Demystifying PACES - Introduction (02 Aug 2023)

SPEAKER_03 0:00

Hello, I'm Dr. Matt Thomas, Dean of Examination at the Royal College of 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 PACE centers throughout the UK. I would encourage you to think of Edinburgh as your college of entry when doing PACES.

SPEAKER_01 0:50

This series has been developed by the trainees and members committee, by trainees who are currently revising the exam, or by those who recently completed the exam. The series will share topic tips on how to prepare for the PACES exam. We will talk about each station in turn, about the setting, and share the experience of examiners and trainees. Importantly, we will give you an overview of the exam changes and PACES 2023. Join us, and for further resources, visit the RCP Education Portal.

SPEAKER_02 1:31

Hello and welcome to the first episode in a new podcast series that's been developed by the Trainee and Members Committee of the Royal College of Physicians of Edinburgh. And this is designed to help you prepare for the MRCP PACES exam. I'm Kat Ralston, a geriatrics registrar and a member of the Trainee and Members Committee. I've got a co-host, Hannah.

SPEAKER_00 1:48

Hi, I'm Hannah Preston. I'm a renal registrar based in Edinburgh and I'm the current Trainees and Members Committee co-chair. Thanks, Hannah.

SPEAKER_02 1:55

So in this introductory episode, we'll be chatting with Dr. Rod Harvey, who's a consultant, acute physician, and endocrinologist in Inverness, and also the current director of examinations at the Royal College of Physicians of Edinburgh. And this is to discuss the new changes that are being introduced to PACES from the third diet. So end of 2023. Welcome, Rod.

SPEAKER_04 2:12

Thank you.

SPEAKER_02 2:12

So thanks so much for joining us. And I think we should just get stuck in. Can we start just by exploring reasons why there's been changes made to the PACES exam and what you hope the changes will bring for the future?

SPEAKER_04 2:21

Yes, the PACES exam, I suppose, evolves continuously over time. And we have to keep up with changes in the curriculum and in medical development in general. So it's a little over 10 years now since it was last revised when we introduced the current station fives in its current format. And during that time, in particular, it wasn't felt that those station five scenarios are very realistic, but also very rushed for the candidates and indeed the examiners. We also felt that it's a feeling that the history taking station, whilst useful as a communication test, is a little bit artificial because it's asking candidates to produce a differential diagnosis having just taken history, whereas normally you would go on to do some form of examination in most cases. So that felt a little bit unsatisfactory. And then finally, the communication ethics encounter, which I think a lot of people think is a really valuable test of what we do in current day practice, also we felt was actually probably longer than it needed to be, giving 14 minutes for something that in real life you would probably have more or less 10 or so to do. And also actually used up quite a lot of time for the examiners for a whole five minutes of examination time when really they're only able to test one skill in that time, which is clinical judgment, because all of the other skills in that scenario are actually tested directly by observation. And then finally, the distribution of marks across the stations is quite unequal in the current format of PACIS. So one end of the spectrum, station five, has potentially 56 marks to be awarded, and the current station four only has 16. And that means different examiners actually weight the exam quite significantly differently. So if you're a station five examiner, you've got much more influence on the overall outcome of the exam for candidates than if you're a station four examiner, which intrinsically can't be a good thing when we're wanting to try to maximize the validity and reproducibility of the exam. So it's for those reasons that there was a feeling that it required a refresh. So that's why we've made the changes we've made.

SPEAKER_02 4:07

Thanks very much. It sounds like overall we're trying to make things a bit more realistic to real life clinical practice, which sounds sensible, and also trying to make the marking more equal across all the stations. I alluded in the introduction to the time scale for the changes happening. So it's in the third diet of 2023, the late September to early December will be when the PACES 23 is happening. And we've alluded to some of the changes that are happening, but what's staying the same?

SPEAKER_04 4:31

Right. Well, I suppose what is absolutely staying the same is station three, which is the current neurology and cardiovascular pair of encounters. So they will not change at all and they won't even change in the position they are in the cycle. It'll still be station three. I think broadly what's staying the same is we're still testing seven skills, and it's the same seven skills that we currently test. To pass the exam, you will still be required to pass each of the seven skills individually and also get a global mark, which is slightly higher than the minimum pass mark of each skill added together. So you have to do a little bit better than just managing each one. So the skills have stayed the same. The pass mark is adjusted slightly to reasons we'll probably come back to a little bit later. And the other thing that stays the same is the method of assessment. Each encounter is still marked by two examiners marking completely independently, and they're marking on the basis of satisfactory, unsatisfactory, or borderline. So the marking scheme is the same. It's really just the format of the particular encounters that has changed. So I would see this is mostly very similar to the current exam. It's more changed by evolution rather than revolution.

SPEAKER_02 5:34

And just to double check, is the total time of the carousel changing?

