1. 1 The PACES Carousel
WHY PACES?
PACES is the acronym for ‘Practical Assessment of Clinical Examination
Skills’, the practical component of the MRCP examination. It was first
held in June 2001 replacing the previous clinical (long case and short
cases) and oral examination. The introduction of a huge revision of the
examination involved major changes for candidates, examiners,
teachers, local organisers, and central administration throughout the
world.
What are the Aims of the PACES Examination?
The aims of the PACES examination have been clearly stated in the
curriculum (MRCP(UK) Part 2 Clinical Examination (PACES) and clinical
guidelines 2001/2). They are to:
• Demonstrate the clinical skills of history taking
• Examine a patient appropriately to detect the presence or absence
of physical signs
• Interpret physical signs
• Make appropriate diagnosis
• Develop and discuss emergency, immediate and long-term
management plans
• Communicate clinical information to colleagues, patients or their
relative
• Discuss ethical issues

2. 2 Revision Notes for MRCP 2 PACES
How does the PACES Carousel Work?
Five candidates rotate through five 20 minute stations, separated by
upto 5 minutes for change-over and waiting (Fig. 1.1). The cycle begins
with a five minute wait which enables candidates at the two talking
stations (stations 2 and 4) to read the introductory material, whilst the
other three hopefully relax. The whole cycle therefore lasts 125 minutes;
it can be entered at any station and, thereafter, the five candidates follow
the same sequence. Two of the clinical examination stations are double
stations; two systems, respiratory and abdominal, at station 1, and
cardiovascular and central nervous, at station 3, are each examined for
ten minutes. Station 5 is now an assessment of a focussed clinical
problem of the type that you might be expected to see in higher specialist
training.
Figure 1.1: Carousel of PACES stations
The talking stations, stations 2 and 4, begin with an al limportant
waiting period outside the room, when the candidates read the
instructions and introductory material and should devise an action plan
for what is to follow. Within the station, they will spend 14 minutes
talking to the patient/subject or surrogate, followed by one minute’s
reflection, during which the subject usually leaves the room and, then,
a five minute discussion with one or both examiners.

3. The PACES Carousel 3
Time
Time-keeping is a key to success for both the PACES examination and
the candidate to succeed. The traditional system of bells and verbal
warnings are used together with additional prompts, for a slow
candidate running out of time. Bells are rung at the beginning and end
of the five 20 minute stations and, usually, at 10 minutes in the two
double stations (1 and 3). The examiner will often draw the candidate’s
attention to a clock, or, better still, will start a stop clock in the room. In
the two talking stations (2 and 4), a verbal 2 minutes warning will be
given at 12 minutes. Time management is also increasingly important
in every clinician’s daily work. Although, it is not explicitly tested in
PACES, it is implicit in the strict, but relevant, time limits set to undertake
the various tasks.
It may occur to the candidates that if they prolong their time
examining a patient, it may shorten the discussion time (and, of course,
potential hostile questions). This is not advisable; although examiners
will award some marks for the candidate’s examination technique they
are observing, the majority of marks will go to the candidate’s correct
clinical findings, the interpretation of them in a diagnosis or differential
diagnosis, and discussion of further relevant management. As in all
examinations, the way to avoid difficult questions is for the candidate
to be pro-active and try, if possible, to control the discussion by talking
good sense. Most examiners will not interrupt them if what they are
saying is relevant. Examiners get irritated by the slow candidate who,
in addition, may go back to repeat their examination, suggesting a lack
of confidence in their findings.
The times allocated for the tasks you are given at each station, and
substation, are realistic by the standards that apply in everyday practice.
On exception to this, which was soon appreciated by PACES examiners,
is that candidates would not have time to perform a full neurological
examination, in the detail specified in the guidelines, in the time
allocated. The solution lay in the introduction to the case where
candidates should be directed specifically to which part of the CNS
they would be required to examine, e.g. “the arms”, “the legs”, “the
cranial nerves”, “speech” etc. Such limitation placed on the examination
of a particular system should not preclude the candidate from saying
in their presentation that he or she would investigate further. A generous
examiner would even supply the missing information!
If you are uncertain about the instructions given relating to the
examination, or any other aspect of the case for that matter, please ask

