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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
This new edition of An Aid to the MRCP Paces Volume 2: Stations 2 and 4 has been fully revised and updated, and reflects feedback from PACES candidates as to which cases frequently appear in each station.
The cases and scenarios have been written in accordance with the latest examining and marking schemes used for the exam providing an invaluable training and revision aid for all MRCP PACES candidates.
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Table of Contents
Epigraph
Title page
Copyright page
Preface
A short history of An Aid to the MRCP PACES
Introduction
Preparation
History taking
Communication skills and medical ethics
The examination
Section D: History-Taking Skills
Preparation, preparation, preparation
Station 2 History-Taking Skills
Case 1 Abdominal swelling
Candidate information
Patient information
Examiner information
Case 2 Ankle swelling
Candidate information
Patient information
Examiner information
Case 3 Asymptomatic hypertension
Candidate information
Patient information
Examiner information
Case 4 Back pain
Candidate information
Patient information
Examiner information
Case 5 Breathlessness
Candidate information
Patient information
Examiner information
Case 6 Burning of the feet
Candidate information
Patient information
Examiner information
Case 7 Chest pain
Candidate information
Patient information
Examiner information
Case 8 Cold and painful fingers
Candidate information
Patient information
Examiner information
Case 9 Collapse? cause
Candidate information
Patient information
Examiner information
Case 10 Confusion
Candidate information
Patient information
Examiner information
Case 11 Cough
Candidate information
Patient information
Examiner information
Case 12 Diabetic feet
Candidate information
Patient information
Examiner information
Case 13 Difficulty in walking
Candidate information
Patient information
Examiner information
Case 14 Dizziness and feeling faint
Candidate information
Patient information
Examiner information
Case 15 Double vision
Candidate information
Patient information
Examiner information
Case 16 Dysphagia
Candidate information
Patient information
Examiner information
Case 17 Epigastric pain and nausea
Candidate information
Patient information
Examiner information
Case 18 Facial swelling
Candidate information
Patient information
Examiner information
Case 19 Funny turns
Candidate information
Patient information
Examiner information
Case 20 Haemoptysis
Candidate information
Patient information
Examiner information
Case 21 Headache
Candidate information
Patient information
Examiner information
Case 22 Hoarse voice
Candidate information
Patient information
Examiner information
Case 23 Hypercalcaemia
Candidate information
Patient information
Examiner information
Case 24 Hyperlipidaemia
Candidate information
Patient information
Examiner information
Case 25 Jaundice
Candidate information
Patient information
Examiner information
Case 26 Joint pains
Candidate information
Patient information
Examiner information
Case 27 Loin pain
Candidate information
Patient information
Examiner information
Case 28 Loss of weight
Candidate information
Patient information
Examiner information
Case 29 Lower gastrointestinal haemorrhage
Candidate information
Patient information
Examiner information
Case 30 Macrocytic anaemia
Candidate information
Patient information
Examiner information
Case 31 Neck lump
Candidate information
Patient information
Examiner information
Case 32 Painful shins
Candidate information
Patient information
Examiner information
Case 33 Painful shoulders
Candidate information
Patient information
Examiner information
Case 34 Palpitations
Candidate information
Patient information
Examiner information
Case 35 Personality change
Candidate information
Patient information
Examiner information
Case 36 Pins and needles
Candidate information
Patient information
Examiner information
Case 37 Polyuria
Candidate information
Patient information
Examiner information
Case 38 Pruritus
Candidate information
Patient information
Examiner information
Case 39 Purpuric rash
Candidate information
Patient information
Examiner information
Case 40 Pyrexia
Candidate information
Patient information
Examiner information
Case 41 Renal colic and haematuria
Candidate information
Patient information
Examiner information
Case 42 Tiredness
Candidate information
Patient information
Examiner information
Case 43 Tremor
Candidate information
Patient information
Examiner information
Case 44 Visual disturbances
Candidate information
Patient information
Examiner information
Case 45 Vomiting
Candidate information
Patient information
Examiner information
Case 46 Vomiting and forgetfulness
Candidate information
Patient information
Examiner information
Case 47 Weakness of the right arm
Candidate information
Patient information
Examiner information
Case 48 Weight gain
Candidate information
Patient information
Examiner information
Case 49 Weight loss and chronic diarrhoea
Candidate information
Patient information
Examiner information
Case 50 Wheeze
Candidate information
Patient information
Examiner information
Section E: Communication Skills and Ethics
A brief history of the evolution of Station 4
Be prepared for the interview
Remembering who it’s about
Establishing rapport
Pay attention and really listen
Knowing when to be quiet
To touch or not to touch?
