Demystifying PACES - Cardiovascular [Station 3] (29 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 PACES. 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 for 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 experts 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 centres throughout the UK.

SPEAKER_04 1:20

I would encourage you to think of Edinburgh as your college of entry when doing PACES EBES EDESEADES CADESCALLECINGESCONICERA, my name is Anda Bularga and I'm a member of the Trainees and Members Committee at the Royal College of Physicians Edinburgh, as well as a cardiology registrar in the South East of Scotland. I'm really delighted to introduce this new podcast series called Demystifying PACES. 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 also advice for PACES candidates. We will also have episodes exploring the exam format and the exam from a candidate's perspective. The series focuses on candidates sitting the exam in the UK and while the principles will be the same for those sitting it internationally, local variation will of course be present. We hope that this will be useful in both your preparation for PACE and also sitting the exam on the day. Thank you very much for listening and for joining us. I'm really delighted to introduce our interviewee today, Professor Andrew Elder, consultant physician in medicine of the elderly, and also the president of the Royal College of Physicians Edinburgh, an honorary professor at the University of Edinburgh. Medical education and teaching has been an important part of Professor Elder's career, and his focus has been on the college's examinations throughout his career. He was a PACES examiner, a host and chair since 1996, and his career developed by becoming also the medical director of the MRCP UK and the chair of the Academy of the Medical Royal Colleges. He's got experience of examining both in the UK but also internationally, and since 2013, he has built collaboration with a number of centers in North America, and most notably at Stanford, and John Hopkins, serving as a visiting scholar and fellow at the former. And he's been supporting the teaching and assessment of core bedside skills and co-founded the Society of Bedside Medicine. Professor Elder, thank you very much for joining us. It's really a pleasure to have you. And I will start today's recording by asking you to tell us a little bit about your experience with PACEDS, particularly from those early days when you were first examining and hosting.

SPEAKER_02 3:56

So first and foremost, Anda, thanks very much for giving up your own time to undertake this interview. You and the tree and members committee do a lot of work in support of not just candidates for our exams, but in lots of other ways. So I thank you for that. Thanks for the invitation to do this, and thanks for the generous introduction. Going back to my early experience of examining pieces when I started as an examiner was very different from what it is now. And in fact, my early experiences of seeing it as an examiner made me want to get involved in changing it. And that was because at that time when I started as an examiner, and I had sat this form of the exam too. The exam was not in the cycle Ofski style that PACE is now is. It was divided into a long pace. You went away on your own for an hour, unobserved by the examiner, which could be about almost anything. You had what was called a vibe up when you sat in front of two examiners without a patient present, and you could again be asked about almost anything. In fact, that part of the exam was notorious for some of the kind of obscure things that you could be asked about. And then the final part that's probably closest to what PACES is now was called short PACES, when you were taken in a very unstructured way around a series of patients, and you might be asked just to look at their hands or to listen to their heart. It was a physical exam, but in a much, much less structured way than PACES now is. So I remember being struck that it was all very inconsistent for trainees, for candidates going through the exam, that the examiners had too much license to ask almost whatever they wanted, what that wasn't standardized either. And if you took a step back from the exam, it wasn't actually clear what it was trying to assess. And anybody who's read a little bit about exams and assessment will know that the first question you always ask when you're putting together an exam is what is the purpose of the assessment? So as I say, my early experience of the exam was that it made me really, really think about whether it was doing what we wanted to do, whether it was fair, and I subsequently got involved in a lot of the changes that came.

SPEAKER_04 6:35

Thank you. Indeed, many changes over the last decades. The last change, as you know, was done quite recently. So we now have a different piece format. And whilst the aim of today's uh episodes is not to go through the details of that, then you can find some more information in our other episodes. We will touch on some of the changes. So today in this episode of the Domestifying Paces podcast, we're going to discuss about one of the examination stations. And I would like us to concentrate on the cardiovascular examination station. We're going to do a little introduction overview of the station, approach to examination, tips, pitfalls, and some system-specific questions as well. So tell us a bit about the cardiovascular examination station. Any changes with the new exam format, what skills are assessed, and how do you expect the candidates to achieve these during the station?