SPEAKER_04 5:37

Yes. So it will still be five overall stations of 20 minutes with five minutes changing over and reading time in between. And of those individual stations, just very much like the current exam, some of them will have two separate encounters of 10 minutes each, and some of them, the new consultation encounters, will actually occupy the entire 20 minutes with the combination of the patient encounter and the questionnaire. So just as in the current exam, we have stations two and four, which are actually occupy the whole 20 minutes, and the other stations are divided into two separate encounters. In the new exam, there will be two stations, which are the two consultation stations, which actually occupy the whole 20 minutes, and the other three stations will actually be divided into two separate 10-minute encounters, which have no direct relationship to each other.

SPEAKER_02 6:21

And there's a good diagram on the MRCV PACE's website you can look at, which can show you what the carousel looks like in terms of the changes as well. And we can put these links in the podcast notes. We've talked a bit about why the changes have been made and what's the same. And the general feeling is quite a lot is the same, but the things that have been changed, it'd be good to get into them in more detail. Could we start, Rod, with the clinical consultation station? I think one of the big changes here is the timing. Can you expand a bit more on this?

SPEAKER_04 6:45

The clinical consultation stations, the candidate will have a full 15 minutes to take a history, examine the patient, address their concerns, manage their concerns, and probably discuss with them the possible diagnosis and the management plan. So really five of the skills that touches on. At the end of that 15 minutes, there then will be a five-minute discussion with the examiner, who will probably focus first of all on establishing what physical signs were found, because the candidate is not necessarily going to explain that directly to the patient. And then depending on whether or not the diagnosis has been explained clearly to the patient, and then explore the most likely diagnosis and differential diagnosis, and then probably follow up with some questioning around investigations and management, which is really clinical judgment. So they will be questioning on skill B, which is physical signs, skill D, the differential diagnosis, and skill E, clinical judgment, which is management. A good candidate probably actually have already provided quite a bit of that information within the 15 minutes. So the way I would probably look at these is that they're not really that dissimilar to the current station five scenarios, but you've just got more time. So currently in station five, you only have eight minutes to do all of those things, and actually the examiner only has two minutes to question you, which also can be quite difficult for the examiner. So there's going to be more time to broadly speaking do the same things. That will mean that candidates will be expected to take a slightly more comprehensive history than the very focused history we do in the current station fives. But broadly speaking, they are really going to be doing the same things, but they're going to have more time and it will be more like a realistic outpatient consultation. It's not necessary outpatients for consultation. You might have an outpatient you might have in an acute medical admissions unit where you're assessing a patient for the first time, or indeed an emergency care type setting.

SPEAKER_02 8:23

It sounds like you're almost doubling the time you have for that clinical history examination and explanation, and also the examiner questioning as well. And can I just ask you to clarify the skills that are being tested in the clinical consultation and what the total marks are for this station?

SPEAKER_04 8:37

Yeah, the L CRS of all seven skills in the exam are tested. Skill C, communication, giving them in the order, you're likely to actually do them as the candidate. Skill A, which is physical examination, skill B, which is identifying physical signs, which will probably be a discussion with the examiner. Skill F, which is managing the patient's concerns. So all of the patients, all the surrogates, if it's a surrogate, will have a concern that they will wish to raise during the consultation, such as, do you think this is cancer? Have I got a brain tumor? Will I be able to drive? That type of thing. And then also skill E, which is clinical judgment and investigation and management plan, is not always just about what tests you're going to do. It might be saying, well, I'll do some tests and then I'll discuss them with colleagues and then I'll get back to you on the telephone or something like that. So it's actually forming a plan with the patient. And I think again, a good candidate would ideally co-produce that plan with the patient and check they're okay with it and comfortable with it in a way that they would kind of wrap up the consultation with that. And then of course, managing patient welfare skill G is also going to be tested. So I think I've covered all seven, but certainly all seven skills are tested in the two consultation stations, as they are in the current station five, but which means there's 28 marks available per consultation station.

SPEAKER_02 9:40

Yeah, so hopefully that clarifies the clinical consultation changes. So just to summarize, there's more time. It's two 20-minute stations, stations two and five, with 15 minutes for your clinical encounter and then five minutes for the interaction with the examiner, testing all the seven skills with total marks of 28 for that station.

SPEAKER_04 9:58

And the only thing I would just add is the examiners will be expected or normally will give a two-minute warning at 13 minutes interview, which is a cue for the candidate to begin to be wrapping up and certainly to be managing concerns if they haven't already done so.

SPEAKER_02 10:11

Lovely. Really helpful to know about when those prompts are coming in as well, about timings, because I remember that being really important when I was doing my PICS exam. So moving on to the communication stations, which is the other big change. Can you tell us a bit more about what's happening with those?