Using the right words
Breaking bad news
Being empathic
Being honest
You are not alone
Checking understanding
Ethics
Law
Finally
Station 4 Communication Skills and Ethics
Category 1: Informed Consent
Case 1 Consent for a lumbar puncture
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 2 Consent for oesophagogastroduodenoscopy (OGD)
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 3 Emergency surgery under the principles of ‘best interests’
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 4 A competent patient’s refusal of treatment
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Category 2: Diagnoses and Management Advice
Case 5 Obesity management
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 6 Side-effects of cardiac medication
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 7 Presentation of a first seizure
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 8 Rheumatoid arthritis
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 9 Valvular heart disease in a young woman
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 10 Air travel with chronic obstructive pulmonary disease
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 11 Polypharmacy
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 12 Blood transfusion
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 13 Hormone replacement therapy
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 14 Lifestyle adjustments after a myocardial infarction
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 15 Smoking cessation
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 16 Starting insulin therapy
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 17 Refusal of analgesia
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Category 3: General Clinical Issues
Case 18 Human immunodeficiency virus testing
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 19 Communication of a human immunodeficiency virus-positive result
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 20 New diagnosis of tuberculosis
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 21 Non-compliance with anti-tuberculous treatment
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 22 Multidrug-resistant tuberculosis
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 23 ‘Hospital superbug’ 1 (Clostridium difficile)
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 24 ‘Hospital superbug’ 2 (methicillin-resistant Staphylococcus aureus)
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 25 Assessing suicide risk
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 26 Genetic counselling
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 27 Fitness for anaesthesia/surgery
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/relative may have
Examiner information
Case 28 Screening for prostate cancer
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Category 4: Breaking Bad News
Case 29 Malignancy in a young patient
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 30 A chronic illness
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Category 5: Ethical and Legal Issues
Case 31 A patient with a functional illness
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 32 Brainstem death testing and organ transplantation
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 33 Hospital postmortem
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 34 Coroner’s postmortem
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 35 Do not attempt resuscitation decisions
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 36 Withholding information from patients
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 37 Maintaining patient confidentiality
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 38 Advance care decisions
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 39 Healthcare decisions for a patient who lacks mental capacity
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 40 Care of the vulnerable adult
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 41 Blood transfusion for a Jehovah’s Witness
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 42 Eligibility for major surgery
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 43 Postponement of an investigation
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 44 Clinical error in drug administration
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 45 Fitness to drive
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 46 Limits of treatment in end-stage disease
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 47 Withdrawing treatment
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 48 Enrolling a patient in a clinical trial
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 49 Industrial Injuries Disablement Benefit
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 50 Internet therapy
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 51 Unrelated live donor transplant
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Category 6: Dealing with Difficult Patients/Relatives
Case 52 A patient desperate for a diagnosis
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 53 A missed tumour
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 54 An unhappy inpatient
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 55 Delay in investigation
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 56 A patient wanting to self-discharge
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Category 7: Professional Issues and Communication with Colleagues
Case 57 Major incident exercise
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 58 A struggling team of doctors
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 59 A colleague with hepatitis B infection
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 60 A colleague with a needlestick injury
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 61 The improper doctor
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 62 The incompetent doctor
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 63 The sick doctor
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 64 Consent for medical examination
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 65 Submitting an audit project
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 66 Treating a prisoner
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 67 A violent and abusive patient
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Case 68 Withdrawing treatment in intensive care
Candidate information
Subject/patient/relative information
Thoughts and questions the patient/subject may have
Examiner information
Section F: Experiences, Anecdotes, Tips, Quotations
Section F: Experiences, Anecdotes, Tips, Quotations
Full PACES experiences in the first person (since 2009)
Full PACES experiences in the first person (before 2009)
Additional Station 2 experiences
Additional Station 4 experiences
Invigilators’ diaries – Stations 2 and 4
Some anecdotes from our most recent surveys
Experiences
Anecdotes
Useful tips
Quotations
Additional comments and quotes from candidates
Appendices
1 Website links
2 Abbreviations
Index
MRCP – it teaches more than it tests
‘MRCP; Member of the Royal College of Physicians . . .
They only give that to crowned heads of Europe.’
From The Citadel by A.J. Cronin
One-fifth of the royalties from this book will be donated to the Missionaries of Charity of Mother Teresa of Calcutta.
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Library of Congress Cataloging-in-Publication Data
An aid to the MRCP PACES. – 4th ed. p. ; cm. Aid to the Membership of the Royal College of Physicians Practical Assessment of Clinical Examination Skills includes bibliographical references and index. Summary: “The first volume in this revised suite of the best-selling MRCP PACES revision guides is now fully updated. It reflects both feedback from PACES candidates as to which cases frequently appear in each station. Also taken into account is the new marking system introduced in which the former four-point marking scale has been changed to a three-point scale and candidates are now marked explicitly on between four and seven separate clinical skills”–Provided by publisher. ISBN 978-0-470-65509-2 (v. 1 : pbk. : alk. paper) – ISBN 978-0-470-65518-4 (v. 2 : pbk. : alk. paper) – ISBN 978-1-118-34805-5 (v. 3 : pbk. : alk. paper) I. Wiley-Blackwell (Firm) II. Title: Aid to the Membership of the Royal College of Physicians Practical Assessment of Clinical Examination Skills. [DNLM: 1. Physical Examination–Great Britain–Examination Questions. 2. Ethics, Clinical–Great Britain–Examination Questions. WB 18.2]610.76–dc232012020848
A catalogue record for this book is available from the British Library.