SPEAKER_02 7:34

Yeah, thanks. And I I think the first thing to say relates to the recent changes in PACE. I commissioned the group when I was medical director of MRCP to undertake the review of Paces. And the particular prompts to that were the feeling that the old form of station five, and I know we don't want to talk about the old exam in any detail, but the old form of station five was felt to be quite hectic, both for candidates and for examiners. As you know, that's now been changed from that old format. And another big question, though, the one you've made me think about, was is it still relevant and valid to ask candidates to both demonstrate their physical exam technique and to discuss and describe their findings? And the working group that reviewed PACES, with I should say lay input, came to the definite conclusion that despite all the technology that we have these days, it is still very helpful for a physician to be able to undertake these, you know, big four system cardio, neurology, abdomen, and respiratory physical exams. There still is a value in it. So I wanted to stress that right at the outset. Physical exam stations weren't continued simply because of tradition, but they've always been there. It was a result of a positive evaluation.

SPEAKER_04 9:05

What skills do we assess in the examination stations, particularly when we think about cardiovascular systems?

SPEAKER_02 9:12

Cardiovascular has five skills within it. Okay. One is skill A, physical exam, and that's your method. Okay, and that stands alone from skill B, which is identifying physical signs, in that you can look like you've got a good method and find nothing that's there and invent a whole lot of stuff that's there, or you can look like your method isn't really very good at all and get everything spot on. A and B are different from each other. Skill D is differential diagnosis, which in this context means with the little bit of history that you've got, and don't forget that little bit of history, plus what you have found. What do you think is the likeliest explanation here for this patient's symptoms and for your findings? So that's the differential diagnosis. The clinical judgment element of it, that's skill D. Now, examiners will assess your clinical judgment in this kind of station in two broad ways. One is how you reason through your own physical findings and the differential diagnosis that you construct. So there's a wee bit of overlap with differential diagnosis there. But also they'll ask some very broad and usually actually pretty straightforward questions about what you would do if you'd seen this patient, for example, in a clinic. So I might say this 50-year-old man that you've just seen that says here that they're breathless, you've described clinically they're in atrial fibrillation and they've got an ejection systolic murmur. What would you do now? That's their judgment. You know, I might ask them what questions would they ask? What investigations would they do? If your investigations show, let's say, aortic stenosis, what would be the possible next steps in managing? Maybe we'll come back to more detail about that discussion in a while. The vital skill, and this is the one that's present through all the stations, is skill G, maintaining patient welfare. When this barking system was first introduced into patients, and I was responsible for it, we were very pleased actually, again with lay input, that we included skill G, because it makes absolutely clear that the way that you interact with your patient, the way that you look after them, the way you speak to them, the way you move them around the bed, the fact that you're not rough with them, that that is just as important as any of these other skills. It's very rare for somebody to fail simply on the grounds of skill G. I think because it's there, it sent a very good message about what we're trying to do with the exam, one of these purposes of the exam.

SPEAKER_04 12:09

Thank you for that. So you're talking about these really kind of five broad skills that are assessed during an examination station. As a candidate, there is always a concern that say you started the station, you're a little bit more anxious, nervous, perhaps you know, the first part of the exam, something doesn't go right, or you've not paid attention to the script, you're struggling with either the method or the ability to detect signs. And I think there is always a concern that that is, you know, the red flag and you failed that station, that's going to have an impact. But from what you're saying, there is some independent assessment between these skills. And I just wanted you kind of to send a message and to see how, from an examiner point of view, how do you calibrate and how do you assess these skills differently? And can a candidate still do well if they don't, for example, have a good method or on the day, don't examine in a comprehensive way?