SPEAKER_04 10:24

Yeah, I think there's two really important things for people to be aware. First of all, the time available to do the interview is reducing from the current 14 minutes to 10 minutes. And the other really important thing is that there will be no interaction between the examiners and the candidate, other than introducing themselves when you come in, but there'll be no questioning. And that means that to do well in that station, the candidate needs to demonstrate the skills that are being tested to the examiners in a way that they can be satisfied that they've done them adequately without actually having to question one of the things. So, as well as managing patient welfare, there are three skills tested in that station. It's clinical communication, managing patients' concerns, and clinical judgment. And most of these scenarios, whether they be breaking bad news, dealing with a complaint, explaining a diagnosis, have a choreography which is fairly standard, which I think candidates would be well advised to be aware of. Essentially, it starts off with the candidate, the doctor, and the patient having a different view of a piece of information. They're in different places. The doctor may have information the patient doesn't have, or they may have different views as to the same piece of information or same event. The candidate needs to impart information and find out the current understanding of the patient. They need to have a discussion and negotiation, which often involves managing the patient's concerns and worries. And then finally, they need to wrap it up with agreeing a common way forward, which is ideally co-produced. So they need to end up in the same place where both parties are reasonably happy as to what's going to happen going forward. They may not be truly happy in the sense that it may be agreeing that the doctor's going to put in an instant form and the patient's going to put in a complaint form, but they've agreed what's going to happen. And if you can achieve those three things, which is communicate skill C, negotiate, which is managing patients' concerns, and then form an agreed plan, which is skill E, then you will have passed that station without difficulty. But the thing that's really important is you need to agree a way forward with the patient by the end of the encounter, because there's going to be no opportunity for that to be tested by the examiners. So that's probably the key difference, I would say. And again, you'll be given a two-minute warning at eight minutes, which is when there's two minutes left to go. So again, I think wrapping up in that last two minutes is really important if you want to get good marks or get a satisfactory judgment in skilly. So those are the things that are fundamentally different. What really hasn't changed is the nature of the type of communication and the nature of the type of event that is the scenario that's being put forward. So again, it will be breaking bad news, explaining the results of a test, dealing with a complaint, that type of thing. So scenarios aren't really very different. It's just the way that you're expected to deal with them will change a little bit.

SPEAKER_02 13:02

That's a really clear explanation of that framework of what that station should look like in terms of the communication skills, negotiation, and coming to an agreement. So thanks for that. And just to talk about where these stations are in the carousel, because I think they're stations one and four. Can you talk about what they're paired with?

SPEAKER_04 13:18

So you're absolutely right. The communication encounters do occur in stations one and four. Now, the first thing to realize is that they always occur as the first encounter of a pair. So station one, the communication encounter is paired with the respiratory examination, which is exactly the same as the respiratory examination in current paces. And in station four, the communication encounter is paired with an abdominal examination, which again is exactly the same as the current abdominal type of examination. So candidates will have an opportunity to read the introductory material outside of the station during the five-minute reading time. And some of those scenarios will be quite long because we're not testing you on your knowledge of medicine. So sometimes they actually may include information that you wouldn't necessarily know, but which you need in order to put across the information. So, for example, if it was a genetic condition, it may explain the genetics of the particular condition without expecting you to know exactly what that is its own right. So they can be reasonably lengthy. So it's really important you take the time to actually read that, assimilate it, and ideally make some notes or at least have a plan in your mind as how you're going to conduct the interview. So you need to have a strategy before you enter the actual consultation room of how you're going to conduct the interview, which is, I guess, what you would probably do if you were doing this in real life. You don't go in without any thought in your mind as to what you're going to do or what you're going to say or what you're trying to achieve. So there's five minute reading time, and it is fairly obvious that you wouldn't want to hold that information in your head while you did a respiratory examination and then do the communication, which is why we set it up that you always do the communication first immediately after you've done the reading. And then at the end of that 10 minutes, they then move on to the physical examination for which there is no specific preparation required. The one thing I would say though is that because there's no examiner interaction, it's not possible for the examiner to draw the episode to a close as they realize the time is coming to an end. It can occasionally feel a little bit abrupt for the candidate if they're in full speech and then the bell goes and you say, right, that's it, stop, now move through into this room and start doing that. I'm don't run examination or a respiratory examination. So again, I think candidates should be aware and take note of that two-minute warning so that they are beginning to bring the interview to a natural conclusion. And then I think it'll feel for them less abrupt and the changeover to doing physical examination, for which there's no time gap between them. As soon as the bell goes, the clock is running for the next encounter. So you do need to be able to do that change over quite swiftly.

SPEAKER_02 15:34

Yeah, some really helpful tips about the timing there, because that's one of the things that's different. So pay attention to that warning from the examiner. And I just want to be really clear about the history. So the history station's been removed. I just want to double check, Rod, that there'll be no history being assessed in the communication ones because traditionally history was one of the communication stations that's being assessed in clinical consultation. Is that right?

