Demystifying PACES - Communication [Stations 1 & 4] (19 Dec 2023)

SPEAKER_00 0:00

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

SPEAKER_01 0:45

Hello, my name is Kat Ralston and I'm a member of the Training and Members Committee as well as a medicine 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 PACE and your experience on the exam day itself.

SPEAKER_02 1:32

So hello everybody, and welcome to this episode of Demystifying PACES, a podcast series that has been developed by the Trainee Members Committee and designed to help you prepare for the MRCP PACES exam. My name is Kirsty Crowe, I'm a renal registrar based in the west of Scotland, and I'm a member of the Trainee Members Committee. In this episode, we're focusing on the communication stations within the PACES examination. I'm precise, I'm joined by Dr. Nicola Zannett, who's a consultant endocrinologist based in Edinburgh. And she's also been involved with PACE examining and the Patients Clinical Examination Board for a number of years. So we're delighted to have her this morning discussing these stations. So Nicola, I'd like to hand over to you and for you to just introduce yourself and give a wee bit of background to listeners to the podcast about your involvement with PACES examinations before we start talking about the stations themselves.

SPEAKER_03 2:22

Absolutely, and thanks very much, Kirsty, for having me on the podcast. As you've said, I've been a PACES examiner for about 10 years. My day job is a diabetologist and a chronologist. I've hosted exams and chaired exams as well. So that's also given me a role in picking the surrogates, the actors who enact these communication scenarios. I've had a number of roles within the exam as well. So for eight years I was running a PACES course in Edinburgh where we used decommissioned scenarios. So again, I've got some experience of sort of picking scenarios, tweaking them, and getting surrogates ready to do these. And in terms of more formal roles, I was on the Clinical Examining Board for five years, and that's the federation body that oversees the running of the PACES exam. It has representation from the three royal colleges. We look at feedback from the exam, we look at pass rates, we look at multiple statistics just to make sure that the exam is fit for purpose. And that's really the group that's overseen the transition to the new PACES 23 format. But more recently, I've been on the scenario editorial committee, which looks specifically at the communication encounters for the exam. And so just to give the listeners a bit of an idea about how these scenarios are developed, there's a scenario writing group which is made up of positions from a range of different specialties, and they write these scenarios and discuss them within their group. From there, they're then passed on to the scenario editorial committee, and we all get a number of scenarios to review and edit ahead of our meetings, which happen three times a year. And so each scenario is edited by two reviewers, and we then present them to the wider group. So that means that by the time a scenario gets used in the exam for the first time, it's been through the hands of a number of physicians, the one who originally wrote it, the committee, the writing committee that's reviewed it, the scenario editorial committee that's had a look at it. And then once it's used in the exam, we also get feedback from the examiners on the day. So if when it's run for real, the examiners feel actually that was tricky to get through in the time allowed, or for whatever reason it didn't work, it gets sent back to the scenario editorial committee and edited for future. So just to give listeners some reassurance that these scenarios have been developed with a fair amount of time and thought and work going into them.

SPEAKER_02 4:22

So that's really reassuring to hear. And it's interesting that not only is there a lot of work put into the development of it, but also the scenario doesn't just get released into the wild as it were, it gets scrutinized thereafter and developed. Because as we know, medicine changes, and I think that's reassuring to know as well. Thank you. It would be great if you could tell us a little bit more about the communication station themselves and what candidates who are in those stations should be expected that they'll be asked to do. What kind of format do they take?

SPEAKER_03 4:52

So there may be some listeners who've done the old-style PACES exam and are now sort of sitting the new format, and some who are coming to the format for the first time. There are some slight differences from how it used to run before. So in two of the stations, station one and station four, you have a 10-minute communication encounter followed by a 10-minute examination encounter, either respiratory or abdo. And those examinations are unlinked to the communication, so completely separate. For these two communication stations, you'll have five minutes outside of the room where you're preparing for it, and you'll always do the communication encounter first. So you do your five minutes of prep and go straight into the communication counter and then do the examination afterwards. And within that 10 minutes, there's a number of different scenarios that you might be given. Broadly, they would cover issues around end of life, explaining errors, explaining a diagnosis, explaining a treatment, explaining results. The key thing that we're really looking at is your ability to communicate with a patient or their relative in lay language, to listen to their concerns, to formulate and agree a plan with them, to couch that all in language that they can understand and to be sensitive and empathic. So those are the broad things that we're assessing with a range of different communication encounters.