SPEAKER_02 13:07

So there's a lot in that. The first thing I would say, And, and I would encourage candidates to think about, is that almost certainly you will not know how you're doing. The examiners are really told that they should not be giving feedback, either good or bad, to candidates as they go on, even to the extent of saying, you know, well done, let's move on to the next station. Because they don't know first and foremost what the co-examiner thinks at that point. So the examiners are encouraged to be neutral or, you know, poker faced or whatever you want to call it. So the feedback you're getting from them will be limited. Obviously, as you've described, things may happen that make you think, oh gosh, that was terrible. But what I would strongly encourage everybody to do is to regard every single encounter in paces as a separate exam because they are all independent of each other. As soon as you finish one, I know it's difficult, just put that in the back of your mind and get on with the next one. The way the marking works, it's done on the basis of skills, not stations. The whole notion of failing a station or failing an encounter is actually meaningless. You can't fail the whole exam on the basis of one encounter unless it's on that skill G business. Yeah? When two examiners you'd be rough with a patient. All other marks that you get in any given encounter, they are factored into your whole performance. So try and, as I say, regard each encounter absolutely independently, particularly as you won't know how well you're doing. You asked about red flags. Well, remember again that apart from skill G, there is nothing that can happen in a given encounter, cardiovascular, we're talking about, that fails you outright for that whole encounter. Yeah. If you examine well but miss the physical signs, you'll get top marks for skill A. You'll get less than top marks, you know, you get borderline or unsatisfactory for skill B. If you get borderline or unsatisfactory for signs, you can't get full marks for differential diagnosis. That's one of the rules of the marking system. But you can still pick up maximum marks for maintaining patient welfare. So try and factor that in. There's nothing other than patient welfare that could fail you absolutely outright in any encounter.

SPEAKER_04 15:53

Thank you for highlighting that message. I think is very important for candidates. In terms of how you decide on calibration for signs in stations, particularly examination stations, is there a particular approach to calibration? Does it depend on the case or the difficulty?

SPEAKER_02 16:11

Yeah, so that's something I'm you know personally quite proud of. I pushed on the introduction of that into the exam. And I said at the beginning about when I was first an examiner and being uncertain of it, the exam's purpose, I was also uncertain of some aspects of its conduct, how you actually went about assessing a candidate, particularly when there's two examiners meant to be assessing the same thing. So calibration is taken extremely seriously by the examiners on each running of paces. And in fact, the carousel, the cycle can't start until the chief examiner has personally heard from all the examiners that they're ready to go. And if they're not agreeing on some aspect of calibration and how they're going to mark, then the exam will not start. And some colleagues listening may have been involved in a city when that's happened, when there's been a delay because of that. So let's think about the cardiovascular station specifically from the point of view of calibration. Each examiner is given a blank sheet that lists the relevant skills that are going to be marked. And they're asked to fill it in saying what they think a satisfactory candidate should do to get the marks for each of these skills. It's not for the station overall. Okay? It's not an overall assessment. It's to think specifically about each of the skills. They then examine the patient themselves. And in doing that, they will be able, you can imagine, to suss out very easily how easy or difficult this patient is to examine. Some people are just tougher to move around the bed, or you know, if they're a bit frailer, that can introduce issues. You would take that into account in your assessment of the candidate. And then just as importantly, the examiner will find what physical signs they can find themselves. And also, you know, they'll think about things that the candidate might come up with and whether it would be reasonable for them to make that error. What would be an example of that? Well, imagine you've got a patient who's got an irregular pulse. You can tell before the exam from feeling the pulse that it's definitely ectopics. Yeah, that it's infrequent irregularity. But you can also imagine that a candidate who's got a shorter period of time, if they stood up and said this was atrial fibrillation, would that definitely be wrong? Right? In examining themselves, you're getting a feeling for what's definitely there and what is reasonable for the candidate to either miss or to come up with that's incorrect. So each examiner sees the patient, they record their own findings, then they discuss with each other. And if there's a treaty examiner there, they'll be in it too. And I think the main message for candidates listening is that if two examiners can't, let's give a common example, if they can't hear any orc diastolic murmur, you will not be failed for not hearing it. You can't be. That's reasonable. It's a general medical exam. The examiners are pitching their assessment at general medical level. So they want failure on scale B, identify physical signs. If you don't hear a murmur, they weren't able to hear. And that's one of the main requirements of the calibration process. But as I've said, it doesn't just apply to the signs. They'll discuss at the beginning. They'll say, well, look, what would we do if somebody didn't look at the JBP at all? Yeah. Can they get a satisfactory mark for skill A? We would say no. I think that if you haven't looked at the jug of or you haven't taken a radial pulse in the cardiovascular exam, can you get satisfactory per skill A for method? They'll also discuss what would be a reasonable differential diagnosis for the candidate to come out with based on the very short history and the physical findings that they get. And they'll also discuss what would be the basic questions that they're going to ask. As I said earlier, typically what investigations would you like to do? What would be the key parts of management for this patient? So there's calibration across all these different domains.

