Preparation

‘Expressionless and without comment they led me away.’*

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The clinical skills required for the MRCP examination, particularly in relation to the short cases, can only be acquired by thoughtful preparation, experience and purposeful practice. Tutors and examiners alike agree that it is more important to spend time examining patients than reading textbooks. The examiners are not looking for encyclopaedic knowledge – they are just anxious to ascertain that you can be trusted to carry out an adequate clinical examination and make a competent clinical assessment. This book aims to help you organize your overall preparation to meet that objective. We have provided preparatory aids including examination routines and short case records (see below). We also aim to give you some insight into what most candidates experience in the examination and we hope to help you prepare psychologically. We would like to stress that although the written examination may appear a formidable hurdle, it often turns out to be less of an obstacle than the PACES. You would be wise to err on the side of safety and prepare for the PACES before, during and after your preparations for the written exam. Thus, we begin with some basic principles of practice and preparations at work.

Clinical Experience in Everyday Work

‘Imagine you are seeing the cases in a clinic and carrying out a routine examination.’ *

The intention of the College in the examination is to gain a reflection of your usual working-day clinical competence for the examiners to judge. In arriving at their final verdict, the examiners may take particular note of factors such as your approach to the patient, your examination technique, spontaneity of shifting from system to system in pursuit of relevant clinical signs, fluidity in giving a coherent account of all the findings and conclusions, and your composure throughout. Though you can acquire all this for the day only, as some successful candidates do who are experts at passing examinations, it would be preferable if you could adopt many of these good habits into your everyday clinical approach. In either event, a long, diligent and disciplined practice is required if your aim is to be able to perform a smooth and polished clinical examination, to display the subtle confidence of a skilled performer, and to suppress signs of anxiety.

One simple approach to the task is that, whatever your job, you should consider all the patients you see as PACES patients from one station or another. Such a practice should not only improve your readiness for the examination but also improve your standard of patient care – the primary objective of every clinician. Look out for all the ‘good signs’ passing through your hospital and use as many of these as possible as practice short cases. Ask your colleagues to let you know of every heart murmur, every abnormal fundus, every case with abnormal neurology, etc. If you are in, or can get to, a teaching hospital, make regular trips not only to clinical meetings and demonstrations but also, more importantly, to visit the specialist wards – neurology, cardiology, chest, rheumatology, dermatology, etc. It is useful to study the signs and conditions even when you know the diagnosis in order to further familiarize yourself with them. It is also a good practice to see cases ‘blind’ to the diagnosis and to try to simulate the examination situation. Imagine that two examiners are standing over you and there is a need to complete an efficient, once-only examination followed by an immediate response to the anticipated questions: ‘What are your findings?’ ‘What is the diagnosis?’ or ‘How would you manage this patient?’.

Simulated Examination Practice

‘I had a lot of practice presenting short cases to a “hawk” of a senior registrar. This experience was invaluable.’ ^†

If a constant effort is made to improve your clinical skills by seeing as many cases as possible, there is no reason why the spontaneity and competence so acquired should not show up on the day. As with all examinations, however, much can be learned about the deficiencies requiring special attention when you put your composite clinical ability to the test in ‘mock’ examinations. In most district general, and all teach­ing, hospitals, the local postgraduate clinical tutors organize Membership teaching and ‘mock’ examination sessions, and you should find out about, and join in, as many of these as you can manage. Unfortunately, a lot of these, though useful, tend to teach in groups and discuss management or look at X-rays, rather than provide the intensive ‘on-the-spot’ practice on patients that is the ideal preparation for PACES. It is, therefore, advisable to supplement these sessions with simula­ted examination practice arranged by yourself. This requires the cooperation of a ‘mock’ examiner (consul­tant, experienced registrar and, on occasion, a fellow examinee) on a one-to-one basis. If you can practise with a variety of ‘mock’ examiners, you will not only broaden the assessment of your imperfections but also learn to respond to the varied approaches of different examiners.

Examination Routines

‘The most important point is to look professional – as if you have done it a hundred times before.’ *

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