PACES Station 5: Our guide to the new exam

By Hannah Brown in MRCP PACES on Monday, August 10, 2009 @ 11:56

Changes to PACES station 5 has caused all manner of problems in the run up to its full introduction for the October 2009 diet.  Exams in June were massively oversubscribed as candidates wanted a last go at the old exam, and the Royal College of Physicians have even added an extra exam in August for some of the surplus candidates.

I’ve said it before on the blog, and I’ll say it again – stop panicking!  One of the principals behind the new station 5 (and this was certainly the experience of the pilot candidates) is that it’s as close to an actual consultation as you’ll get.  You’re only using skills, knowledge and technique that you use day in, day out, and all you need to do is know the rules to the game.

1. Watch the time

As with all the other stations plan your approach to the station keeping a close eye on the time.  You will see two cases, and will have a total of ten minutes for each.  Your examination and history taking (in any order) and the discussion with the patient regarding their treatment and management should take eight minutes, leaving two minutes to talk to the examiner. 

2. Don’t try to cover everything

With the best will in the world there is no way that you’ll be able to complete a full history and examination in eight minutes.  Don’t get bogged down by anything, and you can even try taking the history whilst you exam – but this might need some practicing beforehand as it’s easy to get distracted from what the patient is saying when you’re concentrating on the physical examination.  As long as you can show you arrived at your diagnosis after a logical, chronological thought process then you won’t need (and indeed won’t have time for) a step by step examination and complete history.

3. Remember the patient

Whilst you’re getting carried away with your whistle stop examination and history don’t forget the patient.  Rushing can make you clumsy, and ‘roughness’ will lose you a huge amount of points.  You also need to make sure that you leave enough time to discuss with the patient any further investigations or treatment, and it’s good practice to check that they understand – don’t leave this until the last ten seconds of the time allowed and rush it out like an afterthought, because you won’t have any time to answer the patient’s questions.  Questions the patient might ask include those about the prognosis, and treatment modalities such as: do I need surgery, how serious is the problem, is that inherited etc etc.  Your answers should be brief and concise.

4. Pre-empt the examiners

When you’re performing the examination and taking the history think about the signposting symptoms you identify, and what the differential diagnoses could be, and then you’ll be ready for the examiners’ questions when they come. 

5. Don’t skip ophthalmology

Yes, you might not have to perform a fundoscopy, but if you do have to, and you can’t do it competently, then you’ll lose far more marks in the new style station five than you would have done previously – it’s not worth taking that risk.

6. Don’t try to predict the cases you ‘might’ see and revise accordingly

According to the RCP you can be examined on cases from anywhere in the syllabus and every specialty.  This sounds daunting, but it really isn’t the case.  Revise exactly as you would have done for the old station 5, covering rheumatology, dermatology, endocrinology and ophthalmology, everything else that might crop up you’ll be revising as you work your way through the other specialties.

7. If you can’t find anything wrong with the patient, you haven’t failed

It may well be that the patient doesn’t have any abnormal signs and isn’t in fact ill.  Exam centres book patients weeks in advance, and occasionally their symptoms have dissipated before the exam day.  Tell the examiner you couldn’t find any abnormal signs, and tell them what you looked for.  Don’t get so flustered and run out of time that you don’t have time to talk to the patient about your findings (or lack thereof!).  The ‘patient’ may well be an actor, with no clinical signs, so listen very carefully to what they’re telling you.

8. Practise your amateur dramatics

Think back to your driving test and the over-exaggerated way you had to check your mirrors so the examiner knew you were doing it.  Station 5 needs a little bit of this too – you need to be seen to be actively looking for (before you ask – see below) drug and observation charts, as they might be on the bedside table or at the end of the bed – if you can find them without asking then it shows good observation skills.

9. Talk to the examiners if you need to

Examiners are there to help, no matter how intimidating they may seem.  If you need something that would normally be available to you in a clinical setting, such as blood pressure monitors or observation charts, ask them.  They’ll provide you with the equipment, the stats or tell you it’s not available.  Either way, you’ll get credit for asking.

Station 5 is the only station that needs you to display all seven clinical skills: physical examination, identifying physical signs, clinical communication, differential diagnosis, clinical judgement, managing patients’ concerns and maintaining patient welfare, but really they’re all things you should be doing as a matter of course.  Getting into good habits is key, and read as much as you can from the RCP about the new station is essential.  Already there’s a list of FAQs, which include a link to the ‘top 20 symptoms’ from the new curricula – definitely worth reading up on and then doing some revision around each of these.  The candidate videos are also a great resource, but remember to download them to your computer or otherwise you’ll only be able to view them twice.

Station 5 is all about practice, and making sure that you’re comfortable with the timings and the format.  Forget that it’s a new part of the exam, and concentrate on your examination technique and background knowledge – the rest should come naturally.  Good luck!