4. 4 Revision Notes for MRCP 2 PACES
the examiner for clarification. Examiners will frequently ask the
candidates, after they have read the written instructions, “Do you
understand?”
Marksheets
You must be familiar with the contents of the seven marksheets as they
are the cornerpiece of the PACES examination. They are easily accessed,
either on the website, or in the Regulations (free), in the references above.
More than recording the marks awarded, they contain the necessary
demographic information and detailed breakdown and checklist of the
component parts of each problem posed at each station. This is essential
to the fairness of the marking systems and also enables detailed feedback
to be given to candidates, as well as forming the basis of counselling on
the rare occasions that this is recommended.
Each marksheet has four sections and, partly, uses boxes to be filled
using a 2B pencil, to facilitate computer scanning:
1. Candidate
The candidate prints their NAME and fill in their EXAMINATION
NUMBER and the CENTRE NUMBER boxes on each of the seven pairs
of sheets handed to them by the organising registrar (the sheet number
boxes corresponding to the station is already filled in).
2. Examiner
The examiners write in (a box) a brief description of the CASE followed
by PRINTING and SIGNING their name, and, finally, their
EXAMINATION NUMBER.
3. Conduct of Case
Except for Station 5 (Marksheet 7), which is appreviated, there are three
parts for the four major clinical substations.
At stations 1 and 3, the first part is headed “Physical examination”,
followed by bullet points relevant to that system; the second part is
headed “Identification and interpretation of physical signs” with three
bullet points: “Identifies abnormal physical signs correctly”, “Interprets
signs correctly”, and “Makes correct diagnosis”. The third part is headed
“Discussion related to the case” with two bullet points: “Familiar with
appropriate investigation and sequence” and “Famililar with
appropriate further therapy and management”.

5. The PACES Carousel 5
These second and third parts are identified for the four major
systems (marksheets 1, 2, 4 and 5) and examiners are expected for each
of the three parts to fill ONE of the four boxes: Clear pass, pass, fail,
clear fail. Station 5 (marksheet 7) is divided into the four minor systems
examined and each, in turn, subdivided into the three parts discussed
above (which now become bullet points as there is no room on the
sheet to subdivide them further). For each of the four systems overall
the examiner is required to fill ONE of the four boxes as above. The
crucial part of each marksheet is the bottom line – mirroring life. The
box in the bottom right-hand corner requires the examiner to make
an “overall judgment” using the same four item scale which is
translated into marks: clear fail – 1 mark, fail – 2 marks, pass – 3
marks, clear pass – 4 marks. Adjacent to it is a “Comments” box which
every examiner must complete to explain the decision to give a fail or
clear fail. If the examiner is particularly concerned about some aspect
of the failure which needs to be further explored with the candidate,
another adjacent box, “Counselling Recommended”, is filled in. This
will NOT automatically lead to the candidate being counselled but
will be discussed with the other nine examiners, at the completion of
the cycle, to decide whether further action is required.
The format of the marksheets for the two talking stations, Station 2
(History Taking) (Marksheet 3) and Station 4 Communication Skills
(Marksheet 6) have the same tripartite structure as those for the major
clinical systems, appropriately adapted, but requiring each examiner
to fill in boxes, as well as, identical to the other sheets, the overall
judgement, comments, and counselling boxes. Thus, the first part of
Marksheet 3, is “Data gathering in the interview”. The second is
“Interpretation and use of information gathered”, and the third,
“Discussion related to the case”, all with appropriate bullet points, and
the examiner (and candidate). Similarly, in marksheet 6, the three parts
are headed “Communication skills – conduct of interview”,
“Communication skills – exploration and problem negotiation” and
“Ethics and law” (The bullet points are described below under the two
stations).
The marksheets can be downloaded from the official MRCP website:
http://www.mrcpuk.org/Pages/Home.aspx
Marking System
The overall judgement that determines each examiner’s mark is not
intended to be the numerical mean of the intermediate assessments