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Cover image: © Wiley-Blackwell
Cover design by Sarah Dickinson
Preface
‘MRCP; Member of the Royal College of Physicians … They only give that to crowned heads of Europe.’*
A Short History of An Aid to the MRCP PACES
‘Remember when you were young, you shone like the sun … ’†
At the beginning of the 1980s, Bob Ryder, an SHO working in South Wales, failed the MRCP short cases three times.‡ On each occasion I passed the long case and the viva which constituted the other parts of the MRCP clinical exam in those days but each time failed the short cases. Colleagues from the year below who had been house physicians, with me the SHO, came through and passed§ while I was left humiliated and without this essential qualification for progression in hospital medicine.
The battle to overcome this obstacle became a two or more year epic that took over my life. I transformed from green and inexperienced¶ to complete expert in everything to do with the MRCP short cases as viewed from the point of view of the candidate. I experienced every manifestation of disaster (and eventually triumph) recorded by others in Section F of this volume. By the time of the third attempt, I was so knowledgeable that I was out of tune with the examiner on a neurology case simply because I was thinking so widely on the case concerned. I believed at the time that I came close to passing at that attempt, although one never really knows and it was, after all, the occasion where I failed to feel for a collapsing pulse!** This was an important moment in the story because it was from this failure, along with the experience in the neurology case in my second attempt¶, that the examination routines and checklists, which are so central to this book, emerged. I finally passed on the fourth attempt whilst working as a registrar.†† During the journey, various consultants, senior registrars and colleague registrars tried to help in their various ways and amongst these, one of the consultants in my hospital, Afzal Mir, offered the advice that I should make a list of all the likely short cases and make notes on each and learn them off by heart. His exact advice was to ‘put them on your shaving mirror’. An important point should be made at this juncture. In order to be able to achieve this, one needed to attain the insight that it was indeed possible to do this. In those days there was no textbook for the exam, like the one you are reading, and there was no syllabus. Things had perhaps improved a little since the quote at the top of this Preface from A.J. Cronin* but nevertheless, the MRCP did carry with it an awe, a high failure rate and an aura that the exam was indeed one consisting of cases you had not seen before and questions you did not know the answer to. Indeed, many of us sitting it at the time would have found this a reasonable definition of the MRCP short cases.
A crucial part of my two or more years’ journey that formed the seed that eventually grew into the first edition of this book was the realization that, in fact, behind the mystique, the reality was that the same old cases were indeed appearing in the exam over and over again, that there was a finite list and, indeed, from that list some cases occurred very frequently indeed.‡‡ The realization of this led me to do exactly what Afzal Mir had advised (without the shaving mirror bit!). At the time there was a free, monthly journal that we all received called Hospital Update and it had a regular feature dedicated to helping candidates with the MRCP. In one issue the writer listed 70 cases which he reckoned were the likely short cases to appear in the exam and an eye-balling of this suggested it was fairly comprehensive.
And so I studied each of these 70 cases in the textbooks and made notes which were distilled into their classic features and other things that seemed important to remember and I wrote out an index card for each of the 70. Thus, the original drafts of the main short case records were penned whilst I was still sitting the MRCP.
Another major contributor to my final success with the exam was junior doctor colleague Anne Freeman. She had been on the Whipps Cross MRCP course with me prior to our first sittings of the exam and she passed where I had failed. Until that point, I think we would have considered ourselves equals in knowledge, ability and likelihood of passing.‡ I would describe Anne as being like Hermione Granger.§§ In her highly organized manner, she had written down the likely instructions that might be given in the short cases exam and under each had recorded exactly what she would do and in what order, should she get that instruction. She then practised over and over again on her spouse (Dr Peter Williams, to whom she is especially grateful) until she could do it perfectly without thought or mistake or missing something out, even in the stress of the exam.** I, on the other hand, was not like Hermione Granger. I could examine a whole patient perfectly in ordinary clinical life but had not actually thought through exactly what I would do, and in what order, when confronted with an instruction such as ‘examine this patient’s legs’ until it actually occurred in the exam.¶ And so eventually I did what Anne Freeman had done and the first versions of the checklists (for which I am especially grateful to my wife, Anne Ryder, who wrote them out tidily and then ticked off each point as I practised the examining, pointing out whenever I missed something out!) and primitive versions of the examination routines were born, again whilst I was still sitting the MRCP.
Having finally passed the exam, it seemed a shame to waste all the insights into the exam and the experience I had gained, and all the work creating the 70 short case index cards and the examination routine checklists I had created and practised and honed so laboriously – and so I conceived the idea of putting them in a book for others to have the benefit without having to do so much of the work or, perhaps, to go through the ordeal of failing through poor preparation as I had done. I shortlisted what seemed to be the four major publishers of the moment and on a day in 1982 was sitting in the library of the University Hospital of Wales penning a draft letter to them. At a certain moment I got stuck over something – I have long since forgotten what – and on an impulse went down to Afzal Mir’s office to ask him something to do with whatever it was I was stuck over. It was a defining moment in the history of these volumes. When I left Afzal Mir’s office, the project had changed irrevocably. I was a registrar, he was a consultant. He was extremely interested in the subject himself and my consultation with him ended up with the project being one with both of us involved and me with a list of instructions (consultant to registrar!) as to what to do next!
