Demystifying PACES - Respiratory [Station 1] (31 Jan 2024)

SPEAKER_01 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_02 1:16

So welcome. Thank you so much for joining me today.

SPEAKER_03 1:19

Thank you kindly. Thank you for inviting me, Madalena, and I'm looking forward to the session.

SPEAKER_02 1:24

Me too. And as you know, you are a PACES examiner yourself. There has been a recent rejuggle, let's say, of PACE and the way that it's set out. So we hope that through these episodes we help to give whoever is sitting PACES a little bit of an understanding of what they should be expecting and hopefully a little bit of confidence to sit the exam, as we all know it can be quite stressful. So today we will be talking about the respiratory station. I'm just wondering if we can maybe talk a little bit about the skills that are assessed during that station.

SPEAKER_03 1:58

Yeah, so you mentioned it. I think a lot of candidates in general for the PACES exam have a lot of fear setting the exam. But I would like to say this. So I have trainees in the UK. I've been hosting this exam since 2011. I've been chair of examiners both in the UK and as an international examiner. I have trainees both in the UK, and another part of my job is I run two tertiary centres in Iraq along with the university on top of the stuff that I do here. And one thing that is uniform when you get a lot of the candidates is that there's so much potential for people to do well in the PACES exam if they prepare well. So if they prepare for it, and particularly if they're going to speak to established examiners and have platforms like this brilliant podcast, it should put them in good stead to actually literally score higher marks. The answer to a question is that one of the beauties and one of the reasons why I really like the PACES exam format, form of formative assessment for trainees who would like to go into some speciality training or speciality training, is that it looks at all these different domains. The ones that we're going to focus on today for the respiratory station, the respiratory station, of course, with the new format of the PACES 23 exam is as part of station one. The focus I understand, Marilena, will be on one B, which is the respiratory side of it, which is the 10 minutes of the 20-minute station. So the domains as far as the respiratory 10 minutes 1B, if you like, from that station are as follows. Domain A, which is physical examination, domain B, which is identifying physical science, domain D, which is differential diagnosis, domain E, which is clinical judgment, and domain G, which is uniform throughout all the stations, is maintaining patient welfare. So these are the skills that will be assessed, and I'm happy to go through them a little bit more detail if you ask me to.

SPEAKER_02 3:53

Yes, that would be great. The only thing that I'll ask if it's okay is that you mentioned the joining up of the stations, and that's how it's slightly different in PACES 23. Do you mind if we just quickly go through that first and then we'll go through all the skills one by one?

SPEAKER_03 4:08

No problem. So PACES 23, I have run the new format exam. I have hosted the new format exam. I think it's a better way of doing the exam. A lot of work has gone into the new format of the exam to make it hopefully fairer for the candidates, to make the point allocation equitable across all stations, because it was disproportionate to station five in the past, where it carried about a third of the marks in the past. So that then means that if a candidate doesn't do well in one particular station, particularly if it was station five in the older exam, they're not going to be as disadvantaged this time around. So that's one bit. The second bit as well is that the communication stations, so they established the previous history take in station two and communication station ethics station four will carry domains that the examiners will mark, but there's no interaction between the examiner and the candidate. And that's because we found with time that it doesn't really change the allocated mark at the end of it. So utilizing that five minutes for each of one into other stations where we can assess the candidate better made a difference. So the new format now has sort of mixed in some of the stations to have two parts to them. So station three is the same as before. You have five minutes where you wait to enter the station, no reading material. And then you've got the cardiovascular case followed by the neurology case. And generally for the neurology, as before, the time allocated 10 minutes will be either cranial nerves, upper limbs, lower limbs, or something guided by the examiners, examine this bit and what's relevant. So it's much the same as before. And then we have station one, which now always has to start with a communication station. So that's one A. And then what happens is you have a scenario to read just before you enter the room. So all the other stations now have a scenario apart from three. So you have a scenario to read, you go in, you start the communication, and then once the 10-minute knock on the door occurs, then you move on to the respiratory station. The same applies to station four. So you have four A, but this time it's communication with abdomen as a second half. So station one A, one B is respiratory, preceded by communication, and then four is for A communication, for B abdomen. And then you have stations two and five also have a scenario before you go into the room, it's a clinical consultation where you have 15 minutes with a two-minute warning and 13 minutes with the surrogate or patient or surrogate slash patient. And these are what we call clinical consultations. They're more reflective of what we expect somebody at that stage of training to do when they're reviewing patients. And ideally, one of stations two and five is something similar to what you would see in the acute selected take or a scheduled care, suspected PE, for example, or a chest pain. And then the other would be something that'd be more elective. So, for example, somebody who wants some counseling on refining their antiepileptic drugs, but they've not had that many seizures. And they're usually written by the host, they get vetted by the college stations two and five, but they give us a lot more of a better idea of how we can assess patients. And then as far as the station going back to station one B, the respiratory path, physical examination is basically the ability of examining. And we'll go into that a little bit detail later. That's a crucial bit, and it's at the discretion of the candidates if they prepare well for the exam. So basically, just a respiratory examination has to be correct, needs to be thorough, needs to be fluent, needs to be systematic, and professional techniques when you're doing all the aspects of respiratory. So that's just physical examination. And then domain B is identifying physical signs. And identifying physical signs, and we'll talk about that later, is based on the calibration process and what we the examiners feel were identifiable physical signs, and as importantly, not to make up any signs. And the thing to remember is that physical examination domain A and identifying physical signs domain B, there's no double jeopardy. So you might not have examined the patient very well and you get marked down on domain A, but you've picked up all the physical signs in the calibration sheet, so you get full marks. So one is not really related to the other to avoid double jeopardy. But with that qualification, it still means that if I have somebody with those physical signs, domain B, I am expecting the candidate to be assessing that particular individual patient. So when then I come to domain D, which is differential diagnosis, and then domain B, which is clinical judgment, I'm expecting it to be in relation to that particular patient. And the reason why I say this, and sometimes candidates, but I said spirometry, but I said high resolution CT scan, but I said this, I said yes, it's not enough for us that you just run a list of common respiratory investigations, they have to be relevant to the patient themselves. And that's why B, D, and E are called linked marking. So if somebody gets unsatisfactory because they didn't pick up the relevant signs, but they give a good, reasonable list of investigations that you commonly have with the arms of respiratory medicine. And then based on that, the evaluation, how you'd manage the patient, the most I could give them is a borderline. I can't give them a satisfactory. So that's their linked marking. I could only give a full mark on D and E if they're identifying physical signs of not a U. And then basically, last one is maintaining patient welfare, which is generic to all the stations, is just basically treating the patient respectfully, sensitively, ensuring comfort, safety, and dignity like you would with anyone you care about.