SPEAKER_04 20:40

So are there really kind of past fail signs kind of that last detects from your examples? For example, if somebody felt the pulse and they have not appreciated that the patient is in atrial fibrillation, it has an irregular and irregular pulse, is that a fail? Or they couldn't hear the loud ejection systolic murmur.

SPEAKER_02 21:00

Again, and I would stress that in terms of kind of red flag or you know must-fail criteria, that that can only apply to the given skill, right? It can't apply to the bowl encounter, the bowl station, apart from patient welfare, which can obviate everything else that you've done. But to answer your question directly, yes, there could be a situation, there's commonly a situation. Let's say two examiners agree that there's an easy-to-hear ejection systolic murmur, or in fact, a better example would be somebody with a steronomy scar and loud metallic clicks. Yeah. We would not uncommonly say that if a candidate stands up and says there are normal heart sounds here, and doesn't allude to the fact that there's metallic clicks present, that they cannot get a satisfactory. Yeah. And we may say they would have to be unsatisfactory. Satisfactory for that particular domain of identifying physical signs. But there's rarely just one sign that the examiners will base the marking for identifying physical signs on. It will be, you know, a combination that they picked up the atrial fibrillation, that they didn't say the GDP was elevated, that they picked up the scar, that they picked up the clicks. And they'll base their judgment, and there is judgment in this for the examiners as well. They'll base their judgment across, you know, two, three, or four signs, rather than just being one absolutely central critical one.

SPEAKER_04 22:44

Thank you very much for that. The structure and the timing of the exam. So as we said before, there's not been changes to this. So there is a maximum of six minutes for performing the examination. And then you've got about four minutes for questions discussing the differentials and management plan. The approach to timing, I think there is another moment kind of of anxiety, feels like you know, a short period of time to do everything you want to do during the examination station. From your experience, do you find candidates struggle with the timing on the cardiovascular examination station? And where do they spend too long time on? How can we change that?

SPEAKER_02 23:27

In general, no candidates don't struggle with cardiovascular. They struggle more with neurology timing-wise. It depends on exactly what they're asked to do in neurology. They struggle on respiratory if they, you know, want to not unreasonably do the front and the back of the chest completely. But abdomen and cardiovascular are the ones that are most easily time-managed, it seems to me, for candidates. When people have difficulty with time, it's either, in my opinion, because they are just unpracticed, which is why one of the key elements in PACE's preparation is rehearsal, rehearsal, rehearsal. Doesn't need an examiner watching you, have a colleague watch it. And they'll pick up things that you miss or you do in an unusual-looking way. So it's either because they're just not prepared, or, and I would ask people to think about this, they spend too long on the peripheries. They take great care looking for clubbing, looking for peripheral cyanosis, looking for central cyanosis, looking at the eyes for pallor, for xanthalash, etc. etc. You know, by the time that they've kind of introduced themselves, positioned the patient the way they want them, exposed the patient in whatever way is appropriate, and then done the peripheries, they're actually sometimes three minutes in. If there's findings in the precordium which are tricky, you don't have as long to listen carefully or to go back and listen to a point that you want to listen to again. So I would encourage people to get through the peripheries as fluently and quickly as they can and to rehearse.

SPEAKER_04 25:19

And does that apply also for that kind of part of the exam where you present your findings and discuss differentials and management plan?

SPEAKER_02 25:27

People will find that that flies by. And that also that rehearsing that with a colleague is very, very helpful and important. Just being able to stand up when it's all going around in your head, you know, you're thinking, wait a minute, what did I hear here? So practicing being able to describe what you've found in an ordered way is an important part of it. You're not going to fail if you're completely disordered in your presentation. It will make it harder for the examiners to understand what you've found and what you're thinking, but you're not going to fail because of that. But rehearse that by all means. The other thing I'd say, and about the questioning period is that if you get on to, you know, the genetics of HOCM or drug treatment for cardiac amyloid, then you've passed that part of it. Then the examiners are just looking for things to ask you for. Because remember, they've got to have the same standard for every candidate. So they can't take you higher and higher factually because you're doing well and then mark you down when you don't get something that nobody else has been asked. Yeah. So their assessment of your clinical judgment in the discussion, as I said earlier, is based upon your interpretation of the signs and on your basic approach to the management of this patient. And I'd encourage candidates to think about their discussion in the exam. I know it's a completely different setting, but just pitch it at the level as if you were discussing the patient on a post-day wardrobe. You've got this person here who's got, I don't know, early diastolic murmur and doesn't look like they're in heart failure. What might be the causes? What would you do for that person? Why would you look into it? It's at that level.