SPEAKER_04 15:54

Absolutely, yeah. So history, I mean Google consultation, that key part of that is taking a history. So we are testing history twice, but it will be subsumed into the consultation and encounters. So the communication encounters are all about giving information and understanding the surrogate's point of view. So yes, you should not be taking a history of those. The only caveat I would say is you might want to open by saying, well, what's your understanding of the position, or something like that? Can that it might be expected to establish what the surrogate understands? It might say, Well, you know, you I understand you've had some investigations for these symptoms. What do you know about it so far, or has anybody told you the results so far? Or something like that. It's just establishing where you are in that communication, but you shouldn't be embarking on taking the history of the altered vowel habit or whatever it is that sparked the test. Absolutely not. At best, you'll get no credit, and at worst you'll actually end up being marked down because effectively you won't be doing what the task is.

SPEAKER_02 16:47

Lovely. Yeah, that's really clear. Thanks so much. And finally, can you just confirm what are the total marks for the communication stations?

SPEAKER_04 16:53

Right. For the communication stations, there'll be 16 that you can get in the communication station in total. Or basically, it's four skills that are being tested.

SPEAKER_02 17:02

Great. Communication stations are stations one and four. The difference from before is that they've been reduced in timing to 10 minutes without any examiner interaction and being paired with an examination station and really are relying on information giving so that communication, negotiation, and agreeing a plan with the patient. So I'm going to hand over to Hannah now, who's going to discuss with Rod a bit about the assessment process and preparing for the exam.

SPEAKER_00 17:24

Yeah, we will now chat about the assessment and exam preparation. I guess one of the first questions to ask is has there been any changes to how cases is assessed?

SPEAKER_04 17:34

I think the short answer is no, in the sense that it's still the seven skills, it's still satisfactory, unsatisfactory, borderline, it's still two examiners at every encounter marking independently. So in that sense, it's largely stayed the same. Because the encounters have changed a little bit, there are in fact four or less marks overall that you can achieve. In the current paces, if you get full marks, you get 172 marks. In the Paces 23, if you've got full marks, you get 168. And that's because actually two judgments in differential diagnosis skill D have been lost. Essentially, by removing the history station, we've lost that. That's just a sort of arithmetic fact. And that of course means that there will be a need to adjust the pass mark for skill D. The pass marks for the other skills are likely to remain unchanged, but the provisional pass mark for skill D will be reduced to 15 out of a potential twenty-four, whereas the current one is seventeen out of twenty-eight. Those as a sharp will realize that this provisional pass mark has gone down by two, whereas the total available marks for skill D have gone down by four. That is not designed to make the exam harder, but is based on a statistical analysis of what is likely to maintain it at a normative level. With regard to the overall pass mark, you currently need to score 130 or more to pass, as well as passing all seven skills. In the new exam, candidates will most probably need to score 127 or more, as well as passing all seven skills. So again, although there are four less marks potentially to gain, the provisional new overall pass mark has gone down only by three. These have been judged to most likely retain the standard of the examination at the current standard, which really means that if the same cohort of candidates sat one exam and then sat the other exam, the same proportion of people and ideally the same individuals would actually pass both exams because the aim is to keep the standard in terms of the proportion of people who are able to pass. The difficulty of the exam shouldn't be fundamentally different. I should emphasize, however, that the actual pass marks for each of the seven individual skills and the overall pass score in PACE 23 will only be set and agreed once almost all of the candidates have actually sat the first diet this autumn. That will be done using a rigorous statistical method designed to maintain the overall standard and difficulty of the exam.

SPEAKER_00 19:48

Yeah, no, I think that's really useful and important to go through. And I think also highlighting the fact that it's not just about that total overall score, it's about the fact that you need to be scoring and passing in all of the domains. So therefore, when you're preparing, you need to think about every aspect, not just the total number of points that you get.

SPEAKER_04 20:04

I think that's absolutely right. And I think people shouldn't be too worried that the provisional proposed pass mark for skill D has effectively gone down disproportionately to the amount of marks available. The skill D is not a particularly common skill for candidates to fail the exam on. If they're going to fail by one skill, by far the commonest one, skill B identifying physical signs. That'd be very unusual currently to see a candidate failing the exam only on account of having failed skill D. People often fail skill D on a consequence of not identifying the physical signs correctly. So it's not uncommon to see skill D fail as well as people failing in skill B, because the two are intrinsically linked. If you don't get the signs, then there's a quite significant risk you'll get the diagnosis role.

SPEAKER_00 20:44

Yeah. No, that's really useful to go over. And kind of carrying on from what was said quite far back at the beginning, the fact that there's a bit more of a kind of equality in weighting, I guess, from the overall stations. So do you feel that that would make the distribution of marks throughout the whole exam more equal?

