13.02.2024
The Quesmed Complete Guide to MRCP PACES
Well done on getting through MRCP Part 1 and MRCP Part 2 written! You will have no doubt worked hard to get to this point and you are one step closer to achieving the full MRCP diploma. One final obstacle stands in your way - MRCP Part 2 Clinical, or PACES - and this is your guide to conquering the last hurdle!
What is the MRCP Part 2 Clinical (PACES)?
MRCP Part 2 clinical, often referred to simply as PACES, is a practical exam taken by doctors who have completed MRCP Part 1 and Part 2 written successfully. This includes both UK-trained doctors and international medical graduates (IMGs).
The purpose of PACES is to test the candidate’s ability to perform clinical examination and consultation skills to determine underlying diagnoses and synthesise management plans.
Who undertakes the MRCP Diploma?
MRCP PACES is the final of three exams on the journey towards the MRCP (UK) Diploma. It is completed after MRCP Part 1 and MRCP Part 2 Written, which candidates are eligible to attempt after having had at least 12 months of postgraduate medical experience (this usually means waiting until completion of FY1 in the UK).
The MRCP Diploma is a post-graduate diploma designed to test the skills, knowledge, and behaviours of a doctor who wishes to undergo medical speciality training in the United Kingdom.
Many doctors - within the UK and abroad - undertake the MRCP diploma even if it is not a training requirement in order to provide additional value to their portfolio, but also to develop their skills and knowledge further.
In order to achieve this qualification, you have to sit and successfully pass three exams:
MRCP Part 1
MRCP Part 2 Written
MRCP Part 2 Clinical or ‘PACES’
Any doctor who wishes to start specialist registrar training in the UK within a physician or medical training programme must have completed all parts of the MRCP diploma in order to enter the relevant specialist training. The specialities where MRCP is a requirement are reproduced below:
Exam Format - MRCP Part 2 Clinical (PACES)
The aim of PACES is to ensure the candidate understands common and important disorders that they may come across during their specialist training, at an entry level, and how to manage them practically.
In order to do this, PACES is designed as a practical, face-to-face ‘OSCE’ style examination designed to test the candidate’s ability to perform essential clinical skills across 5 stations lasting 20 minutes each. In total, you will meet 8 patients across these 5 stations (called ‘patient encounters’).
Some of these stations are further broken down into 2 x 10 minute components. Each station is separated by a 5 minute rest, and each station is examined by 2 examiners.
This format is referred to as the PACES carousel, pictured below.
The exam consists of the following stations:
4 Examination stations:
6 minutes for the examination, where the candidate has to perform a clinical examination of one of the major organ systems
4 minutes for a structured viva where the examiner asks the candidate, usually, to summarise their findings, present a likely differential diagnosis, and also a management plan
2 communications stations:
10 minutes for the entire station, covering a range of possible topics, including difficult consultations such as breaking bad news or health behaviour change, as well as ethical and legal dilemmas
There is no viva
2 Consultation stations:
15 minutes for the consultation, where the candidate has to take a focused clinical history and perform a focused clinical examination, followed by an explanation of the likely diagnosis and next steps to the patient
5 minutes for a structured viva, where the examiner usually asks the candidate to summarise the case, provide a differential diagnosis, and management plan
Exam Marking - MRCP Part 2 Clinical (PACES)
As you rotate through the carousel, you hand one examiner at each station an envelope containing your marksheets. There are 16 marksheets within your envelope, one for each examiner, covering each patient encounter.
A typical marksheet for the examination stations is shown below and the full range can be downloaded on the Royal College of Physicians’ website. The examiner will take out the relevant marksheet at the start of your station and begin assessing you when you start.
At each patient encounter, one of 7 key clinical skills (A-G) are assessed by the examiners. You should note that not every skill is examined at every station, as some of the skills may not be relevant in the station. This is why you may notice some of these skills being absent on some of the marksheets. These skills are as follows:
The examiner has to decide if they have seen the skill demonstrated or not, by scoring each skill as ‘satisfactory, borderline, or unsatisfactory’. The marksheets provide some explanatory text that may help the examiner make their decision; for example, as you can see below, finding clinical signs that are not present may result in an unsatisfactory mark being awarded in the physical signs (B) clinical skill:
MRCP PACES Exam dates and Fees
Plan ahead as there are only fixed periods of time (known as ‘diets’) when you can sit the exam, published by the Royal College of Physicians. The exam happens at hospital sites and the Royal College will almost always place you at a site away from your base hospital. You should therefore be prepared to travel, which can sometimes be quite a distance away.
Application deadlines are usually several months in advance of the exam itself, so it is imperative to check ahead of time so you do not miss out on your desired date. You should check the current fees directly on the [RCP website] (https://www.mrcpuk.org/mrcpuk-examinations/paces/exam-dates-and-fees) as it may be subject to change.
Results and unsuccessful attempts
Results are published online, 15 working days after the last exam within the diet. The results release dates are available on the Royal College of Physicians website, so you have an idea of when to expect to hear if your attempt has been successful or not.