SPEAKER_02 6:07

And my understanding is that the communication stations are mapped to a certain number of the core skills that PACES looks at in general. I think to the top of my head that C A G and F, which I think probably know better than me, Nicola, but I think apply to the against clinical judgment and managing patient concerns and patient welfare.

SPEAKER_03 6:29

Thinking about when you mentioned sort of skills that it maps to, actually, we can think about mapping to skills in a number of different ways. You're referring to the marking scheme, which I'll come back to in a minute, but actually the scenario editorial committee, when we're looking at these scenarios, we do actually map it to the curriculum so that we have scenarios that cover the breadth of medicine. So what we don't want is to have a hundred scenarios that are all dealing with frail elderly patients and nothing that deals with cardiovascular disease. So deliberately, these scenarios are meant to cover the breadth of the medical curriculum and the range of presentations that you will see in real life. In terms of the standard and where that maps to with what trainees are doing, if we think about the IMT curriculum in the UK and we now have these competencies in practice or CIPS CIPs, it's CIP level three, which is entrusted to act with indirect supervision. So the scenarios should cover the breadth of the curriculum and really be the kind of thing that we could ask a doctor to go and communicate with a patient without a consultant there present, although they might then want to call upon the consultant for further advice or arrange a further communication encounter between the patient and the consultant. And then in terms of those markable skills that you're referring to in the exam, yes, you're absolutely right. There are four skills that are assessed. These communication encounters cover the fewest number of skills compared to the different encounters in the exam. So firstly, we're looking at your communication skills. And importantly, because there's no questions from the examiner, this is entirely your ability to communicate with the patient in lay language. So avoiding use of jargon, or if you use a medical term, explaining it straight away is a key component of what we're assessing. And so to pick up marks, you want to make sure that this is something that a lay person could understand, and you must avoid the temptation to dazzle the examiner with your medical knowledge by throwing in lots of technical terms, because that really would constitute use of jargon and not good communication. You'll also then be marked on your management plan, which is really about not so much a clinical management plan, but really the softer management plan around that communication encounter. So for example, if I've given you information about a diagnosis, my management plan might involve explaining what the next steps are in terms of treatment or who I'm going to refer you to, but it might also involve signposting you to a specialist nurse or to a third sector organization like Diabetes UK or the British Thyroid Foundation, where you might get more information. So it's management in that broader sense of the information imparted to the patient and the support that the patient needs. Then you're also assessed on managing patient concerns. And that's really important because in all of these scenarios, the surrogate will have been given something that is a particular worry or concern of theirs. And if it doesn't come out naturally through the interaction, if you ask them, is there anything else that you're worried about, they will tell you. So it's really important at some point in the communication encounter to check that you've covered all of their worries. And then the final skill that's assessed is patient welfare. And it's uncommon to lose marks on patient welfare. And in a communication scenario, the ways in which you might lose marks on patient welfare would be if you were very insensitive towards the patient or surrogate, or if you were very dismissive or disrespectful about their views, or if you suggested a course of action that was somehow unsafe. But really it would be very unusual to lose marks on patient welfare. So it's mostly the communication, the management plan, and the managing patient concerns are the key things that are assessed. Great. That's really clear.

SPEAKER_02 9:57

So really candidates should be expecting to have an encounter with a patient, or am I right in saying it could be a patient relative? Is that correct? Or is it always the patient themselves?

SPEAKER_03 10:07

It very often will be, these are always actors. We don't use real patients for these scenarios because they're scenarios that have been written. And it's really important to read the scenario carefully because that will tell you who you're speaking to. In fact, I would strongly recommend anybody preparing for the exam to go onto the MRCP website and look at the sample scenarios that are on there. There's four sample scenarios and it shows you the information for the candidate, but also the information for the surrogate and the information for the examiner. So it really helps you to understand what we're marking. But there are some key bits of information that are standard. And if you've got your eye into what information is always there, it makes it easier on the day to skim past the stuff that's always on the information sheet and zone into the stuff that's specific to that scenario. So these sheets will always have words to the effect that you can take it for granted that you have the consent of the patient to speak to their relative. It's nice if you acknowledge that, you know, so you can just say, hello, I'm Dr. So-and-so. I've been asked to come to speak to you about your mum. And I know that your mum has given permission for me to have this conversation with you, but that's always a given. There's information there about how long you have, you know, 10 minutes. But again, if you know that already, you can skim past that bit. It will at the top tell you who you are, where you are, and who you're speaking to. So for example, you are the doctor on the general medical ward. Your patient is Mrs. Ann Smith. You're speaking to her daughter, Mrs. Mary Jones, and it'll tell you what the communication is about. So usually there'll be words to the effect of your task is to explain to this patient's daughter about her mother's recent stroke. So have a real clear read of that because that will tell you who you're speaking to. And it's not uncommon in exam nerves for people to get a little bit flustered about who's who. If you go in with a clear impression of who you're speaking to and what your task is, it's nice to just confirm roles and names at the beginning, but all of that information will be clearly put in the scenario.