SPEAKER_04 27:19

Thank you for those tips. With regards to the examination technique, can you please summarize for us what does a good cardiovascular exam look like?

SPEAKER_02 27:29

Well, it looks like you've done it before. Right. Believe me, sometimes people come into the exam and it doesn't look like they've done it before. I think cardiovascular exam, amongst the four ones that we do, is a staple of what we do. And with a bit of practice and rehearsal, you should be absolutely certain that you can get through what you're expected to get through in the required time in a way that looks practiced and professional. It's not critical that you do everything in any particular order. There is a standard order, as you know, by which to do things, which would be peripheries, radial pulse, GVP, precordium, that kind of order. But I think you'll draw attention to yourself if you do things completely out of order. If you forget to do something, like if you forget to do the G VP, of course it's okay to go back and do it. And you can't be faulted for that in itself. I've spoken a wee bit there about spending too long on peripheral signs. Remember the blood pressure. Yeah. Sometimes there'll be a chart at the bed that shows the blood pressure. It sometimes is mentioned in the descriptor. If it's not, offer to measure it or ask what it is. In my mind, the easiest time to do that is after you've done the wrist, before you go to the neck. Don't forget the anticubital fossa. So wrist, anticubital fossa, neck. And when you get to anticubital fossa, say, can I take the blood pressure? What is the blood pressure, please? And they'll tell you. So that's one wee detail of it. In terms of what a bad examination looks like, be careful with, and this is a skill G thing, the exposure of the patient. Yeah. The examiners will have thought about that a lot before you come in and they'll have checked with the patient whether the patient's comfortable to be completely exposed for the old exam or simply to have their gown draped over them and to be examined underneath their gown. Yeah. You can obviously look to see if there's any scars under the left breast if it's a female. But check with the patient what they are comfortable with. And don't assume that they're going to be happy to be fully exposed for the cardiovascular exam. Please check that. When cardiovascular, other than that, there aren't any particular other than blood pressure, I would say, there aren't any particular bits that are often done poorly. But it is kind of bread and butter physical exam. So, you know, there's an expectation that you'll have a good routine of it.

SPEAKER_04 30:09

Thinking of a scenario, I wanted to ask: are you expecting candidates to be flexible with their examination? So they cover the main parts as we discussed, the cardiovascular exam. And then, say for example, they heard an early diastolic murmur, they're concerned about aortic regurgitation. Collapsing pulse is one of those signs that we'll discuss a bit later because it can be challenging. You know, we go for undergraduate, postgraduate training, looking for it. But are you expecting everybody to check for a collapsing pulse? Or if a candidate suspects that the patient may have aortic regurgitation, going back and checking for those signs gives them extra points or as a positive mark?

SPEAKER_02 30:50

I think flexibility is fine. If you don't include, you know, checking for a collapsing pulse, elevating the arm, and looking for a water hammer pulse, if you don't include that as a matter of routine in your examination routine, that isn't in itself ever going to fail you on skill A. Okay. If you didn't do the arterial pulse at all, as I said earlier, I think at undergraduate level, we would be worried about that. Never mind at postgraduate level, but not checking for a collapsing pulse as a part of your routine, that could not fail you. I think that if you examine the precordium and you think to yourself, gosh, is that well, I hear a diastolic murmur, an early diastolic murmur. If there's a collapsing pulse, that would add fuel to the fact that it comes from the aortic rather than the pulmonary valve, which and the latter would be much rarer, obviously, then you're showing that you're thinking about it. I don't know. And uh that's probably a level of sophistication within the exam that maybe is more in the worries of candidates than actually happens in real life. People don't fail physical exam cardiovascular system, identifying physical signs because of these kinds of issues. They fail because on scale A, I'm serious here, in a postgraduate exam, their method just looks like they haven't practiced it at all. And they fail skill B because they miss physical signs, not because they're difficult diastolic murmurs or complex congenital heart disease signs, but because they don't hear prosthetic clicks or loud systolic murmurs, or, and we haven't touched on this, they make up stuff that isn't there. And sometimes under pressure, if people haven't found anything, they kind of say, Well, okay, I'm gonna go for it here. Not only do they say there's an ejection systolic murmur here, but they say there's a slow-rising low-volume pulse, and you know, they make things fit to come up with a diagnosis, and that is always going to cause you difficulty if you're wrong.