SPEAKER_02 9:47

Great. So thank you so much for that. I guess just a few questions on my behalf that I know I was revising for PACE, it was what we always panicked about. And if we just take the physical examination, for example, obviously there are set ways that we are taught in medical school that we should do the physical examination. Is that what you look for? That, you know, all candidates do the textbook way of inspection, palpation, percussion, auscultation, front, then back. And then there's always the issue of, you know, vocal parameters, tactile parameters. Should we be doing those? Should we not? Are we actually going to pick up those signs? What is it that you're actually looking for? Is it that you're looking for fluency in whichever way we choose to do it, or is it that you're looking for actually every single aspect of that examination to be done in a fluent manner?

SPEAKER_03 10:35

Very good question. What I would answer is I'm looking for not only fluency, because that tells me if they're practice, and that's important. I'll tell you why in a second. Fluency, thoroughness, and systematic. And the reason being is because when I have somebody who does domain A and they do it so fluently, and the way I've said it and thoroughly, so if they do it fluently and they do it thoroughly and systematically, it's less likely they will forget to do aspects of the examination that are crucial. And that's reflected by how practiced they are. But if they're hesitant, then I'll be like, have they actually done enough respiratory examination? And the second thing as well, just like driving a car, a manual, not an automatic. And when you start off driving a car initially and you're learning touch control and all the other intricacies of it, it can be quite challenging to multitask, for example, turn the radio on, chat to the person next to you. But when you practice and you've got so many hours on DFL, you can do all these other things. So the beauty of being fluent and systematic and thorough in domain A, physical examination, is the fact that you can be an autopilot. So not only you'll be able to concentrate on picking up the signs, but towards the end of the physical examination, you'll be able to come out with something sensible to say. And you're only going to be able to do that if you're an autopilot. I generally ask or expect, and I would share that that is what I've seen from, I would say the overwhelming majority of examiners of paces is inspection from the end of the bed, followed by hands, followed by face, followed by neck, and I'll qualify that in a second, followed by front, then back. And the front and back have to have inspection, palpation, which includes chest expansion and the trachea, the cushion note, and then the auscultation of the chest. Now I've known some examiners who are not too bothered if you start off with the back and then go to the front. But in my years of examining faces, I can't recall a candidate coming to and they start examining after they've done the hands and face, etc. Generally, they're quite good. So most candidates I find that I do allocate their full marks when the examining respiratory, and they usually do it in that order. So people that are going to be listening to this podcast, I think that's a safe bet to do it in that order. What I also say to people is a part of the package of, let's say, the respiratory examination or any of the other examinations, so abdomen, cardiovascular, and neural, is there's no harm in saying I would also like to, because that way you can say it, and it might be something that will take just from a practical point of view, it will take longer time and you won't have that time. So everybody should have that list ready. I would also like to. And I might be at the discretion of the examiner say, Yeah, can you please examine? Now, I usually say to people when they're doing good at spiritual stations that when they're done with their examination, they say, I would like to feel the auxiliary nodes. I would like to check if there's a sputum pot by the bedside or a peak flow meter if it's relevant, and check the temperature chart. And I think if we say that, it's very difficult for me as an examiner to mark you down, have to give you an offer you the marks, or ask you to do it if there's time allocated. I would, however, expect you to make an effort to examine the neck and in particular is the supraclavicular fossa, because a lot of respiratory disease would be related to this, particularly in the context of malignancy. And I would expect people to look at that when they're gone round to the back rather than doing it as part of the face. I wouldn't necessarily mark them down if they flew it and everything, and I thought they did an adequate examination, but that's what I would expect. The second thing I would expect as well is for them to feel for the trachea. And a lot of people forget that. And when they feel for the trachea, sometimes people have long fingernails and they're poking the trachea, that's making it uncomfortable. So that starts impacting on maintaining patient welfare. G. That doesn't happen often, but you can sometimes see the grimacing and pain that is causing the patient. And when they're feeling for the trachea, people I find put the middle finger on the trachea and then the two index and the fourth finger on the ends of the clavicles. But quite often you start off with that, make sure you warn the patient, make sure that you don't cause them discomfort. But what's probably more relevant, especially if it's a subtle deviation of the trachea, because you're only going to get massive tracheal deviation in tension pneumothorax, they shouldn't be in the exam. And the other one would be in having a massive effusion. Again, they're unlikely to be in the exam, or pneumonectomy, possibly in the exam. And if you want to do that, you need to put your finger as well after you feel it between the trachea and the muscle in the neck, so that you can see is it the same on both sides or no? And then that would give you a better indication if you've got tracheal deviation or not. And then finally, what you mentioned, tactile prematus, either vocal resonance or tactile parmates would be more than adequate. I don't think anyone would mark you down for that. I would strongly recommend vocal resonance. I think you can pick up resonance much better with auscultation than tactile fermitus, which sometimes is determined by your body habitators, and you'd have to have something quite gross, vocal, localized pathology to pick it up. So I prefer the vocal resonance just with my experience as a respiratory physician all these years.