SPEAKER_02 11:59

So really, candidates should be using that five minutes, read that information sheet, and that will tell them all they need to know in terms of what their role is in that scenario, who they're talking to, and the explicit tasks that they've been asked to do to help them keep on track and that they don't go off piste and start talking about things that are unnecessary.

SPEAKER_03 12:17

Absolutely. There's note paper outside the room, so you're allowed to take notes and you're allowed to take your notes into the room with you. And what I would suggest is making the notes fairly bullet point so that your eye can easily run down them during the consultation. So at the top of the encounter, it'll say something like, Your role, you're the doctor in clinic, problem explaining a diagnosis of multiple sclerosis, patient is, you know, who they are, and just write those bullet points down because it just doesn't look good if you go in and you're forgetting the name of the person that you're speaking to. There are some other things that are always said on all of these scenarios. It'll always say don't examine the patient, and it'll always say don't take a history. And I think that don't take a history instruction sometimes throws candidates a little bit as well. To be clear, what do we mean by don't take a history? If I can use one of the examples on the website, which is explaining a diagnosis of MS to the patient, it tells you in the information that you're given that she's had some previous visual disturbance, it tells you what test she's had and what the results are. I think it's always good at the start to check what the patient or surrogate knows already, particularly because there's often some information that they will give you for free. So go in, explain who you are, and say I've been asked to come and speak to you today to give you some test results. Is that your understanding of the situation? Yes, it is. Can I just ask, what have you been told already? So I think in terms of taking a history, what we are expecting is that people will check what the surrogate already knows or understands and will make sure that both the surrogate and the candidate are starting from that point of same knowledge. But what we do not want the candidate to do, for example, in that situation of giving a diagnosis of MS, is going back to the beginning and say, so can you tell me when did you lose your vision and how long did it last and when did you get the numbness and tingling in your hands? We don't want you to do that. This isn't about making the diagnosis, the diagnosis is made. It's really just checking that you can establish what the patient's understanding is or the surrogate's understanding and set the scene appropriately for that conversation. And on the scenario, it'll say very clearly what your task is, which is to, in this case, explain the results.

SPEAKER_02 14:20

That's really clear. And you said earlier that there's no candidate-examiner interaction in terms of questions at the end, which is obviously different from previous format. I assume that if the candidate was to ask the examiner a clarification question, they would be directed back to the information sheet.

SPEAKER_03 14:38

Is that correct? So usually you'll just get a please refer to the instructions that you've been given. So again, if there's some ambiguity around it, that may be because that's part of the scenario. So it would be the sort of thing that you should then clarify in conversation with the surrogate or the patient. And again, these scenarios are meant to reflect real life. And if you think about the real life conversations that we have with relatives or patients, it's not uncommon to need to clarify something with them. You know, to say, well, your mother said that you live nearby, but I'm not sure how near that is. And can you tell me a little bit about how often you see her and how much help and support you can provide? So I think you can seek those points of clarification in the conversation with the surrogate, but the examiners won't give you any extra information. They also won't ask you any questions. So any skills that you want to demonstrate have to be demonstrated within that 10-minute conversation with the patient. There isn't the opportunity to then explain what you were trying to do in questions with the examiner.

SPEAKER_02 15:35

Great. And just wondering, thinking about how you on the examiner side of things would be viewing these stations. And you mentioned earlier about calibration of the stations, and it's obviously the scenario comes well vetted before, but on the day there's calibration as well with the patient or relative actor, isn't there? And I was wondering if you could talk a little bit about that, about how that's done.

