Demystifying PACES - Consultation [Stations 2 & 5] (21 Dec 2023)

SPEAKER_00 0:00

Hello, I'm Dr. Matt Thomas, uh 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_02 0:52

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_04 1:38

I would like to introduce my colleague, Dr. Matthew King, who is an acute medicine physician in Edinburgh, who also has extensive experience in PACES examinations and has been involved in the standard setting for PACES 2023. So thank you very much for coming onto this podcast today.

SPEAKER_01 1:55

You're welcome.

SPEAKER_04 1:57

So I wonder that if you could tell us a bit about how the consultation station works. What has changed from what was previously known as station five?

SPEAKER_01 2:08

Okay, so station five involved two scenarios each of 10 minutes where you were doing a full assessment of a patient. And it was generally thought to be very rushed and not realistic. So essentially, one of the major changes to page 23 is to split the two parts of that station five into two separate scenarios and extend them to 20 minutes each. So the new stations two and five are consultation stations. They involve history, examination, and interaction with the patient, addressing the patient concerns. They are realistic to real life. So if you're in an outpatient department, you may come across a patient who has a new complaint and you have to think on your feet and assess that patient on your feet. And the same about an acute assessment patient. So the other scenario will be around an acute assessment. And again, you have to think on your feet with a 15-minute period. So the station is designed to be an integrated station, realistic to real life, involving the combination of history and examination. So the examiners actually like the change. They think it's a realistic scenario and they have a lot more time to do their assessment. This station assesses all seven domains, and the examiners now, compared to the old station five, have a lot more time to do their assessments.

SPEAKER_04 3:24

Wonderful. So you take a history, you examine the patient, and then you've got a communication with the patient. And how does the timing of this station work? So you said it's 20 minutes. Do you get time outside to have a read of the question? And then you go in and is there a warning bell, QA session? How does that all work?

SPEAKER_01 3:43

Yeah, so now, with the exception of the pure examination station, all the stations have time outside for reading, and this station does as well. So now you of course you have the single scenario, you have five minutes reading time, and that five minutes reading time is essential. The details on the sheet outside the station will be very relevant to the case. So everything in that information sheet should be double-checked and read. And things on that sheet are there for a reason. So pay attention to that in your first five minutes. The interaction time itself is 15 minutes, and within that time, there'll be no interruptions other than a two-minute warning to tell you've only got two minutes left with a candidate. So within that 15 minutes, you've got free reign really to do whatever you want in terms of history and examination. And I would emphasize it's important to do both, and if possible, try and do examination and history at the same time. Two-minute warning is often a sign to say that you need to wrap things up. And in particular, a lot of candidates use that as a warning to turn the direction to addressing patients' concerns. Sometimes that can be a little bit artificial. Too many warning initially, the candidate stops doing what they're doing and starts asking the patient what their concerns are. So make it less obvious that you're doing that. But it is a warning sign that you just need to make sure you've done everything and answer the patient's questions. And then the five minutes questioning is extended from the old station five, so it's less stressful for the examiners. There's a lot more time for them to make sure they're assessing all the domains.

SPEAKER_04 5:11

Wonderful. That's really helpful to know. And how do you calibrate this station?

SPEAKER_01 5:17

So the calibration is the essential, it's the most important part of the day for the examiner. So a lot of emphasis and time is spent on that. The way we approach it for this station is to do a run through. So ideally, one of us will look at the scenario as a candidate would, blindly, without knowing what the diagnosis is, before we read the information for the examiners, and we'll do a complete run through. And that makes it a more realistic assessment of what can be expected to be performed and what questions can be asked within that 15-minute period. So we'll do a blind run through, and that also, of course, gives the surrogate time to practice their history and answering the questions. And then we, as a pair of us, the two examiners, decide what would be reasonable to expect someone to have to achieve within the 15 minutes. So we then agree on the clinical signs and what we expect the candidate to cook with as differential diagnosis. And we also usually discuss things that the candidate might say, which might be wrong, and decide how much we mark them down if they say things that are wrong. So we spend quite a lot of detail calibrating as we do in all the stations and try and make it as fair as possible, essentially.