SPEAKER_02 15:48

And when it comes to identifying the physical signs, are we expected to say them out as we're examining the patient, or is it best that we examine the patient and then just have a very thorough and clear summary to reflect the physical signs that we have seen?

SPEAKER_03 16:08

So medical students and undergraduates, I think a lot of the times we're expecting people to talk out loud as they do the examination. Not at all the case in places exams. We expect candidates, and in fact, I've had the odd occasion when they start telling me about the signs and stuff, including negative ones, while they're doing the examination. And I say to them, you don't need to tell me anything, just present your findings after you've completed your examination. The overwhelming majority, thankfully, of candidates do it without saying anything, and that's what I would expect from them. And the reason being is that because they're at a level that I'm expecting for them to pick up all the signs and put them together rather than just purely the ability to pick up physical signs. I've got domain D, domain E to deal with later. So it'd be a lot easier, a lot smoother, a lot more fluent to present the findings in terms of signs, then move on to domains D and D.

SPEAKER_02 17:02

And how long does a candidate have to examine the patient? And how long do they have to answer your questions after?

SPEAKER_03 17:10

Very good. So it's a 10-minute that you have for that allocation of the Spirit examination. You have six minutes to examine the patient and four minutes of questions by whoever leads on that station, one of the examiners, not both. So the six minutes usually get a warning at five minutes. You say we'll say one minute left, and we'll make sure you hear it or should do. And then at six minutes, we'll ask you to step away from the patient as tactfully as possible and then start asking questions. The practice for this is important. So when I'm doing the training for my trainees who are sitting the exam, I always have this what Y call the PACES chat that has a lot of details in it. It takes about an hour usually, it covers the PACES exam. And one thing that I always tell them, particularly for station three, the Cardiovascular Neuro and the Respiration Abdomen, that they need to join the half-four club or create the half-four club. And what the half-four club is, basically, it's often half-fired because of the working Arabs, is for that person who's training for PACES, find someone, if possible, who's also training for PACES almost every single day without fail for a period of three months. Big sacrifice, I know, but it makes a massive difference to pick a respiratory and abdomen, to pick a cranial nerves and a cardiovascular, to pick and just do it, even if the patient doesn't have any signs. And then when you start doing it, then you start developing and evolving into this slick examination. And the other person's job is to time you. Then you can gauge, are you too slow? And as long as you've almost completed the examination at five minutes, that's probably what I'm looking for. Five, five and a half minutes. So then you're left with that extra 30 seconds that you might want to check something again, like a loud secondary poly sound with the right heave, whatever. And then that timing is all about practice. So if you start doing that and do it, do it, do it for every station, then people are well prepared that way. People usually do the respective examination within the allocated time. And then you've got your spiel, I would also like to do, and then we start off with the questions and answers. The questions and answers, the four minutes, I always say to the candidates, please take control of that interaction. So you can either say this patient who's comfortable at rest has evidence of finger clubbing, velcro-like repetitions at the bases of his lungs, who's clearly breathless at rest. He has oxygen by their bedside delivered to him via nasal cannulal. And I think the most likely diagnosis is underlying interstitial lung disease, likely idiopathic bond fibrosis. I would like to do, and then you keep going on, and then the management and you keep going on, then you're gonna leave me with probably I'd be very happy if you gave me that answer if that was the case, but you're gonna leave me to start asking about okay, so what's the latest on antifibrotics in the tadanib and questions like that that might throw you because I need to fill those four minutes? Whereas what I recommend they should do is focus on the question that I ask as an examiner. Some cases, if they're calibrated well and the diagnosis is straightforward, I'll say, what do you think the diagnosis is? Would you like to present your findings and give me the diagnosis? Or if I think it's something that creates a differential, when I was doing the calibration, then I'll say, Can you present your findings, including irrelevant negatives? And then give me a reasonable differential. And that would be based on the calibration sheet that we can talk about later if you wish. And then after that, if I ask them that question, I always ask the candidates, focus on the question and only answer the question asked. Don't keep going. Because then you buy yourself time and you control that interaction. So if I ask that question, answer it, then stop. Do answer it, but stop. Then I have the marksheet. I have to mark domain E. So I have to ask you what S would you like to do? And then you're gonna tell me and then stop. And then I have to ask you in that particular scenario, in the case of Vinyet on top of the bed, and that way you'll realize that the 10 minutes are up and you've done much better rather than blare to something in one minute and I've got three minutes to play with afterwards. I hope that helps.