And so an extremely forceful and creative relationship began, which led to An Aid to the MRCP Short Cases. It was not that we worked as a peaceful collaborative team – rather the thing came into existence through creativity on a battleground occupied by two equally creative and forceful (in very different ways) people with very different talents and approaches. There are famous examples of this type of creative force, e.g. Lennon and McCartney or Waters and Gilmour.¶¶ Looking back, there is no doubt that without the involvement of myself and Afzal working together, an entirely different and inferior book would have emerged (probably the short 100-page pocket book desired by Churchill Livingstone – see below) but at the time I did not realize this and only thought that I was losing control of my project through the consultant–registrar hierarchy! My response was to bring in Anne Freeman, who I am sure would be very happy to be thought of as the Harrison/Starr or the Wright/Mason of the band!¶¶
Anne and I, in fact, also became a highly creative force through the development of the idea of surveying successful MRCP candidates to find out exactly what happened in the exam. It started off with me interviewing colleagues and this led to the development of a questionnaire to find out what instruction they had been given, what their findings were, what they thought the diagnosis was and their confidence in this, what supplementary questions they were asked, and their comments on the experience of that sitting. I distributed it to everyone I could find in my own and neighbouring hospitals, whilst Anne took on, with tremendous response, the immense task of tracking down every successful candidate at one MRCP sitting and getting a questionnaire to them! We asked all to report on both their pass and previous fail experiences.
Our overture to the publishers resulted in offers to publish from Churchill Livingstone (now owned by Elsevier Ltd) and Blackwell Scientific Publications (now owned by John Wiley & Sons) with the former coming in first and so we signed up with them. They were thinking of a 100-page small pocket book (70 brief short cases, a few examination routines, hardly any illustrations) sold at a price that would mean the purchaser would buy without thinking. The actual book, however, created itself once we got down to it and its size could not be controlled by our initial thoughts or the publisher’s aspirations. We based the book on the, by now, extensive surveys of candidates who had sat the exam and told us exactly what happened in it – the length and the breadth. This information turned the list of 70 cases into 150 and from the surveys also emerged the 20 examination routines required to cover most of the short cases which occurred. As to what should be included with each short case, that was determined by ensuring that we gave everything that the candidate might need to know according to what they told us in the surveys. We were determined to cover everything that the surveys dictated might occur or be asked. It was also clear that pictures would help. We battled obsessively over every word and checked and polished it until it was as near perfect as possible. By the time it was finished three years later, the 100-page pocket book had turned into a monster manuscript full of pictures.
I took it to Churchill Livingstone who demanded that it be shrunk down to the size in the original agreement or at least some sort of compromise size. We were absolutely certain that what we had created was what the MRCP short case-sitting candidates wanted and we refused to be persuaded. And so we were rejected by Churchill Livingstone. This was a very depressing eventuality! I resurrected the original three-year-old offer letter from Blackwell Scientific Publications and made an appointment to see the Editorial Director – Peter Saugman. I turned up at his office carrying the massive manuscript and told him the tale. Wearing his very experienced publisher hat, he instantly and completely understood the Churchill Livingstone reaction but also understood something from my passion and certainty about the market for the book. He explained that he was breaking every publishing rule but that he was senior enough to do that and that he would go ahead and publish it in full on a hunch. In 1986, he was rewarded by the appearance of a 400-page textbook-sized book, which rapidly became one bought and studied by almost every MRCP candidate. Indeed, that original red and blue edition can be found on the bookshelves either at home or in the offices of nearly every medical specialty consultant in the UK.
After this, our first and best, we all pursued solo careers, with Afzal making clinical videos of patients depicting how to examine them, and writing other books such as An Atlas of Clinical Diagnosis (Saunders Ltd, second edition, 2003), Anne developing services for the elderly and people with stroke in Gwent, and me pursuing diabetes clinical research in various areas. Meanwhile, Anne in particular continued to accumulate survey data and in the second half of the 1990s we came together again to make the second, blue and yellow, edition of the book (1999). The surveys (which by this stage were very extensive indeed) had uncovered a further 50 short cases that needed to be included and the original material all needed updating.
