The examiner's view about PACES

Dr Neil Dewhurst is an experienced examiner for MRCP:

"Most UK candidates will be on an SHO rotation and after eighteen months should be able to get through MRCP. Some do part 1 after house jobs, but the fastest to the final clinical is two and a half years. We are looking at a doctor of that vintage."

"Station 1 is on the respiratory system and abdomen. There is an introductory spiel like, `This 44 year old man gives a three month history of progressively worsening shortness of breath.' Just as in real life, there might be patients without physical signs. At six minutes candidates are warned that there is one minute left, then they are asked to present findings and discuss management and investigations. At the end of ten minutes, candidates move to a patient with abdominal problems.

"The candidate has five minutes outside station 2, on history taking. They read a general practitioner's letter, for example, `Dear Dr X, I'm very concerned about this patient who has had an increase in bowel motion and is passing blood.' They carry out a task in the letter, like `give your opinion.' At 14 minutes the patient leaves, the candidate has a minute to reflect and examiners ask questions.

"Then the candidate goes to station 3 and faces a 10 minute examination of a patient with a cardiovascular problem and 10 minutes with a patient with a neurological problem.

"Station 4 is the communication station. It may be breaking bad news, explaining a procedure to a patient or relative, explaining withdrawal of feeding or a decision not to resuscitate. My colleagues and I vet scenarios before they are used. We rehearse scenarios with simulated patients and agree what a doctor should do. We are trying to replicate real life.

"The last station includes other systems: eyes, skin, and locomotion. Candidates are asked what they find, how they would investigate and manage, so it is more than just a spot diagnosis.

"Candidates fail because they have poor examination technique or poor history taking skills. Others are unable to interpret findings to put together a differential diagnosis. Increasingly young doctors are aware that revision courses only tell you about exam method, and that application and interpretation of physical signs comes from experience.

"My advice to candidates is to be as experienced as you can. Go back to day one of medical training and read a clinical methods book. Appreciate the applied physiology. Understand what physical signs mean. A lot of junior doctors are poor at analysing them. Be observed in your clinical method by a senior doctor prepared to compliment or criticise. Courses can't provide that but the consultant on your post take ward round can."

BMJ Career Focus 2004;328:155-156