SPEAKER_02 21:06

That does. My last question about actually undertaking the station, and then we'll go on to calibration because I think that fosters a lot of anxiety. But if a candidate finishes their examination early, would you advise that they do during that time to get up to that six minutes?

SPEAKER_03 21:25

Yes. So there are some stations where you can start earlier the discretion of the candidate. So if somebody finished in four minutes or three minutes, I've seen people finish, which is usually not a good indication, apart from one candidate I remember that actually did really well. But otherwise, if they finish in three and four minutes, it means that either the cases were too straightforward or it's something that the candidate. Yeah. So by that point, I say to them, you've got two minutes left or three minutes left, whatever the time is. I'm happy to start, but I would recommend you continue. Continue until the time is up. And if they say no, I'm happy, we can start. We can start. I can't do that for stations two and five, though. Stations two and five, even if everybody goes quiet, we have to wait until the time is up before you ask any questions. But for stations 1B, respiratory, the abdomen 4B, and the cardiovascular ural, station three, you can start earlier than the six minutes to ask questions at the discretion of the candidate.

SPEAKER_02 22:23

So does that mean that then the remaining time will all be taken up with questions?

SPEAKER_03 22:28

Yes, seven minutes, six minutes. Yeah, exactly. So I would strongly advise against. And that goes back to being practiced because it usually does take, even in normal respiratory systems, it usually takes about five and a half minutes to do a thorough examination.

SPEAKER_02 22:43

Excellent. So if it's okay, I think now is probably the best time to talk about calibration and how that's actually performed and what it means. So do you mind maybe just talking us a bit through that?