SPEAKER_04 21:00

Well, that's what is hoped, yes. So four out of the five stations now test all seven skills. So the only station that doesn't test seven skills is station three, which tests five skills. And the distribution of marks between the stations varies between a maximum of 40, which you have for station three, and 28, which you have for the communication encounters, stations two and five. And the other ones I think have 36. So that's a much narrower range of potential marks across the stations. And that certainly means that the marks, if you like, held by individual examiners is more even across the exam, which I think should improve the reliability of the exam. Although we believe that all of the examiners are attempting to examine to the same standard, it would be naive to think that in reality are absolute clones of each other. So it's a good thing to distribute the marks as evenly as possible across our examiner cohort, because that will reduce the effect of a particular examiner either marking particularly easily or particularly harshly. Either way, they will be diluted out by the others. So intrinsically, the fact that the marks are more evenly distributed across the stations should make the exam more reliable. And I think it also makes it fairer for the candidates, because if they come across a particularly difficult case or something, then yes, they may not perform particularly well in that station. At least it won't be a station that can take them down by 50 marks or something. So at the moment, if you have great difficulty or luck, so to speak, in station five, then it's really hard to pass the exam, to be honest, because you can lose too much to be able to make good in the other stations easily. Whereas it is true that you can really do quite badly in some of the other stations and still pass the exams. The past standard is satisfactory, it's not perfection deliberately. So people shouldn't be too worried if they feel they haven't done particularly well at a particular station because first of all, they may actually have done better than they think, but even if their worst fears are realized, they may actually well have picked up enough credit in other stations to have still passed the exam.

SPEAKER_00 22:52

And for trainees who are sitting the last of the current diet, if they are unfortunate enough not to pass that exam, how will that affect them applying for, I guess they might then be into the first diet of the new take?

SPEAKER_04 23:08

Yeah, I think they would be able to apply for it in exactly the same way as anybody currently apply for the next diet. So it won't really affect the people sitting currently because the results are issued continuously throughout the diet where we're satisfied that the exam is reliable and we don't have to wait until we get the whole cohort finished before we can actually issue the results. What will be the case when PACES 23 is introduced is that unfortunately it will not be possible to release the marks until all other candidates have completed the exam, or certainly the vast majority of the candidates have completed the exam, which means that people sitting early on in the diet will need to be waiting quite a long time for their results. And the reason for that is that all of the results need to be put together and analyzed statistically by the central office down in London, where there are statisticians employed to make sure that the standard of the exam that we are actually getting matches the current one. And so although we have indicative pass marks that I've just explained to you, if we found that actually the reality, the performance was quite different, either too many people passing or too few people passing, then it might actually be necessary to adjust the pass mark. We don't think that's likely to be the case, but we won't know the pass marks for certain for the skills and the overall one until everybody has sat, which means that it's only then that we can actually release the results. And that clearly has implications for people who need to know whether they've passed or apply for the next time. I think the timing of the diets will be that anybody who's failed in the first diet phase 2023 will still be able to, if you like, apply for the next diet, which will be the first diet of 2024, in 2024. So they won't be disadvantaged in that sense. But at the moment, until the exam is up and running and we can begin to issue results, I can't remember how many weeks it is at the moment we're achieving, but relatively quickly, then things like the fast track won't be possible to deliver because the fast track requires us to know whether someone's passed or failed within the diet in order to offer them potentially another chance to sit within the same diet.

SPEAKER_00 25:00

No, I think that is very useful for listeners to know about, especially when they're thinking about the timing of doing and sitting paces and the implications that that might have for, you know, job applications and completing training and things like that. So I think that is a really useful take-home message, especially until it can go back to getting the results out quicker. There's been an awful lot of thought and background work behind the scenes that's been happening for a number of years into these changes. But have these changes been piloted across trainees or how has it gone about?

SPEAKER_04 25:29

Yeah, so as you probably realize, it was intended that this would be introduced in 2020 and it used to be called PACES 2020. It's now been rebadged PACIS 23 and the COVID pandemic got in the way. This was piloted quite extensively in 2018 and 2019. I think it was actually probably the summer of 2018 that most of the pilots were done. We ran pilots both in Edinburgh and in London with a number of different configurations, in fact. So we talked about communication being before the visitor examination in stations one and four, but we actually tried it the other way around and realized that it just didn't work. So they have been fully piloted and they've also been run a little bit overseas because some of the Pathfinders we ran overseas, we thought we'd run in the new format, and we ran those initially in the PACES 2023 format. So yeah, we do have quite a bit of experience of it. The pilots are now three or four years ago just for that reason, but it was revisited last year before we just pressed the button or before the federation pressed the button, really, to review whether it was, if you like, still fit for purpose or whether it needed any further tweaking. And the general feeling consideration was that there was no particular reason to make any further changes and that what was valid in 2018-2019 was still valid in terms of 2023 and that we should just proceed forward. Of course, the exam has been approved by GMC, which is our regulator of the examination as well.