SPEAKER_04 32:52

Very important point, I think. In terms of you know, that patient welfare and maintaining that during the examination stations throughout the exam, it's something that's expected to come naturally, but you have told us how important that is and how that is marked rigorously. Have you ever come across situations where this has been done poorly? And what examples do you have of that or what things to avoid completely? So you talk to us about patient exposure during examination stations. Anything else?

SPEAKER_02 33:27

I think in cardiovascular that would be the commonest concern. Examiners and a general thing about examiners, they're looking to help the candidate show what they can do and what they know. They're not looking to trip them up and make things harder for them. Examiners know that candidates are nervous. That's the other thing. So if a candidate came in and launched into a cardiovascular exam and it looked like they weren't thinking about the patient enough in terms of positioning them or asking them about exposure, then the examiner wouldn't say nothing and write down, you know, fail skill G. They would say to them, you know, make sure that your patient's comfortable. We might say, we've checked earlier, and Mr. So-and-so or Mrs. So-and-so or Miss So-and-so would rather only, you know, have her gown draped over for this part of the exam. That's the way we did the exam. Can you do the same? So they'll be trying to help you with that. If you persist then, imagine that that conversation happened and you took the gown off the person again, then clearly that would be a worry beyond, you know, unlikely to be explained just by the nerves of being in the exam. So other than skill G, though, I think your question was, what else do people do badly? Very occasionally, you know, just being a bit brusque or rough with the way you move people or you know, command them to sit forward quickly, particularly if they're frailer. These would be the main things. But the commonest by far, I would say, for skill G is exposure in cardiovascular.

SPEAKER_04 35:09

So we covered a little bit about the exam technique, tips on things to do, things to avoid perhaps doing. I'd like to concentrate a little bit about system-specific questions. And whilst we said today we're not going to cover in detail clinical scenarios or, you know, discuss underlying physiology of these conditions. I would like, if possible, for you to give us some examples of common conditions that appear in a cardiovascular examination station, and perhaps those that are more challenging for candidates and how can they prepare for that? It's something that still sometimes gives me, you know, anxiety is uh thinking about patients with complex congenital heart disease and identifying signs in those patients and how they approach that. What are the common ones and what are the ones that candidates should be prepared for?

SPEAKER_02 36:02

One way that I encourage candidates to think about that question and is to think, and some of them will have been involved in this and others will become involved. Imagine you're the doctor organizing the exam. What kinds of patients would you pick to be in the exam? They're not going to be people who are inpatients who are likely to be too unwell in the morning of the exam. Sometimes inpatients will appear. They can't be unstable. So they've usually got chronic disease and predictable and stable signs. If the organizer knows that they're going to be able to pitch up on the day and that the physical signs will be there. The other general thing to remember when thinking of this is it, I think I've said this already, it's a general medical exam. Yeah. It's not an exam for trainees in cardiology. And the calibration process demands of the examiners that they pitch their assessment at general medical level. You could have a cardiologist on the cardiovascular station, but you'd never have two. And if there is a cardiologist, then the assessment is still pitched at the level of what a generalist can feel, hear, see, and deduce from their assessment. So to use your example, there can be congenital heart disease patients who've had surgery in the exam, but you will be assessed on the basis of what the most obvious and clear physical signs are. If the examiners can't put together what explains these signs, you won't be marked down for failing to explain it. So again, it comes back to the calibration process. I think, as I've said, too, if you think about what stable and reproducible people who are under monitoring or surveillance because of progressive aortic stenosis are commonly in. People with prosthetic valves are very commonly in the exam now. Patients with atrial fibrillation and you know any murmur, or even without a murmur, atrial fibrillation alone can be in the exam. So it's stable things.

