end of the examination and you don't know that exact diagnosis, what's the best way to approach the presentation there? And can you still get full marks on the presentation and differential diagnosis if you don't know exactly what's going on?

SPEAKER_02 16:59

So it's possible. It might be difficult to get full marks, but you don't have to get full marks in every station to pass. And you can definitely still accrue marks by being honest. So start with saying what you could find and what the uncertainty was. If you found nothing abnormal, then say that. Because it is possible that we could put a patient with no signs in the exam. That's generally only if the planned patients don't attend, there was no one well enough on the wards, and it's a panic to put someone in at last minute and it ends up one of the clinic nurses, for example. And so it's definitely a problem if you make up that that person has four fingerbreadth hepatomegaly and there's nothing wrong with them. So be honest. But remember you've been given a patient's STEM, which is the little clue about what's wrong with the patient. So you'll be told this patient presents with abdominal swelling, for example, or this patient's family are worried that they look yellow. So remember that STEM and think about, well, what was the question? Is it about pain? Is it about uh mass? Is it about weight loss? How would I approach that? So you could say, well, I wasn't sure I really found any abnormal clinical findings, but I note that this patient came in with concerns about jaundice. So I would immediately run some bloods, including the refunction tests, to see if genuinely they are jaundiced, and then we would take it from there. And that would show that you still know how to approach a real life patient who complains of a symptom, but you have nothing to find on examination.

SPEAKER_04 18:17

Yeah, definitely. I think that stem was not something we talked about yet, but obviously it's given to candidates just before they go in the room and can be a useful thing to just contextualize what you're doing and fall back on in that presentation section if you need. That's it. That's really been brilliant and loads of useful information about examination and how to present. Just last question is there any kind of top tips on PACE overall or anything else that you feel you'd want to offer candidates before we close?

SPEAKER_02 18:46

So top tips would be don't think it's a trap. We really want to pass you. The examiners are all desperately keen that you do well, we're not looking for really unusual esoteric things. And sometimes people trip themselves up by listing really rare diagnoses and forgetting that common things are common. The other is if something's not going well, to try and leave it behind you. If you do badly in station one, the examiners in station two and three and four and five do not know that. They don't need to know that. And it's still possible to do fairly poorly in one station and pick up enough points elsewhere. It's natural to feel disappointed and stressed if you know you've performed poorly, but you need to try and leave it behind you and remind yourself you can still pass because each station is a clean slate. And the third is remember each patient is a real human being at the end of it. So being nice to the patient, gentle not to harm them, and speaking to them as you would for a normal patient, even when they're not allowed to chat back to you, but showing that humanity goes a long way with warming up the examiners.

SPEAKER_04 19:44

Yeah, perfect. Absolutely. I think that tip about moving on from each station is so important, even though it's so hard to pull off when you're nervous on the day. But I think it's very useful. Thank you so much. We really appreciate that, and good luck to anyone listening to the episode. He's sitting there paces soon.

SPEAKER_02 20:01

Absolutely, good luck to everyone.

SPEAKER_00 20:22

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