SPEAKER_03 15:57

Yeah, absolutely. I'm glad you asked about calibration cursed because I think really good calibration absolutely underpins the quality of this exam. And examiners take calibration very seriously. We spend about an hour before the exam starts calibrating. And what that means is that if you're running through a scenario on the day, the examiners will have run through that scenario already with the surrogate to make sure that they're not going to say anything that's confusing, to make sure that you can cover the information in the right amount of time. And if the examiners can't get through that scenario in the right amount of time, they will make changes to it. So they will decide actually, it just took too long to cover that extra bit. Let's just take that bit out of the scenario and focus on these key points. When the examiners are going through on their marksheet, you mentioned the four skills that are being marked in this station, your clinical communication, your management plan, your managing patient concerns, and your patient welfare. And so we will decide what constitutes satisfactory and what constitutes unsatisfactory performance for those different skills. So if we think about that example on the website where you're having to explain a diagnosis of MS, the clinical communication skills, what we would really be looking for is that you can explain the results of investigations in lay language. So the information will tell you that the MRI has shown some white matter changes. And we would expect you to then say, well, you know, your scan showed some patches of inflammation in the brain. So it's really how you convey that medical terminology into lay language that the person can understand. Think about what a patient would want to know. They'd want to know, well, what do these results mean for me? What might my prognosis be? Will I get on well again? What treatments are open to me? So those are the kinds of things that you're going to be expected to discuss with the patient. This isn't a test of detailed medical knowledge. That test happened when you did your written bits of the exam. So really try not to get bogged down in medical jargon or explain any medical terminology that you do use. It's really about how you convey the information, not your detailed knowledge of specific treatments. If there is a particular piece of complex medical information that needs to be conveyed, then it will often be included in the scenario. So for example, if you have to explain a genetic diagnosis, it'll often tell you what the pattern of inheritance is. And we would expect that you can translate something like autosomal dominant inheritance to your child has a 50-50 chance of inheriting this condition. But we're not necessarily expecting you to remember the pattern of inheritance as such just to be able to explain it. So that's the communication skills, which is really the kind of key skill being assessed. The managing patient concerns really is just to make sure that people do more than pay a passing nod to this. So if, for example, thinking about the MS scenario, well, if somebody says, well, I'm really worried that I might lose my job if my MS progresses, I can see why you're worried about that, but don't worry, that won't be a problem. That's not really addressing their concerns, that's hopping off their concerns. So there does need to be a proper acknowledgement, demonstration of some empathy, perhaps teasing out what are the particular things that really worry you. Don't shy away from bad news. You know, I think acknowledge that there is a possibility that this may affect your future employment if that's what the patient's concern is, but also acknowledge that there's a degree of uncertainty and that for some people the prognosis can be quite variable, that it's not good to get too pessimistic about the future, that there's lots of resources with information, that there's lots of people, specialist nurses, specialist doctors who can support them. That's addressing the concern. And then finding the patient welfare really is just making sure that you're respectful to the patient, that you treat them with dignity and politeness. So we would have put down what we're expecting the person to cover in that consultation. And, you know, as long as you cover that in an adequate manner, you score a satisfactory. If you don't quite get there, you might get a borderline. And if you don't cover something, then you would score an unsatisfactory for that particular skill.

SPEAKER_02 19:46

That's really clear, both how you calibrate the station, but also what you're looking for from the candidate in terms of being an examiner. And as you said already, there's not the questions at the end. So it's not that the candidate explains their rationale and reasoning behind what they've asked, that's based on observation or behaviour, isn't it?

SPEAKER_03 20:03

And actually, Kirsty, thinking about it, because we'd mentioned earlier on, you know, that SIP, that competency in practice, SIP level three, of being entrusted to act within direct supervision. So we're expecting candidates to perform within their scope of practice. So if I think about an example from my last medical take, for example, I had a patient who came in with a fallen unsteadiness and her head CT showed a new brain tumour, which looked like it could be a meningioma, but she had a past history of lung cancer and perhaps could be a metastatic deposit. So within my scope of practice, I delivered that news to her, relayed the uncertainty, explained what investigations we were going to do and that we were going to refer her to the neurooncology multidisciplinary team to review all her scans and make a decision. It's not my job to be giving detailed information about prognosis or treatments because I'm not an oncologist. And so similarly, a candidate in a scenario isn't expected to be making decisions that are beyond their scope of practice. They're expected to fulfill the task that's been outlined in the instructions at the start. And it's perfectly legitimate as part of your management plan to also say, I will refer you on to a specialist, or if you like, I can arrange a further meeting with my consultant to discuss things further. So just think about that level of practice, which is that entrusted to act within direct supervision. That's really the standard that we're marking against.

