I passed my PACES in the second attempt

I passed my PACES in the second attempt.
Unfortunately, I do not have any golden tips or any shortcuts to suggest to my readers here.
However I would still like to share my experience.

MY PREPARATION - FOR THE FIRST ATTEMPT

I started my PACES preparation when I started my core medical training year 2 in August, 2019. I gave my MRCP 2 two years ago in September, 2016 and as you can expect, my knowledge was very rusty. I knew the basics ( I frequently saw sick patients on the wards and tried my best to act up as a registrar when on call by volunteering to clerk the sickest patients) however my differentials of spastic legs and how to diagnose a case of CIDP in 5 minutes was not something I had come across in my 2.5 years as a SHO ( 1.5 years as a non trainee SHO and 1 year as a core medical trainee year 1).

I decided to attend PACES courses. I attended my deanery based course (free) 8 weeks before my exam and that was an eye opener. However I was a bit discouraged ( the mock examiners thought it would be a good idea to show how horrible we were by giving negative remarks - it did not work well for me or the other candidates. Thankfully, this was fed-back to the appropriate team members and they have now made it much better. Hence, I would recommend that core trainees/IMT trainees attend their deanery based courses which are free).

I also attended a PACES (PACES4U) course in Manchester. It was good and I learnt how to pick up signs on cases I did not see everyday in clinical practice and present them.

Unfortunately, I did not bother working on this later on. A colleague of mine who had passed PACES very kindly practiced station 5 with me by coming an hour early and I did not try to do anything extra ( Ie, stay late, ask consultants to quiz me, to observe my clinical skills).

I learnt my lesson the hard way - I failed my cardiology, neurology stations and failed on picking up clinical signs. I did well in the other domains and other stations as I was familiar with those scenarios which all SHO’s working in the NHS are anyway.

MY EXAM ( FIRST ATTEMPT):

My stations:

Station 2: History taking
15/20
This was a middle aged man who came to the unit with sudden onset visual loss which had completely resolved.
I asked the relevant questions BUT forgot to ask if he had any concerns till 2 minutes were remaining. He had more questions and hence I did not score full marks.

My tips:

  1. ALWAYS ask about concerns
  2. You can easily score full marks in this station therefore practice well. We, especially as SHOs working in the NHS, think that we will ace it WITHOUT any practice however we perform differently when we are on the ward than when we are being observed.

Station 3: Cardio: 8/20
Metallic AVR and MVR . I did not pick up the metallic AVR. Made blunders like " there is a pansystolic murmur" and did not mention the metallic AVR.
Neuro: 4/20
CIDP.
The patient was sitting at the edge of the bed. Common sense dictates that I should have made him walk immediately but I lacked that completely ( as I knew I had messed up in the cardio station). I was so worried about my previous examination that I lost it completely. I spent at least 2 minutes lying the patient on the bed when I could have examined him while he was sitting at the edge of the bed ( and could have verbalized " I would ideally like the patient to lie supine however given the difficulty in moving him, I am going to examine him while he is sitting". ) Of course, I could not complete my examination and all I could say was “This patient has loss of fine touch and pain below L3 and has a glove and stocking distribution”.

According to the feedback, I missed the tracheostomy.

My tips:

  1. You will be waiting outside for 5 minutes. When the bell rings, you will go in and your time starts from the point the bell rings. Every second counts. Please be vigilant. Know where the hand gel is, quickly greet your examiners and start examining the patient after the usual formalities.
  2. Once you are done with cardiology, the bell will ring and you will IMMEDIATELY be taken to the neurology station. There is NO break in between. So be mentally prepared.
  3. Forget what you did in the previous station and DO NOT let it affect your subsequent stations.

Station 4: Communication skills : 16/16
Discussion with a patients daughter about her mother who has been admitted to the stroke unit with a hemorrhagic stroke. The CT shows that it is most likely secondary to hypertension. The patient is also on warfarin however the INR is 1.0 on admission.
If you work as a SHO in the NHS, this is your daily bread and butter. I had worked on the stroke ward in my CT1 and I frequently had such discussions with families.
Communication skills are explained really well in the cases for PACES book.
My tips: This is where your SHO clinical work will come in play. So if you work in the NHS as a SHO, please take this golden opportunity to lead such discussions . If you do not feel uncomfortable, you can start by observing your registrar/consultant and then next time, ask one of them to observe you lead it.

