Hearing crackles: why all GPs should pass PACES

Abstract

As a GP registrar, the MRCGP Clinical Skills Assessment (CSA) exam is currently at the forefront of my mind. Vocational Training Scheme teaching focuses on how to pass, evenings are spent revising, and my bank account, now £1700 lighter, still makes me shudder. And yet, perhaps naively, it was still a shock to me to find out that at no point in the CSA exam am I expected to accurately detect real clinical signs. Of course, the CSA assesses many other important skills, including problem-solving skills, personcentred care, and attitudinal aspects. 1 My argument is certainly not with the inclusion of these. However, given that 'The validity of the CSA resides in its realistic simulation of reallife consultations', 2 it seems strange that it includes no real patients, and consequently no real physical signs, both somewhat important components, I would argue, of many real-life consultations. By contrast, the clinical component of Membership of the Royal College of Physicians (MRCP), the PACES exam (Practical Assessment of Clinical Examination Skills), 3 involves real patients with a given condition. Candidates undertake a respiratory, abdominal, cardiovascular, and neurological exam, as well as a history station, communication and ethics station, and two brief clinical consultations. In these, candidates are given 8 minutes with a patient to take a focused history, carry out a relevant examination, respond to the patient's concerns, and explain a management plan. This PACES exam is robust, and considered a rite of passage for medical trainees, who often require multiple attempts to pass. To a GP trainee it often seems unattainably tough. When colleagues pass, we congratulate them, but we also breathe a sigh of relief that we don't have to go through the same arduous process, and, in doing so, we perhaps elevate our colleagues above ourselves. I would argue that this is wrong on many levels. This veneration of MRCP gives the impression that our exit exams are 'easier', or that we couldn't pass a more robust exam should we need to. As a GP trainee who decided to undertake my MRCP exam, I would argue this is far from the truth.

Hearing crackles: why all GPs should pass PACES

“…Crispin Fisher's enjoyable letter 1 brought to mind an experience I had as a teaching GP on a cold morning's surgery.…”

“…We are, after all, only human. Response to a news article on the RCGP website I have read with great interest both the news article published on the RCGP website, 'Thousands of GP appointments "lost" due to children with conjunctivitis being turned away from nursery, says RCGP', 1 and the leaflet produced by the RCGP to educate childcare professionals, parents, and teachers about managing conjunctivitis in young children. 2 General practice is under unprecedented workload pressure, 3 and every attempt to rationalise appointments so that resources can be utilised appropriately ought to be commended.…”

“…I would heartily endorse Rose Brettell's 1 and Crispin Fisher's 2 view that careful physical examination of patients should be paramount and particularly in the isolated setting of the GP's consulting room far away from pathology labs and 'hi-tech' investigative machines.…”

Bad Medicine: Clinical examination

“…Specifically, intimate and invasive examinations should stop for they are illogical. [2][3][4] But the royal colleges have a belief system built on this mumbo jumbo, 5 for much of medicine's status is vested in clinical examination.…”