6. 6 Revision Notes for MRCP 2 PACES
made in the various sections of marksheets 1 – 6, or, even, of the
separate marking of the four minor systems in marksheet 7. This is
because each box filled does not carry equal weight. The value of the
multiple judgements is primarily in providing feedback to candidates
but also enhances broad objective marking by the examiners. It may
help to avoid that they be not overimpressed by one thing the candidate
has done well, ignoring several things not well done, or vice versa. A
further aid to the examiners, available to candidates at the same sources
as the marksheets, are the anchor statements. Thse try to give
substance to the four gradings in assessment, under six headings:
“System of examination”, “Language and communication skills” (in
patient encounters when examining clinical systems as well as the
tarking stations”, “Confidence and rapport”, “Clinical method”,
“Discussion and appreciation of patient’s concerns” and “Clinical
thinking”. When writing comments on a candidate who is being given
an overall fail or clear fail, examiners are encouraged to select
appropriate statements that define the mark; evenn if the patient
achieves an overall pass or clear pass, it can still be helpful to point
out deficiencies (along the way) as an individual examiner will know
nothing of the assessment by the other nine examiners until afterwards.
The pass mark for each of the three diets of PACES held annually is
agreed by the Clinical Examining Board at end of the examination. The
maximum mark attainable by a candidate is to receive a clear pass from
each examiner at every station or substation: 14 × 4 = 56. The minimum
mark would be 14 × 1 = 14. An “ideal” cut off would be that the candidate
should get a pass from each examiner: 14 × 3 = 42. Often the pass mark
is simply 41.
Examiners
Examiners are widely recruited. There is no lower age limit but they
will usually have been consultant physicians, or equivalent, for atleast
4 years, and have been elected FRCP of one of the UK colleges. They
must have some acute general medicine content in their working
practice; therefore, superspecialists may not be eligible but can
contribute to question-setting. Examiners usually retire within 1 to 2
years after retirement from active clinical practice. Increasing emphasis
is placed on examiner training at regular sessions and briefing before
each examination. Observation of an examination, before actually
examining, is mandatory. Others with an interest in the examination
(teachers, course organisers, examiners from other colleges, and

7. The PACES Carousel 7
disciplines) may also observe and their non-participatory role will be
made clear to the candidate.
The performance of examiners is remarkably consistent. Before each
carousel, the paired examiners will see the patients or role players
(surrogates) together and assess the ease or difficulty of a case. They
will agree the criteria they will use in independently awarding the four
grades/marks available. When the candidate has left the examination
room each examiner completes the marksheet and puts it into a
collecting box before finding out the co-examiner’s mark. There is exact
concurrence within one mark in over 95% of candidate-examiner
encounters and exact concurrence in 60%. If necessary, a brief discussion
of any discrepancy within a pair takes place before the next candidate
enters.
Patients
It is a privilege that patients help with the examination, and it is therefore
it is vital that you are as courteous and kind as possible to the patients.
Failure to introduce yourself to and respect these patients – a point
which will be repeated in this text – is unacceptable. Many patients are
nervous about participating, and also are concerned about saying
something that we fail you. Please be courteous to them. Many patients
ask afterwards how successful you have been and are genuinely
concerned you do well!
Aseptic Techniques
It would be a disaster for the Royal Colleges if patients attended the
examination and then developed some form of transferred infection
such as MRSA which can be tracked back to the examination. Aqueous
gel or hand-washing facilities should be available, and should be used
between all patients.
REFERENCE
MRCP(UK) Part 2 Clinical Examination (PACES): A review of the first four
diets (June 2001 – June 2002). J Dacre, GM Besser and P White on behalf of
the MRCP(UK) Clinical Examining Board. J R Coll Edinb 2003;33:285-92.