Preparing for MRCP UK examinations for International Medical Graduates (IMGs)
Abstract
The MRCP UK examination is one of the most difficult for UK graduates. International Medical Graduates (IMGs) will find it even harder for a variety of reasons.
I moved to the UK in 2010 after leaving an international public health career. Travelling from one country to another with a family had become difficult. After GMC registration in 2011, I worked for three years as a foundation doctor followed by being a locum. In August 2014, I secured a permanent non-training post as a Clinical Fellow in Medicine of the Elderly at the Royal Infirmary of Edinburgh. I started preparing for the MRCP UK examinations in 2016 and completed all three examinations by October 2018. This article is a reflection of my personal experience navigating through these examinations written with the intention of sharing helpful information with fellow IMGs aspiring to succeed in the MRCP UK examinations.
Key words: International Medical Graduates, MRCP UK examinations, Practical Assessment of Clinical Examination Skills (PACES), examination preparation, feedback.
Abstract
The MRCP UK examination is one of the most difficult for UK graduates. International Medical Graduates (IMGs) will find it even harder for a variety of reasons.
I moved to the UK in 2010 after leaving an international public health career. Travelling from one country to another with a family had become difficult. After GMC registration in 2011, I worked for three years as a foundation doctor followed by being a locum. In August 2014, I secured a permanent non-training post as a Clinical Fellow in Medicine of the Elderly at the Royal Infirmary of Edinburgh. I started preparing for the MRCP UK examinations in 2016 and completed all three examinations by October 2018. This article is a reflection of my personal experience navigating through these examinations written with the intention of sharing helpful information with fellow IMGs aspiring to succeed in the MRCP UK examinations.
Key words: International Medical Graduates, MRCP UK examinations, Practical Assessment of Clinical Examination Skills (PACES), examination preparation, feedback.
Introduction
The Membership of the Royal Colleges of Physicians of the United Kingdom (MRCP UK) examination is one of the most difficult for UK graduates. International Medical Graduates (IMGs) will find it even more challenging for various reasons. For example: - English not being their first language, - completed undergraduate medical study several years ago, - having worked in resource-constrained settings or in nonclinical roles, - not currently working, - currently working but not on a formal training programme, and/or time pressure because of family or other commitments.
I decided to record my experience of preparing and sitting for the MRCP examinations as I felt it could be useful for IMGs who aspire to pass this exam. I moved to the UK after leaving an international public health career because travelling from one country to another with a family became difficult. After obtaining General Medical Council (GMC) registration I wanted to do a hospital clinical job and spend the rest of the time with my family. During an interview for a Clinical Fellow post in Care of the Elderly, I was asked if I had the MRCP. My answer was “no”. Was I planning to take the MRCP examinations? I said “yes”. I started preparing in 2016 and completed the three examinations by October 2018. While I passed the MRCP written examinations in the first attempts, I needed four attempts to pass the PACES examination.
For anyone preparing for the MRCP UK examinations, a detailed amount of information is available on the MRCP UK website. It is important to read this information before and during preparation for the different stages of this examination.
Preparing for MRCP 1 & 2 exams
Format of the examination
MRCP 1 & 2 are written examinations, each with 200 questions taken under formal invigilated arrangements. MRCP 1 deals more with knowledge of basic science and medical facts: it is important to realise that it has 25 questions on “Clinical Science” dealing with anatomy, physiology, pharmacology genetics and statistics. MRCP 2 is mainly about analytical skills, clinical judgment and application of clinical knowledge. Both examinations cover the breadth of general medicine and the various specialities. It is worth paying attention to the MRCP UK webpage which describes the “format” of the examinations indicating the different specialities, number of questions and the percentage weight of each speciality.
The best way to prepare for the written examinations is by doing thousands of MCQs. A subscription to one of many online MRCP examination questions and working on these are invaluable. I used the British Medical Journal (BMJ) On Examination for part 1 and for a change PassTest for the part 2. The content of both online materials was excellent. After answering each question, right or wrong, feedback follows. This was extremely valuable to consolidate my knowledge.
A very useful function of this online learning is that you can customize the way you want to study. You can choose the number of questions you want to work out at a time, choose mixed questions across the specialities or choose a specific speciality upon which to focus. As you progress with your studies it monitors your overall score on a graph with a grid indicating where the pass mark sits. An indication of your strengths and weaknesses across the specialities is also provided. This enables you to concentrate on areas where you are scoring low. Once you have worked through a sufficient number of questions, you can test yourself using the online mock examination under examination conditions. You can do as many mock examinations as you want.
