How I passed my PACES first time with 168/172
Insight into my actual exam (Stations 2 & 4)
It had already been a gruel up to the show day. It’s funny how weeks of hard work rests upon a mere three hours and a small selection from a large set of cases you prepped from.
My examination centre was in Stockport in the southern suburbs of Manchester. My exam was on a Saturday afternoon, but I travelled up the day before. No chance I was going to rely on trains to get from Surrey to Manchester on the morning my exam. It would have been a stressful trek.
I was actually looking forward to going up to Stockport. One of my closest friends from university lived there so for me it was a bit of a reunion. I spent the evening having a relaxing evening catching up and having Nandos with an early night – slept for nearly 10 hours before the exam date! I wanted to switch off from prep completely. But this is a very personality trait thing. Even throughout school, I had never been the person who would revise up till you enter the examination hall. I always stopped working by the evening before the exam to have a bath, relax or paint.
I booked accommodation for two nights even through strictly could have done with one. I didn’t want the hassle of packing and checking out and taking all my things with me to the exam centre but some candidates did turn up with their cabin bags so took an extent its a personal choice. For me, the less stress in my environment, the more relaxed I would be in the real exam thing. And in my candidate instruction it mentioned that limited place will be available at the examination centre to store personal belongings so I didn’t want too much.
On Arrival to the Exam Centre
My lovely taxi driver helped me find the exact wing where the exam was and dropped me right outside which saved me from walking laps of the hospital ground. I was the first one to arrive, but not by a lot. I was clearly on edge but staff were very friendly. We had to arrive by 12pm but the exam was not due to start until 13:15 and I found the timings a bit awkward food wise. It was a bit too early to have lunch but you definitely needed to eat something as the exam wouldn’t finish until 5pm. Many of the candidates’ brought sandwiches which they had after arriving at the centre.
They briefed us on how the station would be run, how they would work the bells to allow donning and doffing times but really all of it went over my head. Turns out they were so good with walking us through the station carousels during the exam and guided as to what to do when (like when to start reading the candidate instructions, when to go in etc) it didn’t really matter that a lot of the briefing instructions at the start didn’t register. They also gave us our marksheets which we had to fill out – the old school striking through numbers to indicate your candidate number which took my right back to GCSE MCQs.
They told us which station we would be starting on and the order with which we would be doin them, It was written down a sheet of paper not he clipboard they gave us so you didn’t need to memorise this order. The Edinburgh College does 6 stations with one being the rest station. I started on Station 4 (Communications) which I was most nervous about as that’s the one I did the worst on in my mocks the week before so was glad it would be out of the way first. So let me take you through my PACES Carousel with stations in the order that I did them.
My PACES Carousel
Station 4: Communications (16/16)
20 minute station: 14 minute patient/actor interaction, 1 minute reflection, 5 minute for viva
My first Station with Communication Skills. This station lasted 20 minutes, where 14 minutes were allocated to the candidate-patient interaction, 1 minute for reflection and 5 minutes for examiner questions.
My case scenario was a young 40-year-old patient who was having intermittent chest pains. She had all the relevant cardiac investigations completed including stress echocardiogram which did not show any cardiac cause of her chest pains. The candidate’s task was to reassure the patient that no further cardiology investigations were necessary. Overall, the patient was reasonable. She wasn’t angry or demanding but she was very scared and anxious, and she wanted to make sure that absolutely nothing else needed to be done. I started off by taking a very brief history (not more than 1-2 minutes) of her chest pain which revealed that the pain was unlikely to be cardiac (right-sided intermittent, sharp. No radiation to left arm or jaw, no nausea or clamminess). I then explored what her main concerns were to guide the rest of the consultation, in particularly trying to understand why she was worried about the heart. She had a strong family history of ischaemic heart disease, including her sister who had a myocardial infarction young at the age of 50. I then went on to reassure saying based on the type of chest pain she has and the investigations, it is extremely unlikely that her chest pain is coming from the heart. I also highlighted the sensitivity of the stress echocardiogram and said she had a special investigation to see if her heart showed any signs of compromise when put under a pressure and this was also normal which is very reassuring to us as in the medical team. She asked if other investigations can be done, and I said we do have more invasive investigations like angiograms but the risks of these outweigh benefits in her case and will not add anything extra to what we know already. I offered her a second opinion from another consultant if she still wants not sure. I acknowledged her concerns given her family history and agreed with her that she is a high-risk patient. I mentioned the signs to look out for her when chest pain is cardiac (central/left sided, radiation, nausea, clamminess) and take herself to ED immediately if this occurs. I gave general lifestyle advise to improve her risk profile for heart disease and the importance of regular cholesterol/triglyceride and diabetes screen with the GP. I concluded by asking her to summarise what we said so far, offered her another opportunity to express any concerns and ask any questions.
The 1 minute for reflection may as well have not existed because it went by so quickly. The questions which followed included?
- What do you think the patient’s main concerns were?