Station 5: This is the most important station in the PACES exam. These are spot diagnosis therefore it is important you know your “rare conditions” which you may not see on the ward.
Station 5 (1):
Interstitial lung disease secondary to scleroderma : 27/28

This went well.
Station 5 (2):
Neurofibromatosis : 24/28
There was a BP measuring apparatus and the feedback I got later on mentioned that I should have checked the BP myself.

Station 1:
Respiratory: left lower lobe bronchiectasis 12/20
I missed crackles and said that the examination was normal. I honestly could not hear anything however the examiner asked me to examine the chest again especially in the left lower lobe.

I was asked about the types of bronchiectasis which I did not know of.

Abdominal: Alcoholic liver disease : 19/20
This was a typical case we see on the wards all the time. You should be able to score full marks on this. Apparently, I missed splenomegaly in this patient however she was very tired ( I was the last candidate and it was a young lady with ascites and I did not prod her a lot in her left upper quadrant because she was a bit uncomfortable)

MY SECOND ATTEMPT (8th June, 2019).

I was very nervous when I found out I had failed my first attempt in December, 2018.

  1. I had not applied for the FastTrack attempt ( this is explained here: https://www.mrcpuk.org/mrcpuk-examinations/paces/mrcpuk-paces-fast-track) . Hence my next attempt would be in June-August

  2. I was about to give my interviews for my ST3 in acute medicine and geriatrics, I was successful in both of them and I was due to start my post as a registrar in August. I would not have been able to work as a registrar UNLESS I passed my PACES.

  3. I had 2 dependents and our visas were expiring in August, 2019. I had already requested an urgent certificate of sponsorship which I received 5 days before my PACES and had to submit my visa application online 2 days before my exam and book my UKVCAS biometrics appointment 2 days after my exam.

  4. If I failed this attempt, I would give it via FastTrack (I had informed the team beforehand) in July, 2019.

  5. If I failed my FastTrack attempt, I would have to reject the ST3 post which had already been offered to me, risk losing my visa ( as I would have not taken the post for which I had applied for) and then applying for a non training post urgently and apply for another visa urgently ( plus 2 dependents)- The financial strain would have been immense.

  6. I was doing locums to save enough money for the visas and additional PACES exam in July in case I failed this attempt. I was working till 3 days before my exam.

As you can see, I had a lot to lose if I failed this exam. So I tried my best to prepare well for it.

MY PREPARATION:

I knew my mistakes. I knew my weakness. I decided to work on them. I made a WhatsApp group with my other colleagues who were planning to give PACES and actively asked consultants to do PACES teaching sessions. I attended at least 5 sessions with consultants who were senior examiners for the PACES exam. I listened to their feedback and then practiced under their supervision again. I timed myself more even when I was on call. I treated each consultation on my on calls like a PACES exam station.

MY PACES EXAM (SECOND ATTEMPT)

Station 1 Cardiology (8/20)
No signs whatsoever. I said that I could not find any positive findings.
Judging by my score I am sure I missed something - I have a feeling there was a scar over the left radial artery but I didn’t want to say anything stupid.

Neurology
Spastic legs (6/20)
The patient was sitting at the edge of the bed. Common sense prevailed this time and I asked him to walk. Then he came back to the bed and lay down himself and was in his knickers hence I didn’t have to waste time asking him to expose his legs.
I was definitely more slick this time and completed the examination on time.
However I missed power - a major blunder however I covered this mistake by saying that i would like to check the power of this patients lower limbs which I missed as soon as the bell rang.
I messed up in the differentials and whether it was upper motor or lower motor neuron lesion but I was bit more confident this time and did not say anything stupid. When they asked me a question I just said " sorry, I do not know ".

Station 2 (20/20) History taking
Take history from a patients relative - elderly gentleman , background prostate CA , now admitted with confusion, drowsiness.
I was on call in AMU for a week just 3 days before my exam and I saw such cases multiple times. Given that I had my exam a few days later , I made sure I explained everything in detail to patients and their relatives whilst taking a history and secretly timed it as well on multiple occasions.

Station 3 Respiratory (18/20)
Lobectomy scar

Abdominal (20/20)
Functioning renal transplant
They asked me about the causes. I said that the most probable cause is diabetes given that this gentleman has finger prick marks. They asked me about other causes. I said hypertension, polycystic kidneys , glomerulonephritis. They asked me the causes of glomerulonephritis. I decided to say " Sorry I do not know" rather than making a blunder because I felt this may not go the right way.

Station 5
Station 5 (1)
-22/28
Dermatomyositis.

This was pretty straightforward however I said this diagnosis quite late.