SPEAKER_03 22:55

Yeah, calibration is probably one of the most crucial parts of running any exam. And as a chair or a host, you have to make sure that the examiners for each station have allocated adequate time to complete the calibration without being rushed. Even it causes a little bit of delay because it makes a massive difference to the performance of the candidate and to make it also fair to the candidate. Calibration also means that there's less subjectivity to the assessment component because it will ensure that concordance and allocation of the marks between the two examiners is higher. So the desirable concordance will be between eight and ten, seven is acceptable, six a little bit maybe needs to be improved. Anything less than six is unacceptable. So that's an examiner, for example, who allocates satisfactory, and in the same domain, for the same case, the other examiner gives unsatisfactory. You know, it might be unsatisfactory, it might be satisfactory. So who's lenient, who's harsh? That lack of concordance or reduced concordance is not a good reflection on the exam. And understandably, as well, if if candidates, the quality of the exam suffers, if the candidate feels that why would someone think I'm great, just in real life, you know, why would someone think I'm really good at this, but the other one thinks I'm not? There's a lot of subjective components. So the calibration tries to address that. Usually it's 45 minutes to one hour. That gives the examins enough to calibrate the two cases in one. So the communication surrogate usually, plus the respiratories case. In the past, we sometimes brought more than one patient, but nowadays we have them as backups and usually have to calibrate one. And it gives them more consistency between candidates as well. Station two scenario calibration, it takes usually less than that amount, but that's what's allocated. Station three usually have one cardiovascular, one euro, and the same applies to station four for abdomen, and then station five, the same as station two. And during that 45 minutes, an hour, roughly, making sure that everybody's allocated time, they go and see the patients, the examiners, and they should be blinded to what's wrong with the patient, what physical signs they have. As a host, quite often I don't release what's wrong with the patient in terms of diagnoses until the calibration process has been completed. And that way I ensure, and I think most hosts are asked to do this as well. That way I ensure that whatever the examiner's picked up is what we're expecting of the candidate. There's no point in an examiner having some sort of subconscious bias because they've found out that the patient's got mitrosenosis and an echo, and then they think they've heard it during the calibration process. And of course, they'll have a whole hour to calibrate. So they're going to have 30 minutes each, you know, and the candidate is going to have five minutes. So give the poor candidate a chance. So I usually blind the examiners. And a lot of candidates, like you say, are anxious about this. They don't know the process. And what I do also as a host, I explain that process when I welcome the candidates that come to the exam. And it's written in the feedback that I really appreciate it that the host shares that with them because it does put their minds at ease as well and calm the nerves because they think it's fair. And after, say, for example, I'm one of the examiners and I've got another co-examiner, we go and calibrate, say the respiratory station, which is what I was discussing today. I do a full respiratory exam. I write down what signs I've identified. The same should be performed by my colleague. And then we've written down all the physical signs that we've identified. Then we can compare sheets after we've written the physical signs. Thereafter, if I've picked something up and my colleague hadn't picked it up, then we'd have to question whether this is something that I'm gonna be expecting of my candidate. Because if I have a qualified examiner in the MRCT PACES who's an internist who can't pick this particular sign up, why am I expecting somebody who's training in medicine, not even a subspeciality yet? And perhaps maybe I am doing the respiratory station and I'm a respiratory consultant. And inadvertently, my expectation when I'm picking a sign up is that's that's something that I'm expecting to pick up. But then I've got a colleague who's a geriatrician who says, Oh, actually, that's quite difficult to pick up muddle. And then I would say, okay, fair enough. And that puts a little bit better for me as well to know that that shouldn't be my expectation of somebody at that stage of their training. Once we've looked at the signs and we've agreed what signs that we would expect the candidate to pick up, we'll put that on the calibration sheet under domain B, picking up physical signs, and what signs that we wouldn't accept if the candidate makes them up. So there are sometimes scenarios, for example, in the abdomen where you get hepatomegaly, and somebody might say it's plea when it is there isn't one, it's just a lobe on the liver. So then especially it is less likely that you'll be making up signs, but can sometimes happen. Or so, for example, somebody might have had a VATS biopsy and somebody says lobectomy when there's a lung behind that scar. So that's a made-up sign. So then after the physical signs, we've placed them, we've agreed on them. And then based on the case of vignette that we presented to the candidate, we think, okay, so what would be the top differentials in this part of the world? So we say, okay, so we expect based on these findings, they definitely have to mention pulmonary fibrosis. They may mention bronchiectasis, but that will be a bonus. But if they don't mention polyfibrosis, we mark them down. But if they mention polyfibrosis and bronchiectasis, I'm happy with that. You're happy? Yes, I'm happy. And then of course, that once we've agreed to the differential, naturally comes tests that are relevant to those conditions and the management accordingly. So something like IPF, then we think, okay, so we're expecting spirometry, we're expecting a chest x-ray initially, and then expecting a high resolution CT scale. And one point, not just unique to the respiratory station, but I would also recommend a lot of our candidates and trainees to understand a little bit about these investigations. So there's going to be a list of common conditions that you expect with respiratory or cardiovascular or abdomen or duro, and they will have, in relation to them, the band or common investigations that we expect. So what's an HRCT? What's a CT contrast staging? What's that to look for? What's this to look for? So an HRCT would be looking for bronchiactitus, emphysema, and ILD, whereas a staging contrast CT scan, it'd better look at the medieastinum if that's the pathology I'm looking for, etc., etc. etc. So knowing a little bit about these investigations so that when we ask of them on the calibration sheet, it might be that somebody might say CT scan, but it might not be good enough because they might miss that particular differential because CT could be anything. And there are different somebody might say CTPA would be more relevant in the calibration sheets. They might get a borderline rather than a full mark. So once we've put that and we've agreed, then it gives you that consistency, it gives you that concordance because then when the candidate starts coming in one after the other, then we've got our calibration sheet that we should stick to. If I find that rarely the coexaminer is not sticking to it, sometimes we're human beings at the end of the day. I remember doing three cycles, three days in a row. I'm not going to say which center, it was a double cycle as well. By the time it was a third carousel, on the third day, I was so exhausted and my co-examiner so exhausted that sometimes people can get distracted because we are humans at the end of the day, but we don't want that to disadvantage the candidate. So rarely, if you feel that person is not sticking to the calibration sheet, you should give them a nod and remind them this is what the calibration sheet is saying. This is what we agreed on. There should be something. There is rarely the calibration process before we invite the candidates, the two examiners differ. That doesn't happen that often, but you can get some people who can be a bit pedantic and they're asking for too much. So then it's usually inviting the chair or the host to be the one that gives that extra opinion to discern them.

SPEAKER_02 30:54

Yeah. So calibration always happens at the start of the day. Behind the scenes, candidates don't know. We just see, you know, when we go in and you're introduced to the teachings and the examiners. Excellent. Okay. I think that was a very thorough run-through of that and hopefully will help demystify what the process is.