Then, in 2001, the Royal Colleges changed the clinical exam to PACES. Until then the short cases exam had been a room full of patients of all different kinds with the candidate being led round them at random – according to the examiner’s whim – for exactly 30 minutes. Anything from four to 11 patients might be seen. This was now transformed into Stations 1, 3 and 5 of the PACES exam, each 20 minutes long, thus doubling the time spent with short cases and ensuring that patients from all the main medical specialty areas were seen by every candidate. Hence, An Aid to the MRCP Short Cases was transformed into An Aid to the MRCP PACES Volume 1, with the short cases divided into sections according to the Stations. Specialists helped us more than ever with the updating and by now surveys had revealed that there were 20 respiratory cases that might occur, 19 abdominal cases, 27 cardiovascular cases, 52 central nervous system cases, 51 skin cases, 19 locomotor cases, 18 endocrine cases, 21 eye cases and eight ‘other’ cases. The long case and viva sections of the old clinical exam were replaced by Stations 2 (History taking) and 4 (Communication skills and ethics). To help us with these we recruited new blood – a bright and enthusiastic young physician who had recently passed the MRCP – Dev Banerjee, and he led on the Volume 2 project. Dev now confesses that ‘one of the hardest aspects of writing Volume 2 back then before 2003 was coming up with enough surnames. You can not believe how hard it was. Should I refer to the Bible? Should I refer to the Domesday Book? I decided in the end, as I had grown up in Leeds and supported Leeds United all my life, to use the 1970s Leeds United team sheet for surnames. It’s not obvious, but if you look carefully, it is there!’. Finally, in 2003, the third edition was published in silver and gold.
After many years intending to do this, we also created a medical student version of the short cases book on the grounds that medical student short cases exams are essentially the same as the MRCP in that it is the same pool of patients and the examiners are all MRCP trained so that is how they think. However, whilst most MRCP candidates continue to use our books, most medical students have not discovered their version – it has the wrong title because medical students no longer have short cases exams – they have OSCEs! Those who have discovered it report that they have found it useful for their OSCEs.
And now the Royal Colleges have changed the exam again. And so An Aid to the MRCP PACES has become a trilogy. Stations 1 and 3 remain roughly the same and hence Volume 1 covers Stations 1 and 3 and Volume 3 has been created to deal with the new style of Station 5. Each short case has been checked and updated by one or more specialist(s) and these are now acknowledged at the start of the station concerned against the short case they have taken responsibility for. The same applies to the short cases in Station 5. Nevertheless, I have personally checked every suggestion and update and took final editorial responsibility, changing and amending as I thought fit. The order of short cases was again changed according to new surveys (now done online) and yet again a few more new short cases were found from surveys: only four for Volume 1 – kyphoscoliosis and collapsed lung for Respiratory, PEG tube for Abdominal and Ebstein’s anomaly for Cardiovascular. New young blood has again been recruited – a further two bright, young and enthusiastic physicians. The updating of Volume 2 covering Stations 2 (History taking) and 4 (Communication skills and ethics) has been led by Nithya Sukumar. For Volume 3, covering the new Station 5, Ed Fogden has created the new Section H (Integrated clinical assessment).
We are grateful to the specialists, now listed in the appropriate sections, who have checked and updated the short cases in their specialties in Volumes 1 and 3, and who helped Ed Fogden with the scenarios in Section H, Volume 3; and we are especially grateful for the enthusiasm with which they have done this despite the considerable workload involved. We are grateful to Mrs Jane Price, Lead Nurse for Patient Experience, Aneurin Bevan Health Board, for her significant input to the section on Station 4. Her knowledge/experience in communication skills and medical ethics and her years of experience in dealing with these situations in clinical practice and guiding doctors in real-life scenarios have given great insight into the needs of PACES candidates. She has, therefore, contributed significantly to the development of the new cases included in this edition, and she also updated and enhanced the Introduction to Section E. Our surveys have always dictated the content of the books and so we are especially grateful to all the PACES candidates who have taken the trouble to fill in the online MRCP PACES survey at www.ryder-mrcp.org.uk. Finally, we are particularly grateful to our colleagues for their support in the ongoing project, which is a considerable undertaking, and we reiterate the deep thanks to our families expressed in the previous prefaces to Volume 1.
Bob Ryder
2012
Notes
*From The Citadel by A.J. Cronin.
†From the song Shine on You Crazy Diamond by Pink Floyd from the album Wish You Were Here.
‡‘The result comes as a particular shock when you have been sitting exams for many years without failing them.’ Section F, Quotation 374.
§Section F, Experience 108.
¶Section F, Experience 109.
Section F, Experience 145.
**Section F, Experience 144.
††Section F, Experience 175. I measured my pulse just before going in to start this, my final attempt at the MRCP clinical, and the rate I remember is 140 beats/minute, but in retrospect I feel it must have magnified in my mind through the years – nevertheless whatever it was, it was very high. It is clear, though, that stress remains a major component of the exam – see Section F, Experience 15.
‡‡Section F, Useful tip 328 and Quotations 349 and 411–415.
§§A prominent character in the Harry Potter books by J.K. Rowling. Highly organized; expert at preparing for and passing exams.
¶¶Lennon and McCartney were the writing partnership of the Beatles with Harrison and Starr as the other members of the band. Similarly Waters and Gilmore for Pink Floyd with Wright and Mason as the other band members. In both cases it is believed that there was a special creativity through the coming together of the different talents of the individuals concerned, though the relationship was sometimes adversarial.
Introduction
Do not be tempted to skip the introduction here or at the start of each section!!It will give you valuable pointers to help you through the book and the exams.