SPEAKER_04 38:32

What about having somebody who doesn't have any significant signs? So I'm thinking, for example, someone with chest pain and underlying coronary disease, maybe a scar for previous bypass surgery, but no identified murmurs or signs of heart failure. Is that also a possibility?

SPEAKER_02 38:53

It's possible, but it's rare. Typically, a center or organizer would not choose to put a normal in. Occasionally, on the morning or afternoon of an exam, if there's a withdrawal of a patient, then a normal can be put into any system. My experience of that is that it is very difficult for candidates because their expectation is that there will be abnormality and the examiners take that into account. But the golden rule in all your exam stations, and indeed all parts of the exam, is don't make things up. If you don't find anything, then say that. That is the way to manage that, because that's what you should do in real clinical practice. You should be honest. You wouldn't invent a whole lot of signs with a patient who came to the clinic. Even if you were told that they had psychortic stenosis, you would say, Well, gosh, I can't hear that murmur. And you know, doubting other people's diagnoses and being curious about things is fundamental to your clinical practice. If you don't find anything, then say that. But to answer your question directly, it's extremely unlikely, but not impossible, that there'll be somebody with absolutely no physical signs in the cardiovascular station. It was more commonly the case in the prior version of station five. And it may be that there'll be patients with no physical signs in the new integrated communication exam stations, but in the Big Bang, four physical exam stations, it's unusual for there to be somebody who is entirely normal.

SPEAKER_04 40:29

And what is the best way to approach a station where the candidate is unsure of the diagnosis, doesn't pick up on the signs, runs out of time. I appreciate you talking a bit about kind of the challenges and pitfalls, but really this is just to give top tips to candidates.

SPEAKER_02 40:48

You may stand up and say, I believe this patient is an atrial fibrillation with the ancestolic murmur at the characteristic of mitral regurgitation. You could be completely wrong. The examiners won't necessarily, they might, you know, lead you to the correct diagnosis. They're instructed that they are permitted to do that, or they may question you on the basis of what you've found. So they would then say, Well, how would you investigate this patient? You'll get some credit then for saying, well, I'd do an echo or an ECG to confirm if they're age correlation. What would be the key parts of their management? Well, to quantify the severity of the leak and to think about prevention of thromboembolism from the very point of view. You can get marks for that, but you can't be satisfactory in clinical judgment if you're discussing the wrong diagnosis. Okay? I'm saying all that because the candidate may not know that they're wrong or right. If you haven't found anything at all, you're almost certainly incorrect in some way, but the examiner will still manage the situation and will still be trying to look for ways to give you credit in the differential diagnosis and clinical judgment domains, even if you've found nothing. That is not impossible for them to do that.

SPEAKER_04 42:06

So if that's the case, your advice would be to just approach kind of differential for you know the presentation that you've had and discuss what you'd do next. As you'd do, as you said, in clinical practice, perhaps in that post-stake wardrobe. So this kind of gives us a good opportunity now to really discuss the lateral part of the examination station, which is those four minutes that you have to present the case, the findings, and discuss management options and differential diagnosis. How do the best candidates present the case from your experience? I think there is always, again, thinking about undergraduate examinations, postgraduate examinations, about a list of positive, negative signs that you have to tell the examiner about, or do you expect a different approach to this?

SPEAKER_02 42:58

Like you say, it's a postgraduate exam. You're a stage beyond undergraduate. So it comes back to rehearsal. You should, when you pitch up for paces, you should feel confident that you can run through these four big system exams within the time that you know is going to be available to you. If you can't do it, it's probably because the patient is difficult to examine in some way. And if that's the case, the examiners will have found things exactly the same as you have and will take that into account. In thinking about how you present, and again, rehearsal, as I said earlier, is a part of that. Get used to standing up when you've done your exam for six minutes and speaking to a colleague. Tell them summarizing what you found quickly. Remember that the examiners have seen everything that you've done. So sometimes people worry, should they, you know, describe all their findings, even if they're Normal or abnormal. It's not a fail thing if you do that on any of these domains of marking. But you're more likely, if you do that and start running through absolutely everything, you're more likely then to have the examiner say to you, can you just tell me, please, the positive findings and any findings you regard as significant through their absent significant negatives? So my overall advice to people would be just focus on the positive findings that you've got, because they've seen everything you've done and anything that you think is a significant negative. If you wish, add on what you think the likeliest diagnosis is. But if not, they're going to be asking you that anyway. So don't feel that you have to do it either of those ways. You're very unlikely to fail the exam or that part of the exam because of the way that you present. You're much more likely to fail the exam because you look like you've never done a physical exam of the cardiovascular system before, or you find none of the signs, or you make up a whole lot of signs that are not there.