SPEAKER_04 31:13

Yes.

SPEAKER_02 31:13

Lovely. All right. And then obviously you mentioned if a candidate perhaps makes up a sign, or if a candidate isn't quite as thorough as you would want them to be. But can I ask what is a red flag? And what does it mean and what implications does it have?

SPEAKER_03 31:33

It depends on what you mean by a red flag. So do you mean what would be a red flag that would give a fail in that particular domain? What we expect of the candidate?

SPEAKER_02 31:41

Yes, but also I think there are red flags that can be raised if there are concerns about the quality of a candidate in general, if I'm not mistaken.

SPEAKER_03 31:50

Yes. So that's beyond the respiratory per se. They've got red flags where, for example, as part of the calibration process, we can say that if they say this, it will significantly change the differential of the patient, that it takes them down the wrong route, and that should be a fail. I'm not going to necessarily call it a red flag, but I'm not accepting that. However, there are sometimes occasions when candidates done pretty well and they made up a sign, but it hasn't really impacted on the differential so much. But we put it on the calibration sheet, I might give them a borderline in that particular domain. So that's one aspect of it. There are occasions when I would have to say that that would be a fail as when I'm doing the calibration, because equally, how would I be able to differentiate a good candidate from a less performing candidate other than actually being specific with that? So if somebody gives me mixed mitral valve plus psiotic valve disease and there's no mitral valve disease at all, I've disadvantaged the good candidate by allocating the mark. That's one bit. Then you've got red flags where it's maintaining patient welfare. I've had good example in the respiratory station where patients have got significant respiratory ailments. I've seen candidates who put the stethoscope, for example, ask the patient to take deep breaths in and out quite quickly. And sometimes they close their eyes at the candidates trying to listen, but the patient's clearly tiring. The patient is hyperventilating. It's really uncomfortable for them. They've got probably have to do that repeatedly with other candidates later. And that can sometimes mark them down because it might make the patient feel unwell or dizzy or no longer able to participate in the exam. And to be honest, even if I'm seeing them in clinic, I'd have to keep looking at the face to see if they're comfortable. And when I put my stethoscope, they're giving me good enough air entry at particular frequency. So they're giving me enough volume and they're giving me enough frequency that it helps me detect the sounds. They don't have to keep breathing really fast and deep and then get like I did like you're blowing all these balloons in a kid's party. So that's could be a red flag. That's just one example. And then the red flag for the whole exam, I wouldn't necessarily call it a red flag, but if somebody fails in six domains or more, there's seven domains in the exam. So so often A, B, C, D, E, F, if they failed all of those, we would have to prefer them for counseling. And quite often we would recommend that the candidate doesn't sit the next diet, but defer a diet for six months at least, so that they can prepare better for the exam. Or if one single domain was really poorly done across the five stations, and we look at, for example, a leap, and it's like less than 40% or 25% of the full marks, then you know, are they struggling to put science together to provide a reasonable differential diagnosis across the spectrum? That can be specifically raised as a concern as feedback, but it doesn't necessarily mean they have to defer. And then G, there are times when we had to refer them on for counseling and to raise it with the federation, relevant colleges for examining in the UK, to give that back to the candidates. And there are examiners, I'm one of them, who are allocated counselors. So they would get the sheets back, usually a candidate that they don't know to give them feedback, a candidate performed less well, or they had the so-called red flags. I hope that helps. So that's where we would have some red flags with candidates.

SPEAKER_02 35:23

Excellent. Okay. And just a few quick fire questions on respiratory, because I know that your time is very precious. Would it be okay if you maybe obviously I know that you can't tell us specifically for certain examination centers, or you can't tell us what comes up in places in general, but could you maybe give us an idea of the sort of common cases that a candidate may be faced with in a respiratory station?

SPEAKER_03 35:51

Yes. One useful resource that I have been checking for a number of years now, and I used when I was doing these exams many rooms back, is RIDER RY DE ER series on PACES. And they did something very clever. So they basically, for the RIDER 1 book, there's different books, but RIDER ONE has cardiovascular, respiratory abdomen and neuron. And what they've done is they've listed bicommonality by how popular these stations copped up in the exam. And I would argue, say for respiratory, if you go through the first 15 cases that they've put in that book, more likely than not, that's what you're going to see in the exam. More likely than no. And that applies to cardiovascular, to abdomen, and to neural. And neuros particularly important. I've done six months of neurology when I was an SHO and I loved it. So I have that mind where I can put things together. But for a lot of trainees and candidates, it's pattern recognition rather than actually analyzing what they find. So knowing the cases prior to coming into the exam, understanding them a little bit better into patterns gives them a better opportunity. But hospitals that have a dedicated clinical skills area without a nearby hospital or within a hospital will have a slightly different cohort of patients that they're going to invite into the exam because they'll be predominantly outpatients. Whereas those that are within a hospital will have backup lists, and the backup lists are usually inpatients. So the inpatient cohort that come in are going to be the asthma exacerbators, COPD exacerbators, the hornias, the obese type of ventilation syndrome that people might have come in with, the effusions, complications of lung cancer. So that's what you'd expect to see if it was as a backup patient, inpatient, and they might want a bit of oxygen, et cetera. And then the outpatient one, that cohort that I just mentioned, plus all the bronchictases, the ILD, the cystic fibrosis potentially. So yeah, most of them, you know, thorocotomy, pneumonectomy, VAS procedure, chest wall deformity, obesity, or kycoscoliosis. So there's a number of them, but like I said, if that's what they go as a reference, then it's very likely that that's what we'll see in the exam.