‘I would have definitely benefited from more practice in history taking and in communication skills before the exam.’*
‘Both the history section and the communication/ethics section are very rushed in the exam. It will feel very artificial because you will find there is too much to cover in 14 minutes (plus 1 minute thinking time and then 5 minutes questions) but persevere and be empathic.’†
‘I finished the history taking very quickly so had to sit in silence until time was up. That was awful!’‡
From June 2001, the Royal College of Physicians replaced the traditional MRCP ‘clinical’ examination, consisting of 30 minutes of short cases, a long case lasting 1 hour and 20 minutes and a viva lasting 20 minutes, with the MRCP PACES exam (Practical Assessment of Clinical Examination Skills). In Autumn 2009, the College changed the format of Station 5 of this exam. The candidate who reaches the MRCP PACES examination has already demonstrated considerable knowledge of medicine by passing the MRCP Part I and MRCP Part II written examinations. The PACES exam is divided into five stations, each of which is timed for precise periods of 20 minutes. Stations 1, 3 and 5 are divided into two substations of 10 minutes each. The stations are:
Station 1
Respiratory system
Abdominal system
Station 2
History-taking skills
Station 3
Cardiovascular system
Central nervous system
Station 4
Communication skills and ethics
Station 5
Integrated clinical assessment
This volume deals with Station 2 (History-taking skills) and Station 4 (Communication skills and ethics). Stations 1 and 3 are dealt with in Volume 1 of An Aid to the MRCP PACES. For this new edition of An Aid to the MRCP PACES, a third volume has been added to deal with the new Station 5.
The marking system for PACES is subject to change and you should study it at www.mrcpuk.org. At the time of writing, marking was being done in the skills of:
Physical examination
Identifying physical signs
Clinical communication
Differential diagnosis
Clinical judgement
Managing patient concerns
Managing patient welfare.
The table on the following page shows, at the time of writing, the stations at which each of these skills are tested.
At the time of writing, the system is such that, on the mark sheet, the examiner in the station concerned gives for each skill being tested in that station one of the following marks:
Satisfactory
mark = 2
Borderline
mark = 1
Unsatisfactory
mark = 0
If you study the marking system and you can be bothered to do the analysis, you will be able to work out the minimum number of scores of 2 that you need, assuming all other scores are 1. However, in practice, this is probably of limited use because undoubtedly you will be trying to get a score of 2 in everything regardless. Two things are important, however.
The exam is a practical test which assesses various facets of clinical competence in many subtle ways. Although it is generally accepted that clinical competence and communication skills cannot be acquired from textbooks, a book such as this can provide indirect help towards that objective.
Stations 2 and 4 of the PACES examination are designed to be a comprehensive test of a candidate’s ability to obtain an in-depth history, provide information to patients, and other relevant people, about sensitive issues such as malignant and sexually transmitted diseases, and their ability to discuss management and care plans with patients and other clinical staff.
Station 2 will assess your history-taking skills. Two examiners will observe how you gather the appropriate and relevant facts from a patient, assimilate that information into either a diagnosis and/or a management plan, and then assess your discussion with them. During the 5-minute interval before you enter this Station, you will be given written instructions for the case you are going to see. This is often in the form of a letter from the patient’s GP; thus, the Station simulates an outpatient clinic except that you will have two examiners, instead of two students, silently observing you. You will have 14 minutes with the patient and then 1 minute for reflection during which you must decide how you are going to present the crucial part of the history, which issues you will need to discuss with the examiners, and how you will suggest that you would respond to the referring letter.
Station 4 tests communication and ethics and your ability to guide and organize an interview with the subject (mostly an actor masquerading as a patient, relative or a healthcare worker). During the 5-minute interval preceding this Station, you will receive written instructions summarizing the problem you will have to deal with. As for Station 2, you will have 14 minutes with the subject, in the presence of the examiners, during which you must explore and deal with the problem while providing emotional support whenever necessary, and discuss further management. As the subject leaves the Station, you will have just 1 minute to crystallize your thoughts for the 5-minute discussion with the examiners.
All three parties – the patient/actor, the examiners and you – will each have a preprinted sheet at both Stations. The patient/actor will respond to your questions according to their brief from the examiners, their required verbal and non-verbal interactions will also be indicated on their sheet as well as the clinical details of the condition that they are role-playing; the examiners will assess you according to their guidance notes; and you will have your briefing of either the GP letter for the history taking or the scenario for the communications station. All this is done to ensure a level playing field for each candidate.
Take note of ALL written and verbal instruction given as the words used are important. They will give you clues about the emphasis of the scenario case.
We have presented here 50 scenarios for Station 2 and 68 scenarios for Station 4 which cover a diverse range of problems seen in clinical practice. For each scenario, we have given the information which you would have outside the exam room (the candidate’s information), the information that might be written on the patient/actor’s sheet, and what the examiners’ guidelines may look like which they will use to assess your interaction with the subject. We have also given some helpful hints before each Section but these will only prove useful if you have thoroughly prepared yourself for these tasks.
Doctors taking this exam need to have practised these skills and should have knowledge not only of the various clinical conditions likely to be encountered, but also of the myriad ethical and legal issues which may arise. Doctors approaching the PACES exam should make a purposeful preparation for it from the outset and, in the process, learn about structured clinical methods and good bedside behaviour.