SPEAKER_04 6:24

Wonderful. That's a really useful kind of talk through of how you calibrate and how you approach the timing. You've mentioned taking the history and exam together, which definitely makes sense giving the timing and also probably what you would do in clinical practice as well. How detailed should the exam be? Is it a focused exam? And also does the history cover all areas? Or again, is it a focused history given the timing?

SPEAKER_01 6:52

Yeah, that's a difficult one to answer because the expectations from examiners have changed slightly between the old station five and the new station two and five because you've now got double the time. So I think examiners do expect a little bit more than used to be the case on the old station five, but it's still very clearly labeled as a focused encounter. And focus means that you should be prioritizing what questions to ask and prioritizing certain examinations. So we certainly don't expect a full examination, including all the minutiae, like you would do on a true examination station. But you have to do everything that's relevant. So I suppose a good example might be in a neurological case, but probably wouldn't expect you to do cranial nerves, upper limb, and lower limbs. It's just not possible to do all that. But you would do perhaps one of those three, or you would do a focused examination on power or coordination, for example, if you thought it was a cerebellar problem. So it's still focused, but relatively thorough, is the way I would summarize it. And if you can do history and examination together, I think that is a benefit. Some candidates do struggle with that. And I think it's reasonable to start off just with questions. But once you've got the basic questions out, I think it's better then to start examining and give yourself enough time to examine. The exam overall is still heavily dependent on identifying clinical signs. And if you don't pick up the correct clinical signs on this station, then you'll potentially lose marks in your other sections due to link marking. So differential diagnosis and clinical judgment, you will lose marks on if you don't get the correct signs. So make sure that you don't spend too long on the history. And as I say, I would encourage you to start examining and then carry on the history at the same time.

SPEAKER_04 8:32

That's really valuable information because I think so often we start with questions and then we get on such a roll with the questions that we can forget how important the examination part of this still is. And the communication discussion element of the patient, is that explaining kind of what your findings are and what your initial management step plan would be with them?

SPEAKER_01 8:54

Yeah. So all the patients will have questions that they need to get out in the consultation if you give them time. So you should obviously always ask the surrogate, have you got any questions for me? And make sure you give yourself time for them to ask those questions if you to answer. So they're prompted what to say. Some of the prompts might be what's the plan? So it may be as simple as that. Sometimes it's a patient concern. So it might be something along the lines, have I got a cancer doctor or something like that. So I think it's important to listen to what the surrogate is saying and answer them. Some candidates decide to part those questions. So if the question comes up quite early, have I got cancer, for example, you could potentially say to the patient some form of reassurance and come back to it in more detail at the end of the consultation. So I think it's difficult sometimes to know whether to answer them when you haven't done the full assessment or whether to leave it to the end, if that makes sense. So I think you should always answer immediately if possible rather than park those questions, even if it's just a partial response. Some candidates still don't leave time, but even though the timing of the exam has increased dramatically to 15 minutes, some candidates don't leave a sufficient time at the end to answer those questions for the patient. So as I said before, the two-minute warning, that's a little bit of a prompt to wrap things up quickly and then ask the patient and address questions.

SPEAKER_04 10:16

Excellent. And that comes on really nicely to my next question, which was going to be what are common mistakes and pitfalls? And presumably kind of timing is one of them. What other common mistakes do you see?

SPEAKER_01 10:27

I think a very obvious one is not reading information outside. So I think if you've been on another station and you've got the stress of finishing another station, you sit down in a chair, and then you have got five minutes to collect yourself. And the information for these cases usually isn't very long. So it's often surprising that someone comes in and then hasn't read the scenario correctly, has forgotten a bit of vital information or forgotten where they are. You know, is it an outpatient setting? Is it an acute setting? So read the information outside and just make sure you've read that properly and you take that into the exam, knowing what you're going to ask. Timing, as you've mentioned, I think is important. There is that prompt at two minutes. I think don't spend too long doing the history because you think you've got that length of time now, 15 minutes. Some candidates will do a very detailed history and don't leave enough time for examination. As I said already, examination is quite crucial to getting some other marks in those other domains. So try and start the examination, not just at the end after the history, but at least sort of halfway in. And I think those are the main tips. I think the other one I would say is that because it's focused, sometimes candidates get the idea that they can take certain shortcuts. And you can take a few shortcuts, so don't expect a full examination. But a common one I would say is that candidates still examine through clothes. So don't do that. Still make sure the patient is exposed and that you do your examination technique correctly.