SPEAKER_02 38:10

How should we be presenting cases? I remember when I was practicing for PACES, I got told talk to yourself, look in a mirror and practice just talking to yourself. So you're very slick at doing the presentation aspect. What would be the advice that you would give to candidate sitting PACE now?

SPEAKER_03 38:30

So two things. The first thing is the half four, half five club that I mentioned earlier. So part of the practice would be not just timing the examination, the examination technique that then becomes slick, but a big part of it would be to present. And you can get anyone, it doesn't have to be a fellow person who's doing the basis exams because all you need them to do is they just stand up, look at you with a serious poker-like face, and say to you, So what's your differential? What's the diagnosis? They might say that at the beginning, and then you say it, and then what tests would you like, what investigation would you like to do? And then how would you manage this patient? I can get anyone to ask those lists of questions, and it gives me the opportunity when I was practicing to say it out loud. Then Miller is a good suggestion, but it's not the same as presenting to another human being. So I would strongly advise to do that. I would also advise that if you are able to get an examiner to examine you, it's helpful to get any consultant or senior edge to help you with this. But to get an actual examiner and ask them to do it like the PACES format, it becomes like a little mini mock exam. So whenever I teach PACES, I give the PACES chat, but if I'm doing bedside teaching, I make it just like the exam environment and kick off so that I finish the station and then give them feedback afterwards. And they find that really useful.

SPEAKER_02 39:46

And when we are talking about differential, sorry, I'm I'm always doing this backwards. Hopefully, you'll get my trail of thoughts. So let's just talk about the differential lists. Firstly, you mentioned before that the differential needs to be based on the patient that you see in front of you. Is there a set number of differentials that you would expect? Should we have three? Should we have five ready? Obviously, within the realms of being reasonable for that patient in front of us. I think that there's so much you want to show the examiner your knowledge.

SPEAKER_03 40:17

What I would say is focus on the question by the examiner. If the examiner asks you what's the diagnosis, go for one. If then they say, could it be anything else, give another differential or two. Okay? I'll stick to that. If the examiner asks, what's the differential, give three at most. Don't give more than three. Three most likely. And that way you're responding to the examiner's question rather than you just giving loads. Because what will happen is if you're trying to think that you're doing a good thing by giving five differentials, inadvertent thing is the examiner, you might give them in a list where you label something like Whipple's disease that no one's ever seen, and they put a second on the list or something, and that might really put off the examiner. Or you might say this is pneumonia when it's clearly bronchiectasis and they've got bilateral crackles, and the patient looks relatively well, you know. So that's what I would do. Focus on the question. If it's a diagnosis, give a diagnosis and wait for the prompt. If it's a differential, answer the differential.

SPEAKER_02 41:18

And with regards to the signs, again, I'm going backwards. Obviously, mention all the positive signs, but when we're discussing the signs, are you looking to hear all the negatives as well?

SPEAKER_03 41:29

Yeah, good question. I generally, and I think most examiners, unless you feel it's a really important negative, then I wouldn't be too worried about it. I think it depends on the candidate. Because where do you start? When I'm doing the calibration, when I first started examining, I sometimes put like I'd expect them to say some negatives, but I've stopped doing that because I think it's really difficult because the number of negatives that you could argue for are endless and there's so many, right? So I wouldn't put something specifically, but it does tell me that a candidate is good if they give me a really good relevant negative. But I don't want them to tell me loads and loads of negatives that are just a list that they provide. I want them to give me a negative if they think it's a relevant negative. So for example, somebody with finger clubbing, but the patient has COPD, then to give me negative findings, such as I couldn't detect pleural effusion, I couldn't detect signs of collapse, it's suggests underlying malignancy, I couldn't detect crackles, it's just bronchiectasis. I need to find out a little bit more. So that means that somebody's engaging in thinking that I can't link finger clubbing to the patient's presentation. I have to think about pulmonary, extrapulmonary congenital causes as well. That's a good negative dimension, I think. But that's one example.

SPEAKER_02 42:53

In your experience, what is the thing that is not done well in the respiratory station?