Preparation
‘I would suggest that candidates need to have thought of the answers before they are asked, as the questions were really quite predictable.’*
It is a well-known fact that the best preparation for passing the membership examination is to work on the firm of a good clinical teacher. In the real world of today, there are very few such teachers who would regard teaching as a worthwhile and rewarding pursuit, and those who do hold these beliefs are usually too busy to teach because of the increasing clinical and administrative demands. As one clinical tutor once ruefully remarked, ‘In the past we used to teach students and now, in the current environment of political correctness and proper documentation, we spend our time talking about it!’. More than ever, the onus lies with the students to take due care of their learning programme and to make use of any learning opportunity (teaching sessions, clinical meetings, symposia, grand rounds, etc.) during their clinical duties.
History Taking
‘The candidate mistimed the whole station; he raced through the history of the presenting complaint in about 1 minute, proceeded to briefly take the rest of the history, and then realized he had 9 minutes left. The silence was broken by ‘OK then, tell me about those palpitations again’.†
History taking is an art and cannot be acquired simply by reading books. Nonetheless, a book such as this can help you organize your approach to each symptom, select a battery of appropriate questions, interpret the information received, and narrow down the diagnostic hypotheses. It is important that students learn a structured approach from the very beginning during their clinical attachments, but it is never too late for postgraduate students to adapt and develop it.
There are 6–8 principal symptoms in each system and students should consult a book on clinical skills and master a battery of questions for each symptom, and then practise the art of asking these questions at every opportunity during their clinical training. Remembering the questions is easier than the art of asking them, which can be improved by constant practice, self-criticism and helpful comments from a good teacher. A famous neurologist once said, during a teaching session, that diagnosing the cause of headache, the most common symptom in medicine, is like completing a jigsaw puzzle of asking 13 questions. Those who can only count 12 questions should consider asking the final question to the patient as to what he or she thinks is the cause of the headache. The same can be said about any other symptom such as chest pain or palpitations.
It is important to explore the presenting symptoms fully before going on to other aspects of the history taking. The examiners take a dim view of any candidate who skates back and forth from the presenting complaints to past or family history. It becomes easier to identify the chief areas of concern in other parts of the history, and the possible risk factors, only after adequately exploring the presenting complaint(s). Besides, it is imperative to let the patient ventilate fully his or her major concerns both in clinical practice and in the exam. A systems review will be necessary to find out if the patient has any other complaint which he or she has not mentioned.
During your clinical attachments, foundation programme and core training appointments, you should get into the habit of going over your notes each time you take a history, and judging whether you have covered all aspects of the history and then assembled the appropriate differential diagnoses. Once you have done that you should then prepare a summary of the problem(s) and the possible management plan and articulate it vocally to yourself. This habit will serve you well for any examination. As you prepare for the PACES exam, you should act out each history scenario from this book with a fellow candidate and discuss the conclusions and management plans. This will tighten up your history-taking technique and your presentation skills. Remember, the examiners do not know you are clever; you have to demonstrate it. The exercise will also help to make you a methodical and articulate clinician.
Communication Skills and Medical Ethics
The patient said to the candidate, ‘I’m worried this may be something serious’. The candidate replied ‘That doesn’t surprise me’.*
Unlike the history-taking techniques, which are now taught from the very first year of medical training, guidance and instruction on communication skills are still in their infancy. In the past, young doctors acquired these skills by osmosis from their senior colleagues whom they observed during their discussions with patients and relatives. Since 1995, communication skills have been incorporated in the new undergraduate curricula that have been adopted by most medical schools in the UK. The Royal Colleges of the UK and the General Medical Council have all focused their attention on communication skills, and so their assessment is now part of all major clinical examinations. As a result of this increasing emphasis on good communication, appropriate counselling skills and knowledge of ethics, Station 4 has now been devoted to their assessment in the PACES examination. Most candidates approach this Station with some foreboding.
There are three main reasons why a candidate’s heart may sink before entering the communication and ethics station. First, unlike history taking, which has a long-established structure with subsets, communication skills are fluid and elastic and vary from problem to problem and from person to person. Although there are some recognized basic principles of a counselling interview as outlined at the beginning of Section E, each problem, with its inherently unique circumstances, can impose its own constraints, all of which can differ from patient/actor to patient/actor.
Secondly, the multiangled assimilative exercise of communication skills involves learning from tutors, talking to patients, relatives and other healthcare professionals, and studying the diverse range of ethical and legal issues that surround these problems. Unlike a clinical skill, which can be demonstrated by a tutor, communication skills cannot be imparted by a single demonstration or learned by one useful interview with a patient. It is a continuing learning process and most candidates are conscious that their technique and knowledge have some gaps.
