Dr. Saripalli Kundan Reddy, MBBS (Singapore), shares his approach to sitting the PACES exam during COVID-19...and passing!

PACES. Undoubtedly, one of the most difficult examinations that doctors will face as part of their career progression. 

One might even call it a rite of passage.

Unfortunately, the many challenges faced during this already complex assessment have been compounded by the impact of COVID, resulting in changes to both the structure of the examination and the preparatory phases.

Preparing for PACES has always been the bane of many candidates' lives, as it requires many hours of patient interaction, ideally with conditions that are seen in the exam. However, depending on your hospital, it's not always possible to observe and examine a wide variety of patients, and during COVID, checking in on a patient exhibiting a classical case of whatever it might be, can be nigh on impossible!

How COVID impacted the exam

It's fair to say that sitting the exam during COVID was an experience! Some countries have moved to online assessments for certain stations where physical presence of the patient is not necessary. In Singapore, we still had face-to-face interactions but everyone was seated more than a metre apart and there was a plastic shield separating the candidate from the patient for the history taking and communication stations.

And yes, the candidates, patients and examiners had to wear a mask throughout the entire carousel. This definitely affects your facial expressions, your tone, your volume and how you convey your emotions. Thus, it is all the more important to speak slowly and clearly so that patients are able to understand you.

For stations that require a physical examination, hand hygiene became vital. In fact, we were given additional time in between stations and patient encounters to thoroughly clean our equipment with alcohol wipes to reduce the chance of infection transmission. Thankfully, we were not required to don the full personal protective equipment, which I think is necessary in some other countries.

This all definitely added to the stress and palpating through gloves is no easy task. So please ensure that you practice adequately in the proper attire as if in exam conditions and also make the effort to find out from previous candidates what the exam will be like. The case mix and marking scheme, however, remained the same.

International insight

Another word of advice is to know your local guidelines thoroughly, be it for organ donation or driving with medical conditions, for example. Each country has guidelines that differ from one another. Pastest introduces you to the important guidelines that will be tested in PACES and protocols that you need to know as a doctor.

Common ones include dealing with contagious diseases, compensation for medical injuries in the workplace, cause of death certification, organ donation, lasting power of attorney, and so on. The Pastest resource is very UK-specific but you can use the issues listed on the website as a checklist to find out the policies in your own country. For example, after watching the videos, I knew that a driving assessment with medical conditions is an important aspect that would be tested. The videos focus on the DVLA guidelines which are UK-centric. Taking this issue and contextualising it to Singapore, I went on to read local recommendations on driving guidelines.

On a similar note, it is important to know the patient demographics of the country or centre you are taking the examination in. This helps you prepare for the type of cases that are more likely to appear in the exam. In the UK, it is fairly common to see patients with Wilson’s disease or Huntington’s chorea appear in the exam, but in Singapore it is less common although not impossible. One common cause of bronchiectasis in the UK might be due to Kartaganer’s syndrome but in the local context of Singapore, infectious diseases such as Tuberculosis might be more common. Thus, contextualising to local demographics helps you not only to prepare for the cases but also helps you list your order of differentials and investigations.  

I'd now like to share some revision tips in the hope that others will benefit from my experience and hopefully not make the same mistakes I made (thankfully, though, I managed to pass on my first attempt).

Three steps to success

If I were to summarise my preparatory phase in three words, they would be PREPARE, PRACTICE and REVIEW. Key components of this cycle are the assessment of real patients alongside the use of the thorough and extensive Pastest PACES online resource to get more exposure to common cases and fill any knowledge gaps.

Step 1: Prepare

It is vital to ensure that you have at least some basic knowledge prior to assessing patients on the wards. Each patient encounter is very valuable and thus the opportunity needs to be fully utilised (COVID-permitting). No two patients are the same so all will have a strong learning value. Ensure you read up on examination steps and basic knowledge so that you can get the full benefit from each patient encounter.

Guidance on examination procedure and basic history taking skills can all be found in the Pastest resource. I'd also recommend investing in a comprehensive, up-to-date medical or physical examination textbook. It is important that you only learn from reliable sources as during the examination, assessors will want to see you demonstrate the clinically accurate and relevant steps, and not just rely on your own style. In addition, it is important to familiarise yourself with the examination itself, including the types of stations you will encounter, time allocation and mark scheme.

The best way to defeat your enemy is to know it inside out. With Pastest you'll have all this information at your fingertips - quite literally in fact, as it is easy to use through your browser on a mobile device.

Step 2: Practice

As the examination is a clinical one, it will be easy for examiners to tell who has spent the most time practising on the wards. Those who have practised enough will be comfortable speaking to various patients and their bedside manner will be clear and concise. Moreover, the whole process will flow smoothly, giving the examiners reassurance that the candidate knows what they are doing. This only comes with practice. It is therefore important that you form a study group amongst yourself and colleagues, preferably those taking the exam as well, and that, assuming you are able to, you make time to go and see patients either during work or at the end of the day.

The more you practice, the more fluid you will be and the more confident you will be in differentiating normal from pathology. Having said this, it is impossible to see all the patients with conditions that commonly appear in a PACES exam as the content is wide and varied. Moreover, some patient types might not get warded. It is also possible that certain days are "dry" on the wards and patients reject you. This is where the Pastest resource comes into its own, providing a consolidation of all the common cases that usually appear in the PACES exam. Watching the patient cases and trying to pick up the signs to settle on the diagnosis yourself will greatly aid your practice.

Step 3: Review

Once you have prepared and practised, you will identify knowledge gaps or skills that need work. It is important to review and work on these so that you are better prepared for your next cycle.

This stage requires peer or even senior critique so that you can improve your presentation technique. Face-to-face courses are clearly very popular - such as the PASSPaces course - as all your learning is consolidated and you have senior faculty members who will fine-tune and polish your skills to perfection.

However, with many courses across the world cancelled due to COVID-19, the Pastest resource is even more invaluable in this respect as it builds on your knowledge and gives you more in-depth information regarding a particular condition and its associations. This encourages you to look for other related features during the exam, making you stand out from the rest.

Taking PACES is a commitment. You cannot prepare for it in a short period of time, even with all the best resources at hand. Therefore, it is important that you plan when you want to take the exam and start preparation early. There is no need to wait for your exam date to be allocated before you start preparation as the knowledge and skills will be helpful in your career as well, not just for the exam.

Especially in this time of COVID, there might be restrictions in place preventing candidates from freely examining patients. Pastest is an incredibly useful resource in such situations as it allows you to "virtually" examine a patient and continue to prepare for the exam. The mobile-friendly nature of the resource is another bonus as it allows you to access the content when you have a short break at work.

Having recently successfully completed the examination, I can say for sure it is a highly stressful experience. When you start, you only remember things that you have done many times before, somewhat of a spinal reaction. You will not have the time and space to think through your steps or work out a completely new diagnosis if you have not seen or prepared for it before. Therefore, I'd highly recommend starting early, using the approach of PREPARE, PRACTICE, REVIEW, complementing your face-to-face patient encounters with the many conditions available on Pastest's online resource.

And finally, have confidence, and leave the exam knowing that you gave it your all. I wish all doctors taking the PACES exam the best of luck and hope to see you on the other side very soon.