SPEAKER_03 43:00

I think that a lot of candidates I mentioned earlier, feeling for the tricky is not done very well. I think percussion is not always done well. Sometimes it's not hard enough that you can actually detect, especially depending on the patient's body habitat. So I can see a candidate that can easily detect stony dullness where somebody else that it's all sounds dull because they've not because another common one is they misuscultate the axilla, or when they're auscultating their back in particular, they're too close to the spine, where it should be mid clivicular line. And sometimes another common mistake is when they're taking breaths in and out, is with the patient's mouth closed. And you're not going to hear it. That needs to be with the patient's mouth open, and you need to check. These are quite common mistakes that I see.

SPEAKER_02 43:51

And I guess if we start rounding up now, I know that you've mentioned a lot about practice in terms of the respiratory station. In particular, what would be your advice to someone so that they could aim to achieve top marks in the respiratory station?

SPEAKER_03 44:08

Yeah, so like I said, practice earlier, practice, practice, practice so that it becomes slick, and that domain A is now on D Bell, and it gives you the confidence to pick up the science and put them together and come out with something sensible because you're an autopilot. That's why practice is important. Knowing the common investigations to respiratory to a little bit of detail about them, spirometry, so dynamic lung volume, static lung volumes, diffusion capacity, a six-minute walk test, blood gases, plain chest radiograph, high resolution CT scans, CT chest staging, CT chest non-contrast. I think that's the main ones. And then, of course, things that are related to other conditions that can be manifestation of systemic disease like vasculitis, et cetera, et cetera, or immunology with total IG, et cetera. So just knowing a little bit about that. So when you've been asked when you come into domain E, you clearly know a lot of what you're going to be talking about. And then the last bit, as I mentioned earlier, a resource such as RIDER that I mentioned earlier, or a resource that allows you to identify relatively common respiratory pathology in the outpatient setting and in the inpatient setting that might come up in the exam and understand the pathology, understand what the common signs that we'd expect to find on these are. And then, of course, if there's an opportunity that you have on the wards, or as a PACIS course that you fancy going to, then by all means, it will help you pick up the signs in real time rather than just reading them from a book. It'll always be better that you've seen it before rather than seeing it in the exam.

SPEAKER_02 45:34

Thank you. Thank you so much for that. And my very, very last question: what advice would you give to a candidate who has struggled during the station?

SPEAKER_03 45:44

So if I think someone's struggling because they're anxious from the outset, depends on how experienced you are as an examiner. And although they say to us that it has to be a sort of not serious face that's off-putting, but not a face that's grimacing and making them feel they're not doing well or over familiar and smiley that they think they're doing really well. I just think a normal interaction. But what I do sometimes do, and I guess that's more when I become more experienced examiner, even if I'm not leading on the station, if I think somebody's really anxious and they might have had a bad station beforehand, I usually detect it within the first 30 seconds or a minute when they start examining. And I'll say to them, listen, let's step back a little bit, take a deep breath in, out, personal breathing. Okay, you've got time. And then that will put their mind at ease, and then they can keep going. If I don't think, as examiners, it's not a teaching case, it's an examination. So even if I thought that the candidate had done not so well or didn't score many marks, that's not something I can share with them at that point at the end, unfortunately. The only time to share it would be to have legible writing on the mark sheets that then can be fed back to the candidate by relevant people, or the candidate might actually ask advice from somebody else to make sure that that writing is legible, relevant, and I think would benefit the candidate when they get their feedback or when they go and speak to an experienced examiner so that they know what the gaps and skills are that they need to address later. But I can't do it then and then. I wish I could, but it's not meant to be for that.

SPEAKER_02 47:20

Yeah. Okay. So basically, if a candidate has struggled in the station before they come to you, just take a deep breath. It's a new station, just try your hardest to put it behind you.

SPEAKER_03 47:30

And I often try and do that as a host. I've got a list of things that I tell the candidates when they come. And I hope maybe others are listening to this podcast, including fellow hosts and co-hosts, to I have a list of things that I go through with the candidates. And one of them is this if you feel that you've done badly at one particular station, you might be mistaken, you might have done very well. That happens all the time. And put it behind you. There's no point in self-deprecating and just go on to the next station. Have we seen people that completely messed up a station that have gone to pass the exam because they did well in the other stations? Yes. So that makes them a little bit more confident rather than waiting for that to happen in the exam and all them before.

SPEAKER_02 48:10

Lovely. I think that's a good place to end. Positive. You know, just keep going. Thank you so much for spending your time. Thank you for all your top tips. I'm sure that all our listeners will be so very grateful. I'm sure that all our listeners would hope that they're in your examination center.

SPEAKER_03 48:24

I hope so. They're more than welcome.

SPEAKER_02 48:26

Thank you so much. I'll make sure all the advice that you've put is on the show footnotes. So for anyone listening, please feel free to have a look at those and please keep tuning in. We've got lots of episodes coming to you to help you with your PACES preparation.

SPEAKER_03 48:39

Thank you kindly again, Madelina.

SPEAKER_00 48:53

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 podcast. 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 centres throughout the UK. I would encourage you to think of Edinburgh as your college of entry when doing PACE.