Thirdly, even an apparently straightforward counselling scenario may present an unexpected hurdle, either because of its unique circumstances or because the interviewer forgot some simple principle. We know of a real-life incident when a consultant, during his round in a coronary care unit, was a witness to an unsuccessful cardiopulmonary resuscitation on one of his patients. As he and his entourage emerged from the door, the deceased patient’s wife, who had just arrived, asked him about her husband. The consultant told her, as sympathetically as he could, that her husband had passed away. On hearing this the lady fainted, fell on the concrete floor before anyone could catch her and sustained a nasty cut to her forehead. Sometime later, she charitably remarked, ‘It was my own fault. I should have been sitting!’. During a busy and eventful round, the consultant had forgotten to observe the basic principles of privacy and comfort which should be afforded to all recipients of bad news. He did not take the lady into a side room, get a nurse to sit with her to offer support and coffee, and then give her the bad news.
These considerations, apart from highlighting the concerns of the candidates, clearly reinforce a well-known fact that there is no shortcut to experience in acquiring communication skills. Medical students should grasp the fundamentals of communication, learn from personal and video demonstrations, and observe intently as many consultations as possible during their rotation through general practice and hospital placements when senior doctors speak to patients and relatives. They should seek permission to sit in on any interview between a senior clinician and a patient or a relative. As their training advances, and during their junior appointments, they should practise their own communication skills.
Candidates approaching this exam should have already gained some experience and they should use this book in developing it further and improving upon it. There are 68 scenarios on communication skills and ethics, subdivided into seven sections/categories, and we would suggest that two candidates should play out each scenario, one acting as the subject and the other the doctor, and then discuss the problem and the performance in the light of the examiner’s information. After playing out each scenario, they should discuss the various ethical and legal issues arising from it. We have provided relevant references to our sources of such information and candidates should look up these for themselves. Possession of adequate knowledge about the various aspects of each problem is essential in order to spare some thought and time to decide on the proper and appropriate kinetic behaviour (body language) in tune with that scenario. It is difficult to be thoughtful of a patient’s sensitivities if you are struggling to recall information from distant and faded memory lacunae. Remember that even if all the points raised are addressed, the candidate will still fail if the overall impression of the examiners is of poor empathy and a hesitant interaction with the subject.
To sum up, those candidates who have acquired some personal experience of communication skills, who have studied and gained a thorough knowledge of these 68 scenarios, and who have been through them with fellow candidates would be leaving very little to chance. From our accumulated experience, we have come to believe that no candidate passes the MRCP examination by pure luck, and a candidate who leaves gaps on the chance that the examiners may not explore them may be unsuccessful.
The Examination
‘They (the examiners) are stone cold in expression and that often makes you think that you are doing badly but that’s not always true.’*
By the time you seriously consider taking the PACES examination, you should have gained enough experience in taking a history on almost any presenting complaint, obtained some instruction and experience in counselling and communication, studied several times a standard textbook on medicine and one on clinical skills, and have had many opportunities to summarize and present case histories in various forums. If, in addition, you were blessed with some critical appraisal of your presentations from senior colleagues and, in turn, you have constantly improved your performance by taking a comprehensive account of history and counselling scenarios, including preparing a succinct summary for presentation, then you have made the adequate preliminary preparation to study this book for your final preparation.
Study this book thoroughly; grasp the details of each scenario in the two main sections, play out each scenario with your fellow candidates and polish up your presentation. Get into the habit of summarizing the chief points in each scenario and practise presenting them to anyone who is prepared to listen and provide some helpful criticism. Practise speaking clearly and fluently in front of a mirror and into a tape recorder and play it back. When you have done all of this then you should feel confident and self-assured to enter the PACES exam.
Notes
*See comment on Section F, Experience 32.
†See comment on Section F, Experience 39.
‡See comment on Section F, Experience 33.
*See comment on Section F, Experience 20.
†See Section F, Invigilators’ diaries, Stations 2 and 4.
*See Section F, Invigilators’ diaries, Stations 2 and 4.
*See comment on Section F, Experience 21.
Section DHistory-Taking Skills
‘A candidate, after seeing a patient with funny turns, gave no indication of any tests to be performed, any follow-up or any thoughts about the causes for the funny turns, and ended the consultation by saying “Thanks, we’ve finished now”.’*
These books exist as they are because of many previous candidates who, over the years, have completed our surveys and given us invaluable insight into the candidate experience. Please give something back by doing the same for the candidates of the future. For all of your sittings, whether they be a triumphant pass or a disastrous fail …
Remember to fill in the survey atwww.ryder-mrcp.org.uk
THANK YOU
The history-taking station in the PACES examination tests the candidates’ ability to explore and probe the presenting complaint(s), gather and interpret information, formulate a plan of action, communicate it to the patient and then discuss the conclusions and management plan with the examiners. The cases presented in the exam, and in this book, are the ones that doctors encounter in their everyday clinical practice and the ones that all candidates should be familiar with. Yet there is strong anecdotal evidence from reliable sources that since the PACES examination was introduced, many candidates have performed poorly both in this station as well as in Station 4. It seems perverse that doctors, trained in the basic skill of medicine from the very first year of medical school and experienced in taking histories from their patients every day, should perform badly. Looking at the reports we have received from our surveys, there seem to be four main reasons for this.