SPEAKER_02 21:18

So essentially, as you say, you can allude to the fact that an onward referral or a discussion with your senior colleague might be appropriate, but you do still have to demonstrate those key skills that we've already talked about before, then you can't just say, oh well, this is over my head. I'll get the consultant goodbye. That would be a very short and not very effective scenario, I'm guessing. Correct. That wouldn't be good use of your 10 minutes. So we've covered a little bit about what common scenario types might come up, and we've talked a bit about how it might be conveying some complex medical information or a new diagnosis, touching on patient concerns. Are there any other kind of major scenario types that tend to come up? Not asking for specifics of scenarios, but kind of Broad areas that the candidates should be prepared that they might encounter?

SPEAKER_03 22:04

Yep. So previously these communication encounters were very much kind of focused, I suppose, on ethics. And now I suppose there's communication in the broader sense of the word, but there are still some ethical principles that come through. So for example, discussions around end-of-life care, around ceilings of care. We're no longer formally asking people what are the ethical principles that are being covered here. But obviously there's issues around autonomy, patients having a right to make their own decisions, you know, capacity to make decisions. You might also have scenarios where you've got to, for example, again, thinking about my recent medical take, we had somebody who came in with a seizure and I had to have the whole discussion around driving and break the news that unfortunately, you know, you can't drive. I think people often get a bit worried about what level of ethical knowledge is needed for these scenarios. I think the important thing is the broad principles and where the information might be rather than having a detailed knowledge of medical law or medical ethics. So, you know, in real life, if I'm going to see somebody who's had a collapse, I usually will refresh my memory on the DVLA website about what the specific rules are about how long they need to be off driving. So we're not expecting people to remember all of that information in their heads. But I think to have an understanding that there is a law to keep us safe and that if somebody has had any kind of seizure or collapse, fit, faint, funny turn, it's going to affect their ability to drive, and that there's a body in the UK called the DVLA that has rules about this. You know, I think to have a broad understanding around the fact that people should have autonomy to make decisions about themselves, that we sometimes have concerns where people may lack capacity to make those decisions. How do we assess capacity? That's the sort of level of ethical knowledge that we're expecting, but not a detailed word-for-word recollection of what's on DVLA guidance. It's probably worth maybe having a bit of a skim through the DVLA website and the professional guidance and the GMC website, just thinking about those ethical principles that might come up in some of these scenarios.

SPEAKER_02 24:00

That's great. And I'm assuming that our international candidates will be marked to the same level and expected to perform at the same level as those sitting exam in the UK. So it's particularly useful for them to know what kind of level of UK law and ethics we're expecting them to know for these exams. And as you say, those websites are probably a good place to start in understanding what standards the professions are expected to uphold and on what basis, particularly from GMC.

SPEAKER_03 24:26

Yes, I mean bear in mind that even within the UK, there are differences in some aspects of legislation. So for example, the Mental Health Act is different in Scotland versus England and Wales. So we would never expect anybody to have detailed knowledge of the law. But the principles are the same, that for example, you would always use the least restrictive means of dealing with somebody who lacks capacity and the principles of assessing capacity are the same. So definitely not expecting a detailed level of knowledge. Again, quite often candidates will say something along the lines of, I've only recently started working in this hospital. I'll just need to double check what the protocols are. In my last hospital, in this situation, I would have asked the specialist nurse to come and speak to you. So if you're kind of not quite sure what the local rules are, it's perfectly acceptable within the scenario to allude to the fact that you normally work somewhere else, and these are the broad principles. You know, in my hospital, we call it the patient experience team. I'll just need to check what the details are for the local team here that deals with complaints. That's absolutely fine. It doesn't matter if the terminology is a little bit different, but I think understanding broadly that if someone's unhappy, they have a right to complain, but you have an opportunity in this interaction to hopefully diffuse a situation and deal with their concerns, and understanding that there's a body that has rules around driving and understanding around the broad principles of capacity and consent, that's really the level that we're looking at. Nothing more detailed than that.