SPEAKER_04 11:52

Excellent. That's really helpful. I think this is what it should be like when you are examining and taking history from a real patient. You need to show the examiners what you are like as a day-to-day doctor, essentially. So, what does a good candidate look like? Those ones that stick out and you're like, yeah, they're great. How does it flow?

SPEAKER_01 12:12

Yeah, as an examiner, we obviously have to mark the seven domains. So a good candidate is someone that we can tell has got the correct diagnosis as they go along. So you can identify those people quite clearly because this is a focus station. They ask all the relevant questions and they do the relevant examination, and you realize straight away that they know what the case is about. So you can easily demonstrate to the examiners you know what the scenario is all about by the way you approach the patient. So the examiners have to mark all the domains. So when they start questioning, they'll be asking the domains that haven't been answered, really. So they approach it in different ways. I think if you've done really well, they might just say, Well, tell me what you think the diagnosis is. If the examiner isn't quite sure you know what's happening, they might go back to basics and tell me what did you find on examination? So the examiners approach the questions differently depending on how you've been performing. But a good candidate can tell that they've picked up the real meat of the scenario as they're going along, and you can tell from their focus that they've got that.

SPEAKER_04 13:16

And you talked right at the start about station two and station five. Are there differences kind of between them based on, I don't know, acuity? And I guess we don't need to go into exact details, but are there common themes that come up in one or the other, for example?

SPEAKER_01 13:33

I think my understanding is that there's no real difference between stations two and five. They're both consultation station. The hosts are encouraged to have one that is an acute scenario with the emphasis on an acute presentation that you might see in acute seniors, and the other one that should be more an outpatient chronic disease presentation. So you should have a mixture of those two. Other than that, the scenarios can be really anything, and there's a big variety on what conditions are examined in those stations. The one thing I would say is that traditionally in the old station five, the patients were often answering all the questions themselves. Because it's now 15 minutes and there's more questioning involved, sometimes now the patients might have a surrogate. So I think you might find that increasingly the case that you have not just the one patient in front of you, but you have a separate surrogate who's actually answering the questions. If you do the exam internationally, that is often the case anyway, because local patients may not speak English. So in that situation, you may have the patient with signs, but the person answering the questions is a separate surrogate. So don't be put off if you have that situation, if there's a separate surrogate answering the questions. And I think you'll find that increasingly in the UK because some patients aren't prepared to answer that amount of detailed questions and basically acting, because still quite a lot of the questions that you answer are actually not real-lived questions to make the scenario more challenging. For example, they often change real characteristics in the patient's history.

SPEAKER_04 15:08

From that, can you have a patient that has no signs? So a surrogate just as one patient rather than a patient with signs and then a patient kind of doing the answering.

SPEAKER_01 15:17

Absolutely, yeah. So the exam you are allowed to have patients with no signs. And I think that's something to be aware of because another common pitfall actually is that candidates do make up signs. So I think it's always important to be true to yourself and not fall into that trap. I think it's probably fair to say that you're slightly more likely to get someone with no signs on station five because you can still have a scenario based around a normal examination. It's not encouraged with hosts and examiners to do that because, as I said already, the exam still is heavily important on being able to identify signs. So it's actually discouraged for having someone with no signs. It's more likely the patient will have signs, but it is possible that they will have nothing to find. So stick to your guns and be true to yourself, is what I would say when assessing these patients.

SPEAKER_04 16:04

Amazing. Now I was going to come on next to the kind of presentation and answering questions section, because I think that's often a part which probably scares candidates if you're used to taking the history and exams from patients on a day-to-day basis, but the presenting your findings and answering questions, how would you approach that?

