In my third year of medical school, I volunteered to help with the running of the PACES exam at one of the big Glasgow teaching hospitals. It was an opportunity to spend all day dinging a bell, to eat an heroic quantity of Quality Street, and to, between circuits, be shown some clinical findings more complex than those we were usually given in our medical school OSCEs.
In June, I sat PACES.
You may recall that the last time I wrote, I had put myself into some kind of fugue state refreshing the results website.
And, you know, saying that, it still doesn’t feel quite real, even two weeks later.
And — well, let me explain this, a little bit.
In the UK, one of the criterion for progressing in a medical career is to complete the necessary postgraduate qualifications to become a member of the relevant specialist “College”. There is a Royal College of Surgeons, and a Royal College of Emergency Medicine, and a Royal College of General Practitioners, and so on. The membership qualifications for the Royal College of Physicians come in three parts, of which PACES is the final part. In all, they have taken three years, untold hours, and a significant amount of actual money spent on exam fees, revision materials, and all the caffeine in Glasgow. I also have less hair than when I started.
The first two parts are multiple choice. The first part is six hours long (with a break in the middle), and I have previously described it as being not unlike spending six hours having one’s brains kicked in by a rugby team. I took it four times. The last time was in the Newcastle United football stadium, one of the stranger places I’ve ever been in the name of my medical education. The second part is nine hours long, and I sat that only once but in a room that contained no air during the hottest two days there have ever been in the west of Scotland. After 27 hours worth of multiple choice exam, I had lost the will to live but had grown very comfortable with colouring in boxes in 2B pencil.
The third part is not like that.
I think the thing that will perhaps best describe PACES is for me to say that even while in the middle of actually taking it, I was aware that I was muttering frantic karmic apologies to every single doctor at whom I had dinged that bell back when I was a third year medical student.
“You will be fine,” my consultants had been saying to me in the week leading up to it. “You’re a good doctor.” This was kind of them, but I kept reminding them that being competent at my job and appearing competent in this exam were two very different kinds of competent.
You wake up too early in the morning. You try to eat breakfast. You travel to a hospital that is not your own, and may not be exactly in the back of beyond but certainly feels like it. I went off to the conference suite of a hotel that is attached to the national specialist cardiology centre — a place that I have spent a lot of time on the phone to, but, despite nine years of living in Scotland, had never seen for myself. “This is Dalmuir, where this train will terminate,” said the Scotrail tannoy, which felt ominous. You sit in a room where time stops, making nervous small talk with the other four people who are taking the exam with you, filling in your name and candidate number on sixteen separate pieces of paper and flicking frantically through Cases for PACES as you try to remember the indications for liver transplant.
The next two hours pass at warp speed.
The basic structure is the same for everyone: assessments of communication skills and ethics, examinations in the four major body systems, and a final station two-case grab-bag of can-be-absolutely-anything. The patients are sometimes actors, but are mostly real patients who have been recruited in for the day. In my version of the exam, I was asked to take a history from a woman who I promptly blanked on half of her presenting complaint, I was asked to counsel a young man who was angry with my boss, I struggled to find anything at all wrong with the patient whose abdomen I was examining, and trying to listen for heart sounds I briefly wondered if my stethoscope had turned itself off. In the middle of telling me about his syncope, one patient, who had also mentioned that he was on a blood-thinning medication, said that he had hit his head on the ground when he had fainted. “I haven’t really,” he said when I started trying to look for a head injury. “I’m allowed to tell you that I haven’t really.” The whole time, there were two examiners, watching, scribbling things on those pieces of paper that I had painstakingly filled in back in the room-where-time-stopped.
As each of my examinations was completed, I turned to them, tried for a winning smile, and began, “Mr Jones is a fifty seven year old gentleman. He is comfortable at rest…”
In this exam, stage fright is a real thing.
A week earlier, in Edinburgh, I had sat down after making a speech to the great and the good of the Scottish Episcopal Church and said that if failing my exam was the price I had to pay for being there, it would have been worth it. (I could, after all, have sat it again in the autumn, which would have been a pain but hardly the end of the world.) Now, on the other side of it, it’s not that I’d necessarily recommend spending three days at General Synod as a revision strategy for PACES, but the experience does throw a person’s whole idea of what counts as an intimidating room into rather harsh perspective.
They go on to ask questions. I said things like, “I would want to get an abdominal ultrasound,” and, “I would expect the left hemidiaphragm to be raised on chest x-ray,” and, “Oh, hell, I’m sorry, I totally forgot to ask him about that,” and, at one point, “Well, on a SPECT scan you’d normally see, uh — ” and, screwing my nose up as I tried and failed to articulate it, drew a picture of what you’d normally see on a SPECT scan with my fingers in the air.
And then that bloody bell dings and you get the hell out of there while shouting through the door, “I’d do an ESR and a CRP, too!”
Forget having your brains kicked in by a rugby team.
“I think I’ve been smacked in the face with a baseball bat,” I said, collapsing in the car.
It wouldn’t have been the end of the world, of course, to take it again, but am I ever glad that I haven’t got to.