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The way I see it

The new MRCP PACES station 5

Authors: Gautam Mehta, Bilal Iqbal 

Publication date:  11 Aug 2010


Gautam Mehta and Bilal Iqbal talk you through changes to the membership of the Royal College of Physicians exam

Patient safety and quality in health care are at the heart of developments in postgraduate medical education. These principles are echoed in the recent changes to the part 2 clinical examination (PACES) component of the membership of the Royal College of Physicians (MRCP).

Modernising Medical Careers emphasised competency based training and workplace based assessment, recognising that knowledge and clinical skills do not necessarily relate to doctors’ complex behaviours and interactions in everyday practice.

Alongside these changes to medical training, the MRCP clinical examination has evolved into a broad and detailed assessment of clinical performance and professionalism. The MRCP PACES examination was introduced in 2001 and is made up of five stations: station 1 (respiratory and abdominal system); station 2 (history taking skills); station 3 (cardiovascular and central nervous system); station 4 (communication skills); and station 5 (skin, eye, locomotor, and endocrine systems). In October 2009, the structure of station 5 was changed to the “integrative clinical assessment,” which involves two 10 minute encounters, each known as a “brief clinical consultation.”

Format of the new station 5

The candidate has a brief introductory explanatory referral and then has eight minutes to do a focused history and examination to solve the clinical problem, answer any questions the patient might have, and explain the investigation and management plan to the patient. The remaining two minutes spent with the examiners are to relate the findings and differential diagnosis and to provide an outline of the investigation and management plans in greater detail than that given to the patient. The focused history and examination do not necessarily have to be done in a specific order, but should be seen as an opportunity for integrative assessment, as seen on a post-take ward round.

The purpose of this change is to push the boundaries of assessment away from basic knowledge and technique, and towards the higher order skills that define professionalism and performance. Therefore, the new station 5 does not simply assess a candidate’s aptitude with a stethoscope or tendon hammer, or their knowledge of differential diagnoses, but instead considers their global performance as a professional.

Preparation for the new station 5

Although cases for the new station 5 may be drawn from any system, most cases still relate to the old station 5 systems: skin, eyes, endocrine system, and locomotor system. Further common scenarios relate to acute medical problems that have not previously been covered in the exam, such as chest pain, hypotension, deterioration in renal function, haematological problems,and medicine for elderly people.

Remember that time is of the essence, and you are not required to perform a thorough history or examination, or work to a routine. For example, you may take part of the history while examining the patient. The focus is on clinical judgment, so the questions you ask are as important as the breadth of your history. Practice integrating your history and examination into a seven minute window, so that you have an idea of how quickly you have to perform.

Checklist for the new station 5

Candidate information (5 minutes)

Explanatory referrals are provided in the five minute interval before the station.

  • Read the explanatory referrals carefully, and identify the clinical problem(s)

  • Develop a preliminary differential diagnosis based on the limited information available before seeing the patient, which will initially help guide the focused history

Focused history and examination (7 minutes)

The history and examination should not be seen as separate components, where the history is followed by the examination. Instead, both history and examination should be integrated. It is acceptable to take a history, then examine the patient, and then re-focus on the history.

  • The examination of the patient should begin as soon as you set eyes on him or her

  • Look for any obvious signs that may prompt a diagnosis

  • Begin with open questions, centred on the patient’s symptoms

  • Try to refine the differential diagnosis at every stage of the consultation

  • Conclude the history with closed specific questions to further refine the differential diagnosis

  • It is important to establish the patient’s agenda by using communication skills

  • For inpatient scenarios, don’t forget to look at, for example, the observation chart, the drug chart, and the glucose chart

  • If the diagnosis is clear, the examination should be conducted to demonstrate the associated clinical features and answer the current clinical problem

  • If the diagnosis is unclear, the examination should reflect the working differential diagnosis

  • With an integrated approach to assessment, a lot of information can be deduced in the limited time provided with the patient

Feedback to the patient (1 minute)

This is an important part of any clinical encounter, and you will be marked on this component.

  • Explain the diagnosis or differential diagnoses using the techniques of checking and repetition, and avoid the use of jargon

  • Relate these to the patient’s symptoms to help him or her understand

  • Explain your initial plans for further investigation and management, again avoiding jargon

  • Address the patient’s concerns

  • Conclude by checking that the patient understands the information, and ask if there are any other questions

Feedback to the examiner (2 minutes)

  • Summarise the key history and examination findings

  • Provide a diagnosis or differential diagnoses, giving supporting evidence

  • Outline an investigation and management plan (in greater detail than the one given to the patient).

Final advice

Although the new station 5 comprises a fifth of the exam, because of the new marking scheme the station accounts for almost a third of the total marks. This is because the station tests all seven of the core clinical skills, unlike the other stations, which each test between four and five. It is important, however, not to overprepare for this station just because of the allocation of marks—the station is a synthesis of all you have prepared for the other stations. The key is timing, and maintaining professional behaviour throughout.

Competing interests: None declared.

Gautam Mehta specialist registrar in gastroenterologyfellow in medical education  Institute of Hepatology, University College London
Bilal Iqbal specialist registrar in cardiology  Faculty of Medicine, Hammersmith Hospital Campus, Imperial College London

Correspondence to: G Mehta  gautam.mehta@ucl.ac.uk

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