Station 5 (2) - 27/28
Yound lady with suddent onset vision loss.

SO WHAT DID I DO DIFFERENTLY THE SECOND TIME:

  1. I focused more on clinical presentation skills and picking up signs.

  2. I asked my colleagues in hospital to tell me about cases for paces. I made a WhatsApp group in which all paces candidates pitched in and we used to meet on the ward and practice.

  3. I used the feedback I got from my previous exam to work on my skills. That was very helpful. If you fail , ask for feedback.

  4. I used my time when I was on call to examine patients thoroughly in a timed manner just like in the paces exam.

  5. I also asked the post taking consultant to discuss these cases I clerked in just like I would do in the exam. This way I improved my presentation skills.

  6. I practiced with my consultants who are paces examiners. Their input was invaluable. It was difficult getting everyone who was preparing for paces so at times, it was just me and the consultant and their one to one feedback was very helpful. I emailed them myself and cc’d my colleagues into it. I did not wait for others to join as they were busy on the wards. Sometimes they went ahead with their supervised sessions without me when I was busy however I tried my best to attend as many sessions as I could.

  7. I practiced in-front of my colleagues. My CT2 colleague who passed PACES in his CT1 very kindly used to come early in the morning to practice station 5 with me.

  8. I did not attend any course this time. I felt that I would waste valuable time which I could spend on the ward.

  9. I did not go to hospital on weekends or stay in hospital after 6 PM- I made it a point not to compromise my family time with my wife and baby daughter.

WHAT I NOTICED IN THE SECOND ATTEMPT:

  1. I was more confident
  2. I did not make blunders. If I did not know anything I did not say anything as I realized that this exam is not a test of our knowledge but clinical skills and how well we can perform under duress which is basically what a registrar in the NHS does.
  3. It’s all good acting. In order to become a good actor, you’ve to practice.

FAQs:
Does it matter which college I appear from - London, Edinburgh or Glasgow?

No. It does not. And if someone suggests that one of these is difficult and one is hard, then you should not listen to them for any further advice.

Why are there 3 colleges then?

Their are a lot of PACES candidates and there is a lot of work which goes into it. There are external examiners as well as internal examiners. They need to make sure that the candidates have not attended any courses or worked at the hospital their PACES exam is based at. They also need to make sure that they have a good cohort of patients, back up patients and make arrangements for the exam day. One center cannot do this on its own and hence this why the PACES exam has 3 major centers which help coordinate the exams.

What books should I use?

Remember, this is not an exam of your knowledge but clinical judgement. The only book I used was cases for PACES which is available here:
https://www.amazon.co.uk/Cases-PACES-Stephen-Hoole/dp/1118983572

What other resources did you use?

PACES podcasts here: https://soundcloud.com/mededleeds

And these: https://drpodcast.co.uk/collections/medicine-podcasts

During my first attempt:
https://www.pastest.com/mrcp-2-paces/online-revision/

I did not resubscribe to this again for my second attempt as I had made notes on my CASES for PACES book and made notes on examination steps.

Multiple MRCP groups on Facebook:https://www.facebook.com/search/top/?q=mrcp%20paces&epa=SEARCH_BOX

UCD medicine neurology videos:

MRCP PACES videos on You-tube

I have heard the examiners do not want to pass certain individuals.
This is completely wrong. I failed the first time because I was deficient in picking up clinical signs. The marking was very fair. The second time, I felt I did not do too well however the people who assessed me in hospital during practice sessions stated that I made a marked improvement.

Did you have a study partner?

No, I did not. I had a PACES WhatsApp group and we met just thrice:
Twice with consultants, once at 8 AM to practice under supervision of our colleague who had passed his PACES a few months ago.

How were the sessions with the consultants?

These were the most useful. They were PACES examiners and although I examined patients under their supervision 4 times ( twice with my colleagues and twice alone as my colleagues were busy on their respective wards).

They gave very useful feedback. I worked on that and had the opportunity to present to them again.

So you attended just 4 sessions? How is that possible?

This is not it. I practiced when I was on call - and I was on call a lot. I presented my clerked cases to the post take consultant, examined patients and did a full consultant like station 5 in timed conditions when I was clerking patients and most important of all - I practiced the MRCP PACES sample scenarios here:

https://www.mrcpuk.org/mrcpuk-examinations/paces/sample-scenarios with my wife at home.

How did you practice with your spouse?

