Changes to PACES: Information for examiners, July 2009
PACES was introduced in 2001 and the basic format has been highly successful with over 30,000 candidates sitting the examination worldwide. Much of PACES will remain the same, however from October 2009, significant changes were made to the examination worldwide.
The main changes are:
- the name, content and structure of Station 5
- the marking system
Please note that the overall standard of the examination will remain the same; that is, the examination overall will be no harder or easier to pass.
New Station 5: Integrated Clinical Assessment
The new Integrated Clinical Assessment station will assess the way in which candidates approach a clinical problem in an integrated manner, using history taking, examination, and communication with a patient or a surrogate patient. It will reflect the way in which clinical problems are considered in the ward, emergency medical admissions unit, or medical outpatient clinic in normal clinical practice.
There will be two cases in this 20 minute station – each lasting 10 minutes (each case will be known as a ‘Brief Clinical Consultation’).
The way in which candidates approach this station will be very different to the formal examination of systems at Stations 1 and 3, and very different to the structured and comprehensive history taking and communication exercise at Stations 2 and 4.
Candidates will aim to elicit sufficient history to make an assessment of the problem presented and will carry out an examination that is relevant to assessing the problem presented. The history taking and the examination are not intended to be comprehensive – this station is not a “long case” nor is it a full outpatient consultation.
Candidates will have 8 minutes to take a focussed history, carry out a relevant examination, and respond to the patient’s concerns. During the remaining 2 minutes, an examiner will ask the candidate to describe the positive physical findings and to give a preferred diagnosis and any differential diagnosis. Candidates will always be given the full 8 minutes with each of their patients at Station 5 and the examiners will not begin their 2 minute discussion until the 8 minutes have elapsed. Candidates undertake two 10 minute encounters in the Station.
It is NOT necessary, nor would it be possible for candidates to undertake a complete history or comprehensive examination in the available time. The aim of the encounters is to allow candidates to show that they can focus on the most important parts of history and examination when posed with a clinical problem. In addition, the candidate will be expected to explain their management plan succinctly to the patient and answer any questions they might have.
It is important to note that candidates may examine the patient and take aspects of the history in any order, or concurrently. For example, where the patient complains of a physical abnormality, they may wish to examine affected areas while asking the patient about relevant history.
The cases presented to candidates will all offer a clinical problem relevant to general or acute medicine that can be addressed in an 8 minute consultation. They may be skin, locomotor, endocrine, or eye problems as found in the previous Station 5, but the cases would be presented as clinical problems that can be assessed from history and examination, and with the requirement to respond to the patient’s concerns. The cases may also comprise clinical problems encountered by trainee physicians in routine hospital medical practice and contained in the Curriculum for General and Acute Medicine (available on the JRCPTB website in the UK).
Examination of the optic fundus will still be required in some encounters. Patients with problems relating to disciplines or areas less commonly represented in the current examination, for example acute medicine, haematology, infectious disease and elderly medicine, may now also be encountered.
These changes are summarised in the table below:
| Total Station Duration |
20 minutes |
20 minutes |
| Number of Patient Encounters |
4, each of 5 minutes |
2, each of 10 minutes |
| Focus of Assessment |
Examination and Diagnosis |
Focused History, Relevant Examination, Problem Solving and Communication |
| System of Content |
Limited to Dermatology, Endocrinology, Rheumatology and Opthalmology |
Any System |
| Time with Patient |
Variable |
8 minutes per encounter |
Please refer to the
Examination Format page for more information.
The New Marking System
Candidates are now marked explicitly on between four and seven separate clinical skills at each encounter, as described below:
| |
Clinical Skill |
Skill Descriptor |
|
A |
Physical Examination |
Demonstrate correct, thorough, systematic, (or focused in Station 5 encounters), appropriate, fluent, and professional technique of physical examination. |
|
B |
Identifying Physical Signs |
Identify physical signs correctly, and not find physical signs that are not present. |
|
C |
Clinical Communication |
Elicit a clinical history relevant to the patient’s complaints, in a systematic, thorough (or focused in Station 5 encounters), fluent and professional manner. |
|
D |
Differential Diagnosis |
Create a sensible differential diagnosis for a patient that the candidate has personally clinically assessed. |
|
E |
Clinical Judgement |
Select or negotiate a sensible and appropriate management plan for a patient, relative or clinical situation. Select appropriate investigations or treatments for a patient that the candidate has personally clinically assessed. Apply clinical knowledge, including knowledge of law and ethics, to the case. |
|
F |
Managing Patients' Concerns |
Seek, detect, acknowledge and address patients’ or relatives’ concerns. Listen to a patient or relative, confirm their understanding of the matter under discussion and demonstrate empathy. |
Different numbers and combinations of the skills are assessed at each encounter, as per the table below:
| 1 |
Respiratory |
A:B:D:E:G |
| 1 |
Abdomen |
A:B:E:D:G |
| 2 |
History |
C:D:E:F:G |
| 3 |
Cardiovascular |
A:B:D:E:G |
| 3 |
Nervous System |
A:B:D:E:G |
| 4 |
Communication |
C:E:F:G |
| 5 |
New Station 5 (1) |
All seven |
The current four-point marking scale will be replaced with a three-point scale of Unsatisfactory (0 marks), Borderline (1 mark) and Satisfactory (2 marks). Examiners are no longer required to award an overall judgment mark for the candidate’s overall performance at each encounter, but simply to mark each separate skill on the new three-point scale. The marks given for each of the new skills contribute directly to the total score.
The pass mark will be defined by a formal standard setting process that will also take close account of the historical PACES pass standard.
A video and supporting information for PACES examiners is available here.