SPEAKER_00 26:46

Yeah, great. And I think Kat was actually involved in one of these pilot exams. So, Kat, how did you find it?

SPEAKER_02 26:51

Yes, I started the PACES 2020 pilot in August 2018, about four months before I did PACES for real in the end of November. So it's quite a while ago, but I think I'd only just started revising. So I certainly didn't feel sort of proper PACE as ready at that point. But interestingly, I've had to look back at the mark sheets and I actually did a bit better in the pilot than I did in the real exam, particularly in the brief clinical consultation station, which is interesting. So I remember the clinical consultation one felt much more realistic in the pilot in terms of the timing. So in the real exam, that eight minutes just didn't feel like enough time and it felt very rushed. So having 15 minutes felt much more realistic. I think I had a patient with Parkinson's disease, and you know, you can't speak to an exam in someone in eight minutes. So it felt much more realistic and normal than the old one. And in the communication ones, I remember my actual paces, there was like a very long, awkward pause at the end when there was nothing more to say in my communication one, which is about an end-of-life discussion. We had too much time and I got full marks in that station. So it wasn't as if I'd forgotten to cover anything. It was just, it was too much time, that 14 minutes and then the five minutes of questions, and to a lesser degree, but similar in the history one. So I also think that reducing that to 10 minutes feels more realistic as well. So my takeaways were positive from that pilot, and I hope that gives candidates maybe a bit of reassurance that I've been through both of them. And I I certainly thought it felt more realistic to clinical practice.

SPEAKER_00 28:07

That's really good to hear. I think people will be reassured by that and also know that Horrin senior registrars have tried it and been through it and think it's good. So examiners have presumably received or are receiving training at the moment for the new exam format. Is that right?

SPEAKER_04 28:21

Yep, I think that's both of those statements are true. That fundamentally no examiner will be allowed to examine basis 23 unless they have completed formal training, i.e., they have been signed off as having been trained. So what has been going on so far is a number of briefing sessions that most of the colleges, the London, Glasgow, and Edinburgh College, have all conducted meetings with their examiners, which have been either webcast and recorded, basically raising awareness very much like we're doing at the moment and answering some of those questions. So that is effectively informal training of briefing them about what changes are, uh how it will impact on them, etc. But in addition to that, they will also need to have watched or attended a webcast done by the Federation, which again reiterates the changes and then demonstrated their understanding of that by completing a small questionnaire, a little test effectively with some true false answers in it. And only when they've managed to get 100% in their test will they be deemed to have passed the exams. They're not difficult questions, and as we've already alluded to, the changes actually aren't that massive. But the examiners will or at the very least have been trained and signed off with an understanding. And of course, some of them will actually have had an opportunity to participate in other opportunities. So I think people should be assured that people will have been well trained. And of course, the other people that were training at the moment or bring up to speed are the hosts, but also the administrative staff who support a lot of the actual delivery of the exams on the day. So making sure that people understand how to set out the rooms and the physical layout requirements for the exam, which is not hugely different than the current one, but there are some issues that people need to be aware of, particularly the need to be able to switch rapidly between the communication encounter of the subsequent physical examination encounter, which like to be in the same room, or if they're not, they need to be in very closely adjoining rooms.

SPEAKER_00 30:09

Yeah, I think that's important to touch base on because there's a lot that goes behind the scenes in the admin and the setup of the day and to ensure the smooth running of the event is really important and it makes or breaks the day patients as well. Because some of these patients have been examination patients for years. So I guess are they also informed of the changes?

SPEAKER_04 30:27

Probably not to a huge degree, because most of the patients are the ones that, if you like, uh are used on a regular basis from a database of ones, are people with physical signs that come in for the abdominal respiratory biology and cardiovascular examinations. And those aren't changing. So from the patient perspective, those ones, there's no change at all. For the communication encounters, centers have slight different approaches, but many will use professional actors for it, which we find usually very effective. Some will use effectively amateur actors who may be members of staff, etc. But again, these people tend to change more rapidly over time as to who will be available to take on those roles. So most centers wouldn't have a database of people to be participating in the penation encounters other than professional actors who obviously will be briefed as to the time available and what they need to do. But in fact, what they do is not really very different from the current one. They just do it in 10 minutes rather than 14 minutes. So not a major difference. And then the club consultations, again, as far as possible, we're looking to find fresh materials so that it's actually somebody with a real illness. Often those station five scenarios are actually written quite close to the actual exam using someone who has actually presented with a real problem fairly recently. What may be used, and people do need to be aware, is that as we often do overseas, it may be that a surrogate is used, an actor is used to actually give the history and communicate with a candidate in the consultation encounter, and a patient is present for the physical examination. Now that's quite common overseas because often the patients don't speak English and they effectively need to have somebody who's an interpreter. They're often introduced to their brother, their wife, or somebody like this to justify their presence. And the same would be here. The advantage from running the exam is that, for example, you can have a patient who has a known physical sign to be examined who doesn't necessarily have to have anything like the history that is being used. So if, for example, the story was somebody with a transient ischemic attack and an actor gave that history, then one might find a patient or have a patient specified who had atrial fibrillation and the relevant finding was atrial fibrillation, which obviously would be the risk factor for the transientistemic attack. So that's probably the main difference where we may use actors in the station fives. My suspicion is that won't appear particularly frequently initially. Although when there are bounce scenarios, i.e., scenarios produced by the ecologists, which will probably evolve over time, then hosts will be able to use a scenario that's given to them, much in the way as they're given the communication encounters at the moment. And then the requirement would just simply be to find a patient who had visible signs that essentially match the scenario, but didn't really have to speak themselves. So again, those actors would be, if you like, trained and briefed as appropriate at the time.