I learnt a great deal from online examination MCQs but it was crucial to attend a course for both written examinations. I attended a 5-day course during the month before sitting each examination. These courses covered basic clinical science and subspecialties such as radiology, dermatology, rheumatology. I found going away for a course particularly useful as I got a protected time to focus, revise and learn. You also meet and can share experience with other candidates.
The MRCP UK Practical Assessment of Clinical Examination Skills (PACES) examination
PACES is a clinical skill assessment examination with two examiners observing and marking independently while a candidate interacts with a patient or a surrogate. Each candidate will go through five stations and a total of seven clinical skills will be assessed. To enhance your chances of passing this examination thorough and focused preparation is vital. There are certain essential aspects in this preparation:
1. Familiarity with the examination format: The MRCP website gives an excellent description of how the examination is organised. However, reading about the format and actually sitting the examination are different matters. The setup of PACES is complicated. The best way to understand what actually happens on the day is attending a PACES course with a mock examination set up in exactly the same manner as the actual examination. This will reduce the anxiety about the process. Knowing this is one less stress and could enhance your chance of success.
2. Familiarity with competencies that are tested: the PACES examination tests clinical examination skills in station 1 and 3 and your communication skills in station 2 and 4. In station 5 (integrated clinical examination) both communication and examination skills are tested. All seven skills are tested in this station and it carries most marks. This is clearly shown on each station marking sheet and are downloadable from the MRCP UK website. It is useful to familiarise yourself with the various competencies that are assessed and how they are marked.
3. Clinical practice for the examination: This is a vital part of PACES preparation and much preparation time should be dedicated to it. The best way is to practise with someone who is also preparing for PACES (a PACES buddy). This enables mutual feedback and learning. With your PACES buddy, your practice needs to cover the various competencies and skills in clinical examination and communications. If you are on a formal training programme, rotating through the various specialities will create opportunities to acquire broader clinical skills and competencies. However, if you are not and are always working in one speciality, then you need to frequently go to different wards (e.g. gastrointestinal, renal, cardiology, respiratory and neurology) to practise clinical skills on patients with physical signs. This means going to see patients in the evening and weekends. Depending on your personal gap in examination skills arranging to sit in a specialist clinic could also be very useful. I arranged to sit in Parkinson’s, cardiology, respiratory and kidney transplant clinics and it was all worthwhile. These are termed high yield clinics as most frequent PACES cases appear from such clinics.
Practising for communication skills requires the same level of attention as the clinical examination skills. Practising with a PACES buddy in a role-playing model and using PACES mark sheets yields a high benefit. Once the consultation is finished, the person who was acting as a patient will fill the mark sheet and give feedback to the other candidate. For the communication station, what I found equally effective was to practice with a family member who acted as a patient and gave feedback at the end of the consultation. For the history and ethics stations, I printed all the communications scenarios on the MRCP website and role-played each of them. This practice and the feedback at the end of each of the consultations were extremely valuable. Beyond communications skills, these consultations helped me to develop skill in terms of timing, pacing and wrapping up the consultation.
Additionally, practising for PACES under the observation of a consultant or a registrar is an effective approach for preparation. I have had several opportunities to be observed by different consultants (some of whom are PACES examiners) and registrars with greatly helpful feedback. Therefore, wherever you are working, it is worthwhile to explore PACES teaching conducted by consultants and registrars.
4. PACES courses: Next to practising for PACES, attending a PACES course in the weeks prior to the examination increases your chances of success. The key advantages of a PACES course are:
a. to understand the examination process and timing. Going through a mock examination will allow understanding of what to expect on the day;
b. boost communication and clinical examination skills and competencies;
c. opportunity to practise eliciting uncommon clinical signs and discussing diagnosis and differential diagnosis; and
d. meet with fellow candidates and share experiences.
There are several PACES courses available in the UK. While some take place during the week others are conducted over weekends or evenings. I attended an excellent 3-day PACES course organised by the Royal College of Physicians Edinburgh (RCPE) and NHS Lothian.