I used to time my examinations and do all systems, each in 6 minutes. Then I used to check my examination notes ( from PasTest videos) to ensure I did not miss anything and repeat the examination till I was perfect. My wife, who is a doctor as well ( but currently not working) gave me feedback and soon, she was as good a PACES examiner as any of my consultants as she had observed me multiple times.

I also practiced the MRCP sample scenarios with her. She acted them all out and then marked me like an examiner.

This helped me alot.

What PACES courses should I attend?

If you are a trainee ( CMT/IMT) then your deanery will offer you a free course in your deanery. You must attend that. Also, one of the mandatory training days includes PACES sessions so that is very useful to attend.

What about paid ones?

You will not be funded for these courses. Other than travel/accommodation. Please confirm this with your study budget officer as this varies from trust to trust.

I attended the Manchester PACES4U course because my colleague attended it and passed it in the first attempt ( although I failed), it was cheaper and closer to my home town.

All the courses are good as long as you have a good preparation for the exam. Do not go half prepared because you will be overwhelmed otherwise. It is best to attend it 4 -6 weeks before your exam so that you can work hard on the feedback given to you. The rule that " the more expensive it is, the better it is" does not apply to paid PACES courses.

Should I take study leave before the exam?

I took 5 days off before my first attempt. I wasted 4 of them just getting tense at home.

I took 3 days off before my second attempt. My exam was on Saturday.

I was on back to back on calls till Tuesday.

We had to go to another city on Wednesday to meet estate agents the whole day to look for a new accommodation for my ST3 post.

My Certificate of sponsorship came 5 days before my PACES exam and I spent the whole evening applying for my and my dependents’ visa and trying to figure out the complicated UKVCAS system.

So I actually had 2 days of proper leave before my exam and had to drive 3 hours on the day before my exam to the center.

My honest advice would be to do as many on calls as you can ( provided you can follow my method of practicing on patients you clerk) and do not take more then 3 days off before the exam. However every person is different. You know yourself the best.
You cannot possibly prepare anything in the last 3 days other than revise what you have been working on over the past few weeks - months.

STUDY LEAVE:
Please book your study leave as soon as you get your exam date.

Book PACES courses well in advance as their slots run out a few weeks in advance.

Remember - accommodation/ travel/meals are reimbursed so talk to your study budget officer and deanery about this. Ideally, it should be funded by them. All you have to do is pay for the course and the exam.

TRAVELLING:
Travel one day in advance to wherever your exam is. Leave at around 3 PM to avoid the 5 PM -6 PM rush hour.

Drive to the examination center first. It is usually in the medical education center or outpatients department of the hospital. This way, you will know how to get there and where to park when you go to the exam center the following day

Stay in a nice hotel ( Holiday inn, Premier Inn ) which has comfortable beds, breakfast in the hotel/BnB and is secure. Make sure that you request a quiet room.

Have a nice meal the night before and try to get into bed by 8 PM. Avoid studying at that point ( although in all fairness, I did practice all of my examination stations on my trusty pillow the night before my exam in 30 min - 6 min per system- cardio, cranial nerves, upper limb, lower limb, resp, abdomen).

THE EXAM DAY

Wake up early and have a full breakfast. I personally love the breakfast served at hotels and BnB’s. You SHOULD NOT open your books. You have done everything.

Remember to check out and take everything with you. Drive to the exam hall (remember to pay for parking- This is not your own trust where your parking permit will work) and again, DO NOT open your books.

The team will have a look at your documents ( remember to print out and sign your admission document), check your ID ( remember to take your passport/ relevant ID documents mentioned on the RCP website) and then the lead examiner will come.

(S)he will try to relax you by getting to know you - your names, grades, where you work and how you have travelled. This allows the candidates to de-stress a bit and get to know each other as well.

Visit the toilet before your exam starts.

THE EXAM:
As explained above, it is pretty straightforward.
I will explain some important points which I wished I knew before my first attempt:

  1. You will NOT be given any time between cardio and CNS, station 5(1) and station 5 (2), respiratory and abdomen.
    So you will not have time to give yourself a pep-talk between these stations. So if you, like my first attempt mess up in cardio, you will be shunted immediately to neurology ( so be prepared to forget about everything in that 5 second walk from cardio to neuro station).

  2. When you are waiting;
    Outside the examination stations, revise your steps again. This will help you forget the previous stations.

Outside communications, history and station 5, you will be given a piece of paper. Write your whole plan on it. Questions to ask, D/Ds, important points, and also “ASK ABOUT CONCERNS” in capital letters.