SPEAKER_00 33:10

Yeah. There's been some concern that changes to paces may disproportionately affect overseas candidates who are not UK trained. What are your thoughts and feelings on this?

SPEAKER_04 33:20

I don't actually think that's likely to be the case. I can understand why people might be concerned. I think it could unfairly affect both candidates sitting overseas who are probably not UK trained, but also candidates sitting in the UK who possibly trained overseas. I think maybe where that concern has come from is the feeling that there's now two communication encounters, whereas previously one and that possibly one area where overseas candidates historically have been weaker is sometimes in some of the communication. That is certainly the case in some centers overseas, where some of the communication stations have been quite challenging, often because there's a different culture between doctors and patients, which is quite difficult for people to overcome. So I think what you really need to remember is that we're still testing the same seven skills. And apart from removing four marks from differential diagnosis, there's exactly the same number of marks available in all of the skills. It's just the way that their spread is different and more even. I think actually that for the reasons explained is that actually with there being more time, there's more opportunity to demonstrate your communication skills. I think arguably being very rushed in station five in its current form, if some of the communicational elements are not your natural strength, that actually might make it harder for you. Whereas if you've got the 15 minutes, then you've got the time to actually do it. So I don't really think it will disadvantage that group particularly. I accept that some groups find some bits of the exam more difficult than others, and that's the fact. We're very aware of differential attainment, and that is actually monitored. There are many, many reasons for it. So it's very difficult to put a finger on exactly this is the cause and this is what we need to do, but we are actually doing anything we can to mitigate it. But I think in this case, I don't think those candidates should be particularly worried. But everybody past the exam has to demonstrate that they can meet our smarking or seven skills so that it's a non-compensated exam. It's no good to be really good at physical examination but allows it communication or vice versa.

SPEAKER_00 35:06

Yeah. No, I think that's very good to go over it. And as you said, the fundamentals of what are being marked and looked for have not changed. And carrying on from that, we've heard all before about best ways to prepare for paces and tips and tricks. Do you think that the new station format changes at the way we should be revising, or do you actually think that, as Kat was saying, it's maybe a bit more like our day-to-day practice? How should the take-home messages of how to revise?

SPEAKER_04 35:32

Okay, I think fundamentally probably there isn't a need to change what you're revising because the exam hasn't that fundamentally changed really. So I think for the physical examination stations, which haven't changed, there's no substitute for examining as many patients as you possibly can, practicing doing it and doing it under direct observation of your colleagues or consultants who are willing to do it and doing it timed and then having feedback. There's no better thing than just doing a large amount of it and going on courses may be fine. That maybe get you access to some more patients and a little bit of other things. But I think actually just doing it regularly yourself. And really, when you think about skillatophysical examination, well-prepared candidate really should pass that without any problem because you should by that point have unconscious competence. So you should know how to do a neurological examination, cardiovascular examination, et cetera, subconsciously. And so even in the exam, you should be on autopilot at that point. You shouldn't be having to think about now do I do the tendon reflex next or whatever. If you're thinking about that, it's like learning to drive a car. You start with conscious incompetence and you move into eventually conscious competence, but finally you're in that unconscious competence where you can change gear without thinking about it. That's how you need to get for paces, really, so that you exude that appearance that you know what you're doing, which also helps because of course the examiners then think you know what you're doing, which makes them more likely to give you a satisfactory mark. So I think, you know, practice for the physical exams is just the same as it currently is. The communication encounters are important, Adam. I think we recognise the importance of communication and effectively we doubled the amount of communication in it. So instead of having one, we've got two. And that, of course, does mean that there's twice as many marks to be got out of communication. So I think again, practicing that, but if you're working in the UK, you should be doing that in your normal day-to-day life. You will normally be dealing with difficult encounters in wards, having to explain diagnosis to patients, to dealing with queries from patients' relatives, concerns that things have gone wrong. So all of those things are actually the sort of thing that you will be being tested on. I think it's no harm though to try out some of those encounters. And to be honest, they're not that hard to make up. So even if you haven't got access to written material, then somebody could make one up for you quite easily and then observe you. I think it is important to be observed doing it and to have that immediate feedback and criticism. And I think one thing that's really useful that most candidates find is that preparing in pairs or small groups is useful because you could learn as much as a candidate by observing somebody else and criticizing them and effectively being the examiner or certainly observing them and maybe a third person using maybe an experienced examiner, then giving feedback and criticism. So I think observing how others do as well as trying to do it yourself is a really good way of learning. So be aware that of the communication encounters, and I think probably practicing to make sure that you're wrapping it up and agreeing a plan at the end, because the difference is there's no scope for the examiner to dig you out of the hole by asking you what you would have done if you'd actually had a chance to explain it to the patient. Whereas at the moment you can sometimes redeem yourself that way with won't be a scope for new exam. So I think just practicing that. And then the clinical consultations, again, I think if you can do outpatients, if you do medical receiving, maybe emergency care, these are all scenarios which are really the scenario you're testing, which is to take a history, do a focused physical examination, think about some tests, explain to the patient what you're going to do and address their concerns. And that's what we do in everyday life. So I think making sure you do it in your day-to-day practice and maybe try to do it properly, but not cut corners in your day-to-day practice. We'll see where things are pressurized, time-wise, and in real life work, that can be easier said than done. But that's a way I would say that you probably really can prepare well.