- Are you sure you elicited all her concerns? – I thought this was odd and I panicked a little bit thinking I missed some things. In the end I stuck to my guts and said something along the lines that I have multiple opportunities for the patient to express her concerns and I do believe her main concern was of having a heart attacking view of her family was history. I thought I was repeated myself in the question
- What were the main ethical principles? – I mentioned autonomy (patient’s choice on her medical treatment), Beneficence (doing good for her to make sure she has the right investigations given her high risk of cardiac heart disease state), Non-maleficence (not doing harm from invasive investigations which are unlikely to benefit) and Justice (taking up an angiogram slot when someone else may have a greater clinical need) are all applicable to this scenario.
- The next part if a but fuzzy, but the examiners asked something along the lines how much weight should be given to patient choice. And I said patients are not allowed to request treatment but are allowed to refuse it provided they have capacity. Then he asked my question on how you assess capacity. I replied saying capacity assessment has two sections the first one assessing patient’s general cognition and any background of dementia and second whether the patient can understand, retains, weigh up information and communicate their decision back to you. To this, he asked do patients with dementia not have capacity then? I mentioned capacity is decision and time specific – for example, patient with dementia may have capacity for certain decisions like consenting to blood tests but not on making decision regarding their discharge destination.
Rest Station
The Edinburgh College PACES examinations included a rest station. I was quite relived by most nightmare station – Communications skills was over without having to face an angry station. I spend my time filling out some numbers on PACES exam sheets (I had only crossed off my candidate numbers and didn’t realise I also had to write it in at the top). I had a loo break and some water and the PACES Volunteer doctor manning the rest station was like a personal cheerleader and kept saying you’ll be fine, you’ll be fine. He said just don’t carry on thinking of what you did on one station to the next as that’s what happened in his own PACES when he did it. It was nice to have someone to chat to in the rest station, made the time go by a bit quicker.
Station 2: History Taking (20/20)
20 minute station: 14 minute for history taking, 1 minute for reflection, 5 minutes for viva
My next station was that I was in a general medical clinic and a young 35-year-old woman presented with painful hands. She was recently started on citalopram from her GP. Her observations were all stable. I spent the 5 minutes allocated before the station trying to come up as many differentials as possible for painful hands and then tailor the questions I would ask. The top three differentials I came up with were – Rheumatoid arthritis, SLE and Raynaud’s phenomenon. Before I went in, I had already made a plan that I would be asking questions about pain in her hands, where specifically was it, which joints were affected, was it a symmetrical or asymmetrical pattern. I also planned to ask if the pain/stiffness was worse in the morning to investigate inflammatory types of pain and if she ever noted her hands changing colour from white to blue to red. I was going to explore impact on quality of life and any associated features (e.g. shortness of breath, uveitis, fever, photosensitive rashes).
The patient itself had a classic history of joint stiffness which was worse in the mornings and improved as the day went on. She had an associated rash on face and arms which was possibly photophobic as it only came on during a hiking holiday. It had a significant impact on her life as she had two sons for whom she had to get ready first thing in the morning and it was taking her a lot longer to do simple things. She had a recent bereavement in the family, and everything was contributing to her low mood but she was optimistic that if her pain and stiffness are better she could improve. I went through generally on past medical history, family history, drug and social history. I then explained that I thought there was an inflammatory process which was causing her pain and stiffness. I said this may possibly be rheumatoid arthritis or SLE and if she had heard anything about those. I explained that a confirmed diagnosis would require further special blood tests and X-rays of the joints affected. I said we will refer her onwards to be seen by a rheumatologist.
I believe the patient helped me out a bit here. There were only two minutes remaining and I asked her to summarise what she understood and the next steps of management which she quickly did but asked other very important questions like what I will do in the meantime for her symptoms before she said the rheumatologists and I mentioned I will give her painkillers pending specialist review (things I should have said without patient prompt). I ended the consultation asking her if she had further questions to which she thankfully said no because by then I was out of time to answer any.
I thought I would have plenty of time to what seemed like a straightforward history (and it wasn’t too bad) but I was running out towards the end and there were other things I should have said with respect to patient management which only became evident to me when the examiner started asking questions. They didn’t seem to penalise me though as I was able to answer them in the viva section.
She didn’t go through asking me for my differentials, possibly because I had already explained those during the history. She asked me how I would manage the patient – I explained I would like to do a full examination of the hands, including eyes, skin, heart and chest. She asked me what blood tests I was referring to when I spoke to the patient, and I went through those – FBC (sign if chronic disease, WBC to rule out infection), Acute phase reactants (CRP, ESR), Auto antibodies (RF and anti-CCP for Rheumatoid arthritis, Connective tissue disease screen including ANA, Anti-dsDNA for SLE) and finally baseline renal and liver function tests as the treatments for these drugs given can affect these. I asked for X-rays of affected joints looking for changes associated with RA such as loss of joint space and periosteal swelling. Finally, I said early referral to Rheumatology to commence DMARDs is now recommended if it is RA. She asked me what else would you do for the patient, and I mumbled some nonsense of exploring into her mood and if she is coping. But then she directly asked me what advice would you have given to her about her rash at which point I said I should have advised her to stay away from the sun, wear covered clothing and apply sunscreens and use large hats when going out wherever possible.