SPEAKER_01 16:25

Yeah, I think I've hinted about this already. I think if you know what the diagnosis is and you're confident about your assessment, then you should say that. So the advice would be that if you know what the diagnosis is and you are sure of it, tell the examiner straight away, I think this patient has got syndrome X. And I say this because of these bindings and these features on the history. So I think if you know what's going on, tell the examiner and just reel off all the information. If you're not so sure, then I think it's probably better to go back to basics. So if you don't know what the main diagnosis is, tell the examiners what you found on examination and what you thought the important bits of the history were, and then sort of explain your thinking in a bit more detail. And I think the examiners will guide you on that as well. As I said already, the examiners don't always approach every candidate with the same opening line. It might depend on what they've done during that 15 minutes, how they approach the situation. So I think my advice is just to be honest, though, again, because you still find candidates who, when put under pressure, if you say, What science did you find? they panic and start making up things if they didn't find anything. And that's the wrong thing to do, obviously. They get into trouble. So just be honest and don't try and make new things up when you get in questions. Just be honest with what you assess during that 15 minutes.

SPEAKER_04 17:43

What kind of questions might be typical? Would it be, what have you found? How would you like to take this patient forward? What would your management plan be, for example?

SPEAKER_01 17:53

The examiners have to assess all the seven domains in this station. So they can mark some of those as you go along. So they can mark your examination technique as you go along. And if you've explained the diagnosis to the patient and explained the plan, we can also sometimes mark those domains, differential diagnosis, technical judgment as well. But essentially, the main thing we want to improve as examiners is the domains we've not marked. So it does depend how you've done the assessment as to what questions you subsequently get asked. So if you haven't given a differential diagnosis to the patient, the examiner's going to ask you that. And likewise, if we don't think you've addressed the patient's concerns, we might ask you, what do you think the patient's concerns were and how would you address these? So it does depend a little bit on what you've covered already within the 15 minutes. But because the examiner's got five minutes at the end there, they've got plenty of time to elaborate and make sure uncertainties that they've seen during your assessment. So if they weren't quite sure that you've addressed the patient's concerns correctly, or you weren't quite sure that you've done all aspects of the management, they'll query you as to what else you could do, for example. So I think you usually find that the questions for examiners be more firmly in the blanks of what you've not already done, but often with an opening line that's more general. So probably an initial thing might be what do you think the differential diagnosis is, for example, might be a good opening line from the examiners.

SPEAKER_04 19:16

That's really good to know. And also nice to know, reassuring to know that rather than a kind of a set list of standardized questions, the examiners are trying to get you to hit all of those domains. You're not trying to make people bail, you're trying to tease things out of people where you might just not have necessarily picked it up in time. So that's really helpful. I think this whole discussion about the consultation stations has been really useful. I just wanted to summarize what would your top tips be for candidates taking on this station?

SPEAKER_01 19:49

Yeah, I think we've talked about some of these already, but I think firstmost I think is reading the scenario outside. Sounds obvious, but in the heated situation, I think some candidates don't take time to read over that properly or at least to sort of take in what it says properly. The information outside is very short usually. So everything on that sheet is usually important. So I think it's very unlikely there'll be things that aren't important on that sheet. So if there's some past history given or some information on that sheet outside given, it is probably relevant to the patient. So pay attention to that. And then once inside, I think we've said already make sure you're focused and thinking around the diagnosis you go along. And I think the other thing is making sure you listen to what the patient says. So even though this new station is twice the length of the old one, when I've examined it, which hasn't been many times to be fair, so far, the candidates still don't give enough time to address the patient's concerns. So make sure you listen to what the patient is saying to you and make sure you answer their questions fully. Otherwise, you lose marks on that patient concern section.

SPEAKER_04 20:54

Excellent. That's great. And I know that the NRCP PACES section of the website has got information about each station where candidates can go to to find out some more information. So thank you very much, Matt, for coming on and discussing the new PACES setup and station. And hopefully, candidates will find it really useful to listen to this as they think about booking the exam or as they undertake their practice for this exam. So thank you so much for giving up your time, it's most appreciated.

SPEAKER_01 21:28

No problem. And good luck, everyone, with the exam.

SPEAKER_03 21:51

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