SPEAKER_00 39:01

Yeah, I would definitely agree with that. I think going around, finding someone else that's doing it or a couple of you that you can go to, let other people know that you've got an exam coming up and you want to practice, because they'll definitely help. And then just going over and over and over the exams and actually not forgetting the presenting part. You can often go to a patient on your own and go and examine them. But I remember you have to go and do that and then present. And if there's no one to present to, we'll just go shut yourself in the cupboard or something and then talk through the presentation because it's that verbalization of your findings in a succinct and eloquent way that is really important as well.

SPEAKER_04 39:31

I think so. And I think it's useful to remember that the examiner's got a task to do as well and they're marking on individual skills. So I would very much recommend people listen to the question that the examiner asks and answer that question and not give superfluous information. For example, in the physical examination stations, the examiner has four minutes to test three skills, which is skill B, what physical size did you find? Skill D, what do you think is the differential diagnosis? And then skill E, effectively, what's your management plan? So I generally will have three questions for three skills and I want three answers. If I ask, you know, what physical size do you find, and I get an answer, I think this patient's got mitroncerosis, then that isn't really the question I've asked. It makes it harder for me. Or if I get a statement saying they'd like to examine the hernial alvarosphysis and do erectile examination, which is quite common for candidates to say because I think they think they've been taught in courses they have to say this or they'll be barred down, which just isn't the case. But basically running the clock down and gaining the credit. So I would say, listen to the questions, they're asked for a purpose because we are really short on time, and answer the question that's asked. And if you haven't got something quite right, there may be a scope to redeem yourself. Whereas if you go straight in with the diagnosis and it's wrong, then you're lost. So generally speaking, for those ones, it'll be those three questions, more or less. I think many examiners do that. And if the examiner stops you, that's usually because they're wanting to ask another question, which actually is focused on a skill they need to test and they're running out of time. So again, they may sound a little bit abrupt if you're being cut across, but it's usually because actually the examiner's wanting to get on to another question to be able to give you some credit.

SPEAKER_00 40:56

Yeah, that's really good to know. So just to wrap things up, where can Canada to find out more information about these changes? Is the website the best place to head to?

SPEAKER_04 41:04

I think the MRCP UK website has a substantial amount of material on it, which has appeared in the last month and then making more material appearing going forward. There are a number of videos of the different consultations, mock-up videos, which you can watch. There's really quite a large amount of material there, and I would encourage people to go and have a look. And there will also be material appearing and links to that material on the Community Physicians of Edinburgh website as well. So I think do look at the official MRCP UK website. It's surprising, apparently, a number of candidates who've never looked at it if you sit the exam. But yet there's actually a wealth of supporting information there for them, which must make it easier, particularly if you've not had the misfortune of having sat the exam previously, then it does give information as to what to expect. And that can be a bit daunting, I think, turning up to something you've never been to and it all feels a bit strange. So the more you can be prepared and the less strange it seems on the day, the better.

SPEAKER_00 41:51

Yeah, definitely. Well, to wrap that up, thank you so much for giving up your time to talk to Kat and I and the listeners. I think everyone will have found that incredibly useful. So this episode will be released, but then there'll be a series of episodes to come in the future that will come out after the first diet's taken place. And we'll be going through kind of each station on different episodes, talking to past candidates, talking to very experienced examiners, getting top tips and experiences. So hopefully you can join us for the rest of the series and learn more. And please do kind of share it with your friends and colleagues who are going to be taking part in PACES in the future. So thank you very much. It's been really useful.

SPEAKER_04 42:31

Thank you. Thanks very much.