SPEAKER_04 45:11

You mentioned about the differential and the questions that will follow on. From what you're saying, there is not a prepared way in terms of a candidate presenting the case they're behind, telling you the differential, and then the management. It's okay to wait to be asked questions. Or do you think there is a better way to do it?

SPEAKER_02 45:31

No, I don't think there's any magic. I don't think there's any rule. I think everybody's different. We're different in the way we speak to colleagues in clinical rounds. And part of that's confidence, part of that is experience. But as we're saying, this is a postgraduate exam. The expectation would be the doctor will be able to run through the physical exam in the time available and to stand up and present what they've found in a way that is understandable by a colleague. Just like you're on the phone or in the middle of the night, you've got to try and describe what you have found. It's at that kind of level. Can I communicate the information about my own findings to another professional? It's at that level.

SPEAKER_04 46:17

And not leaving time for the questions, is that a challenge?

SPEAKER_02 46:22

The examiners, as I said earlier, they're looking to help you through to demonstrate what you can do, to show what you know. They'll manage the time. And it would be extraordinary for a candidate to keep on speaking and speaking and have an examiner who doesn't bring them back to the point or gets them on to the next thing that they feel they need to ask to assess, clinical judgment in particular. Occasionally a candidate will get so bogged down in the description of their signs, you know, it can be difficult for the examiners to understand, or they change their mind, or you end up with very little time to be asked about investigation and management. But you know, the examiners will in general be ensuring that that doesn't happen. But you might find you get very few questions on investigation and management, and those that you get are very, very straightforward.

SPEAKER_04 47:10

Thank you. Well, I think we covered quite a bit of information during this episode of our pieces podcast. Before we end, I'd like you to please give us some take-home messages, particularly thinking about the cardiovascular examination station and candidates preparing to sit the exam.

SPEAKER_02 47:30

Yeah, thanks, Anda. I remember thinking about the exam a lot when I was a candidate two, and I know that it seems different from that side of the fence than it seems from an examiner's point of view. But what I would stress is what I said at the beginning now, for an examination that still uses real patients, and that's very important, we think, this exam is about as standardized as we can make it. The examiners take great care to assess candidates at a fair and reasonable general medical level. Remember, the examiners are being marked too. At the end of every cycle, their agreement, their concordance with each other at that station is seen by all the other examiners. And if they're not in agreement, questions are then asked about, well, how did you calibrate? So there's scrutiny of the examiners too, and they're aware of that. So it's very standardized. It still involves examiner judgment, and that's why candidates can see disagreement between two examiners about what they've done. In terms of your preparation, I can't emphasize rehearsal enough. It helps to go around now and then with the PACES examiner, but lots of the time you'll learn lots of stuff about yourself, how you look when you're examining, what you forget to do, what you're like at presenting information. You'll learn just as much by doing it with another colleague, either somebody who's recently sat PACES or somebody who's preparing along with you. Going into the timings and getting through the encounter in the requisite time shouldn't be a problem, ideally, nor should describing what you've found. I guess the final thing is, you know, PACES is not fundamentally a detailed knowledge test. By passing part one and part two written, you've shown the amount of knowledge you have. So you often find the questions that are asked other than your description of your findings to be absolutely uh standard, routine investigation and management. It's not a high-level factual exam in that way. So focus on rehearsal technique, picking up signs and describing them to other people.

SPEAKER_04 49:58

Thank you very much, Professor Elder. We're our candidates, we wish you good luck in your preparation for the exam. We hope that you found these episodes useful and we hope to hear from you and receive your feedback. All the best, and thank you very much for listening.

SPEAKER_00 50:41

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