SPEAKER_02 25:49

And I guess that also aligns with what you were saying earlier about clear communication with the patient and minimising jargon. You're not going to fire off a whole lot of legal terms and DVLA specifics to a patient. You're going to be explaining to them in broad brush strokes, really, the information that's essential to them. And you might not be needing to use the specific named title of the specialist nurse in your area. So that's not relevant to them. That's probably information overload anyway. So it's all part of that communication.

SPEAKER_03 26:17

Correct. I mean, you know, in your head, you know, you may be thinking the principles here are, you know, beneficence doing good and non-benficence not doing harm. Or you may be thinking about things in a slightly different structure. People quite often use the brand structure when they're discussing treatments with patients, like what are the benefits, what are the risks, what are the alternatives, what if we do nothing? I don't think you want to sit there and articulate that to the patient. Again, people sometimes use ice, ideas, concerns, expectations. It starts to look a little stiltered if you sort of say to the patient, what are your ideas, concerns, and expectations? But I think these are the kinds of principles that we'd like to see filtering through your conversation with them. So did you have any ideas about what this might be? Is there anything you're particularly worried about? I've discussed the plans with you, but was there anything else you were hoping that I would cover with you? You know, paraphrasing those structures that we all use as aid memoirs to kind of go through these ethical principles. And that will allow the examiners to see that this person understands doing good, not doing harm, autonomy, etc.

SPEAKER_02 27:15

Okay. We've talked quite a bit about what the examiner is looking for, things to watch out for from a candidate point of view in terms of pitfalls. And I know that you've obviously previously organized and talked on PACE's for preparation courses. I wondered if you had any tips for our listeners who are planning to set the exam soon, how they can actually practice effectively for these stations, as well as looking at the resources that we've just talked about.

SPEAKER_03 27:41

Yeah, I think for these, it's probably good if you can buddy up with another two people, print off the scenarios from the website and go through them with a stopwatch. So do it with the exam timings. In the exam, the examiners at eight minutes should give you a two-minute warning. And that's quite a good time to think, have I elicited the patient's concerns? Or did I just elicit them but brush past them and say I'll come back to them? Do I need to circle back to that? And if you've covered the patient concerns, then it's a good time to start wrapping up to think about checking what the patient's or surrogate's understanding of things is. So people will often either say, Can I just summarize for you what we've covered, or we've talked about a lot, can you summarize for me what we've covered? And that's often quite a good way to check that you've been clear. Because if the surrogate hasn't understood what you've said, then you've not really covered it adequately. So that's a good way of seeing where we're at. And then just sort of wrapping up, you know, the plan, we're going to refer you for this test. I'm going to get you to see the specialist. I'm going to give you this piece of information, etc. That's a good way to use your last two minutes. Your time outside the room, make good use of that just to jot on the piece of paper, you know, who you are, who you're speaking to, and what your task is. And try to remember that is your task. And so if the conversation starts to veer down a bit of a rabbit hole, bring yourself back to the task because that's what we'll have calibrated in the scenario and that's what we're going to be marking you against. Finally, I would say don't get flustered if the surrogate is angry or upset. Often these are actors, and I'm always amazed at how they can turn the tears and the anger on and off. Generally, in real life, when you go into a scenario, you know, an encounter with an angry relative or patient, it's uncomfortable because you don't know how or when it will end. This is an exam, it's a nervous intense time. But go in knowing in the back of your mind, these scenarios are set up so that if you are reasonable and you communicate well, the surrogate will calm down and there will be an end to it. It's 10 minutes. So it's never going to be as unpleasant or difficult as some of these interactions can be in real life. But do expect that some surrogates may be really angry or really upset. And that's part of the communication skills is can you then really listen, empathize, try and work out what you can help with and help give information and calm the person down.

SPEAKER_02 29:52

Those are really good top tips and takeaway messages as well. I think, particularly about the patients that would get potentially being quite emotional because that can scare people that they've not done well in the scenario. But thank you very much, Nicola. That's been an extremely helpful overview and insight into the PACES communication stations and particularly in the useful tips about what the examiners are looking for from candidates and how to prepare. And that brings us to the end of our episode or the Demystifying PACES podcast. And we would encourage listeners to check out our other episodes that we've released in this series to help you in your PACES preparation. Feel free to get in touch with the training members committee team if you feel that there's any additional topics on the PACES podcast that you think would be helpful to include that we haven't already. So I wish everybody who's listening good luck for their upcoming examination. Good luck from me too.

SPEAKER_04 30:55

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