In order to pass the MRCP PACES exam successfully, the candidate must:
Obtain a minimum score of 130 out of a possible 172
Not fail any single clinical skill (i.e. a minimum score needs to be achieved for each clinical skill)
It is therefore possible to fail an entire station and still pass PACES if the overall score and each individual clinical skill has been passed.
Your results will be summarised on a matrix provided to you after the exam when results are announced. As you can see in this example matrix below, each encounter is scored, but the overall pass mark is determined by the candidate meeting the minimum mark across each individual clinical skill, plus an overall score of at least 130.
All components of the MRCP diploma must be completed within 7 years of the candidate’s first successful attempt at the MRCP Part 1 examination.
If unsuccessful, candidates are permitted a maximum number of 6 attempts. If the exam has not been passed after 6 attempts, then the candidate will need to be supported in additional training with appropriate evidence before further attempts are allowed.
How to prepare
The PACES revision materials at Quesmed are a great place to start your revision; with over 100 simulated clinical videos of typical encounters you may come across in the exam, as well as a dedicated reference textbook, it is a great place to get a sense of what you may come across and to kick-start your revision.
But PACES is a difficult exam and your approach should be multi-faceted. To help you on your journey, we spoke to some top-performing doctors who completed the MRCP diploma for their tips and tricks when it comes to preparing. Here is what they advised:
Leave plenty of revision time
Ideally, you want to spend at least 6 months preparing for this exam
This will give you plenty of time to not only learn the theory, but also start putting into practice what you have read
Make sure you plan your revision strategy at the start so that you cover everything you need to in the time you have allowed for your revision
Practice makes perfect
Practice, practice, practice!
Practice on real patients that you see on the medical take - approach them as you would a PACES patient by being systematic and thinking, ‘What else would I do if I were to encounter this patient in the exam?’
This allows time spent at work to be effective revision also
But you don’t need to practice on patients alone; patients are a great source of clinical signs but it can be difficult to perfect your systematic, seamless examination skills on hospital patients
Therefore, don’t hesitate to practice on your friends, family, and teddy bears! Getting your examination slick and effortlessly under 6 minutes is all about repetition, and healthy individuals (or teddies!) are a great way of perfecting this
Seek out a PACES teaching group at your local hospital, and if there isn’t one, meet up with your colleagues regularly to go and see relevant patients on the wards
By performing examinations or consultations as part of a group, you will gain confidence in performing in front of others and remaining calm and collected when being observed
Watch Videos
The Quesmed PACES revision tool will allow you to see a lot of the clinical signs and presentations that you will encounter in the exam from home
It also provides a detailed reference textbook, which can help you learn the theory that will underpin your exam performance
Obtaining a subscription to an online revision tool like this will help you take your revision to the next level and allow you to reinforce the signs and presentations you are seeing on real patients in hospital
Don’t neglect the theory
Good practical skills as well as the ability to formulate diagnoses and synthesise management plans depends on a good understanding of the underlying medicine
So, don’t depend on in-hospital learning alone
Find a good PACES textbook and learn the theory as well
Then, put the theory into practice every day at work
Time yourself
Whether that’s through a formal mock test set up at your hospital, or through roping in friends and family - you should practice your skills under the time limits that you will face in the exam
Remember, 6 minutes is a very short time to perform a full examination, and you need to be able to perform the examination effectively with minimal effort or much thought; this is so that you can really focus during the limited time on the clinical signs you are seeing, rather than what the next step would be in your examination
Breaks and health
Remember to take regular breaks and maintain your health
This is a marathon, not a sprint
Seek support from your friends, family, and colleagues at work if you are struggling
Getting ready for exam day
Here are some checklists for you to go through before and on the day of the exam to ensure you are ready for the day!
Before the exam day:
Review the [rules and regulations] (https://www.mrcpuk.org/mrcpuk-examinations/regulations) of the PACES exam
Print and check your admission documents sent to you
Plan your route to the exam centre and ensure you leave plenty of time for transport delays
Ensure your photographic identification is ready to come with you - this needs to be an appropriate ID with your full name, signature, and photograph
Ensure the name on your admission document matches the name on your ID, and contact the RCP if not as soon as possible
Ensure you have leave arranged from your hospital to attend the exam
On the exam day:
Arrive in advance of the exam start time - an hour before the reporting time on your admission document
Be aware that your bags, coats, and devices will have to be stored in a separate room
Make sure you are dressed appropriately in a smart manner as you would for work, in clothes that allow you to move freely to examine patients (avoid tight or excessively flowing clothing)
You can bring your own stethoscope but other equipment will be supplied if required; if you have any other medical equipment with you, you should let the lead examiner know and they can advise whether or not you should take it in with you
Be aware of anything that might make it more difficult for you to demonstrate empathy and understanding in stations that require communication skills, for example a facial veil or dark glasses. If you do not clearly demonstrate these abilities, examiners will mark the corresponding skills as unsatisfactory
References
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