  1. You will not have time between the 2 station 5 sessions therefore use the 5 minutes you have outside the examination station to jot down steps of BOTH stations.

AFTER THE EXAM:
Avoid discussing cases with your fellow candidates as they change cases from candidate to candidate in the same session - ie they may have 2 cardio cases and they swap them around in the same session.

If you are driving back and feel you need a break, do not get in the car and drive onto the motorway. Give yourself a break. Call your friends or family. Vent it all out, you will get loads of support and will make you feel better - and a safer driver.

RESULT DAY:
The results come out after 10 working days. Try not to think about this as you should enjoy this time. The results come at any time from 10 AM to midnight UK time on the 10th working day.

WHAT THIS EXAM TAUGHT ME:
I still may not be able to diagnose HOCM, CIDP, MS in 5 minutes. However I have learnt how to communicate well to patients, their relatives. I have also learnt how to examine patients in a focused manner and make a management plan based on a few differentials I have in mind. I have learnt picking up important clinical signs without investigations which can change the management plan of the patient- which the on call medical registrar may have to do when (s)he is asked to see a patient in RESUS. Overall, this exam has definitely made me a better doctor.

However, the most important thing I have learnt is managing my stress. staying calm in the most tense moments and using my judgement to manage a patient. It has prepared me for that day as a consultant when a loved one is unwell, I have to attend court for a legal proceeding, I have a long clinic list to manage and my ward is understaffed. It has prepared me to deal with being a good doctor, and most importantly a good human being when things go south.

It has humbled me - as doctors, we think we cannot fail. We try to provide the best care possible to our patients and strive for excellence, at the cost of our own sanity and compromise our family time. This exam made me think that life is not all about that. It is about balance. It is about not being a good doctor, but being a good father, a good husband and a good friend. I have had a few stressful and emotional moments during this journey but at the end, it has changed me. I hope that I am not only a better doctor but a better human being now.

THIS POST IS DEDICATED TO:

My wife, Tayyaba Aizaz who heard “lets practice stations” everyday at 7PM after I came home and despite being completely worn out after spending the day with a one year old , never said no.

My baby, Meesha - my study partner who tried her very best to eat my cases for PACES book. You are very young now. But if you read this if I am not here, you are the only reason that made me NOT give up. You were the light at the end of the tunnel, not only for me but for your mum who put up with my stresses.
The people who went out of their way to practice stations with me , stayed till late and believed in me. Despite making blunders, they kept me going by assuring me that were there and had done that.

My amazing consultants- from Wexham Park Hospital, Slough , Harrogate Hospital and York Hospital who not only taught me to become a good doctor, but made me a better human being. Your advice and support has been invaluable. I will never forget the day I walked into the renal ward after failing my exam and a consultant asked the other consultants if they passed in the first attempt - none of them raised their hand. Second attempt? One raised his hand. Three attempts? 2 raised their hands. 3 attempts? 1 raised her hand. Fourth attempt? The best consultant ( who is also my mentor) raised her hand - You guys kept me going.

All the registrars I have worked with - Thank you for letting me see sick patients, supervising me and telling me that it will all be okay.

To my lovely FY1s, nurses, ward clerks and HCA’s whose support has been amazing throughout - Your small reassurances like " Naaa, you will do it. If you do not pass, who will" helped me alot.

And last but not least,

My parents - who have dealt with my dramas throughout my life and know more about me than I know about myself.

MY PLAN TO HELP:
How can I not help. I am planning to arrange FREE PACES sessions in York Hospital and then in Scarborough Hospital ( where I will start in August). I plan to find a few good patients, a consultant who is a current PACES examiner and then let him/her supervise you and then I will try my best to give you one to one advice.
If you are interested, please contact me via Facebook: https://www.facebook.com/omar.ay.37

The only pre-requisite for this is that the doctor should be working in NHS and should be able to provide his/her GMC number, job details to me when I request them from you.

TO THE READER,
This exam is not only a test of knowledge and skills but is a major test of nerves. For many people whom I know, this exam came at a point of their lives and careers when there were a lot of life changing events going around them. At the end of the day, each person is unique and has his/her own strengthens and weaknesses. What affects one person in one way might not affect someone else the same way. It is about finding what works for you, what your strengths are and channeling them in such a way that they get you through this. This teaches you to deal with tough situations outside your work-life as well and teaches you more about yourself.

Remember, if I could do it so can you. And those who know me, know that I am no genius but I keep trying till it works out.

Best of luck and please share your experience once you pass.