The RCPE also runs free PACES classes at the College venue once a year. It is lecture-based teaching delivered by PACES examiners over three separate evenings each lasting 90 minutes. It covers the examination format and the competencies assessed at individual stations. While this is a very informative lecture, it is no substitute for a PACES course. The RCPE usually live-stream their lectures to various centres within the UK and globally. You can check on their website if there is a centre listed for live-streaming close to where you live.
5. PACES preparation aids: there are plenty of resources (books, audios and videos) for PACES preparation. PACES preparation books come at different sizes, volumes and prices. I bought two books: one small and one large. However, I used “Cases for PACES” which is a small volume PACES book during most of my preparation time. It is pocket-sized and you can take it to the ward to aid with practice. If your budget is limited, I would recommend having one of the smaller volume books..
There are some useful free materials on YouTube. An example is PACEStv posted by Leicester University. There are also PACES audio-visual online materials on a subscription basis and they cover all five PACES stations in the same timed manner as the PACES examination. These materials cover a broad range of cases that appear in the examination and watching them helps learning and understanding the format of the examination. However, the purpose of these aids is to help with the preparation and practising clinical skills and one should avoid the temptation to spend a large chunk of study time on reading, watching or listening without actually practising.
6. The week prior to the examination: preparing for PACES while working and engaging in family life can be both emotionally and physically exhausting. Therefore, you need to prepare yourself to arrive on the day with stamina and confidence. During the last week keep practising for PACES. However, you should avoid night shifts just prior to your examination. Try to get adequate sleep in the nights before your examination. Prior to your trip check you have your examination admission paper, photographic ID, and a stethoscope. (All the other examination equipment you need will be available in the examination rooms). Travel one day in advance of your examination date unless you are living in the same town. On this day have a break from studying and try to relax during the trip and on arrival. Consider visiting the hospital where you will be having the examination. By now you have prepared more than enough, and you deserve to rest. Get to bed early and try to get a good night sleep. Travelling several days in advance of the examination, studying to the last minute and lack of sleep affected my performance during one examination sitting and I would stongly discourage such actions.
7. On the day of the examination: report on time at the hospital venue. You will receive a group briefing with other candidates. Listen carefully and follow the instructions. You could be starting at any of the five stations. In stations 2, 4 and 5 you will have written instructions outside the examination room. Read these instructions and prepare yourself in the five minutes before you go into the room. These are 5 precious minutes and make the best use of them to prepare yourself using the clinical information you are given. You will be provided with paper and a pencil. Jot down your ideas regarding how to approach the clinical situation and the patient you are about to meet. For the stations 1 and 3, you will be given simple instructions once inside the room. So, remain seated outside until five minutes have passed. There are facilitators standing outside the examination rooms who will guide you around to the different stations.
Also, feel free to ask the facilitators if you feel uncertain about where to go or what to do. If you are well prepared and fortunate on the day you will sail through every station. However, you may encounter a difficult station/s and you might feel disheartened about your performance. Do not allow these feelings to hamper your performance on subsequent stations. Bear in mind each station is a separate examination and marked accordingly. Seven skills and competencies are assessed across individual stations. Even if you truly fail in one or two stations you can compensate in subsequent stations. Additionally, in the stations where you felt you underperformed, you will still be collecting points that will add to the overall mark.
8. Endnotes: On the days before you are going to sit for PACES, you probably have been doing your day job of talking to and examining patients, requesting investigations and treating them. You might have been doing it for many years. Do exactly the same thing in the examination. Treat the patient (or surrogate) sitting in front of you or lying in bed next to you as your own patient. Be kind and considerate to them and you will get full marks in every station for maintaining patient welfare (one of 7 skills tested). And think: “what best can I do to make this person feel and get better?” Try to demonstrate the skills and behaviour that you practise every working day. When your time is up, thank the patient, help him or her to dress and turn to face the examiners. Stand straight up, look confident, listen to the examiner’s questions carefully and answer with a clear voice. If you do not know the answer, then say so. You will be given a chance for further questions. In the heat of the examination it is difficult to be yourself. However, try to be calm and be yourself and you will achieve more.
After the examination, if you feel you did not do well then you are feeling just as many candidates who have been through PACES do. It will take about ten working days before the results are released. In the meantime, take a well-deserved break from study and examinations.
Transparency declaration: This article is a reflection of my experience of the MRCP UK examinations process.
