PACES consultation station (Stations 2 and 5): a 15-minute structure

How the encounter runs

• In the 5-minute interval you read a short note or referral letter describing the patient's problem.
• You then have 15 minutes to take a focused history, perform a relevant examination, explain your findings and working diagnosis, agree a management plan and address the patient's concerns.
• You get a warning at 13 minutes. The full 15 minutes must pass before the examiners' questions begin, even if you finish early.
• Then 5 minutes of questions from the examiners on your findings, differential diagnosis and plan.
• The history may come from the patient or from a surrogate.

What the scenarios look like

The Federation's guidance for writing consultation scenarios lists the kinds of problems that work well:

• Incidental findings: for example, a neck swelling noticed in a patient admitted for a cholecystectomy.
• Complications of chronic disease: for example, a patient with rheumatoid arthritis with early signs of interstitial lung disease and increasing breathlessness.
• Transient symptoms with no physical signs: such as a TIA, palpitations or a pulmonary embolism, where the history is everything.
• Stable cardiovascular disease presenting acutely: for example, valvular heart disease presenting with collapse or palpitations.
• Skin, rheumatological, endocrine and eye problems, presented as clinical problems rather than spot diagnoses.

Scenarios focus on common problems relevant to internal medicine training, not on specialist knowledge. Typical presentations include chest pain, headache, collapse in a young person, anaemia and recurrent nosebleeds, usually framed as a referral to same-day emergency care or clinic. Each patient has a concern that shapes the conversation, such as whether they can keep working or playing sport, or whether this could be cancer.

A 15-minute structure

The 5 minutes with the examiners

• Open with a concise summary: who the patient is, the key history and examination findings, your working diagnosis and the patient's main concern.
• Give a differential, most likely first.
• Outline investigations and management, starting with what matters most for safety.
• Expect questions on what you would do next if the first test is normal or abnormal.

Worked example

Referral: "Please see this 62-year-old woman with rheumatoid arthritis who reports increasing breathlessness over six months."

• History: tempo of breathlessness, cough, exercise tolerance, rheumatoid disease activity and treatment (including methotrexate), smoking, occupational exposures, symptoms suggesting other causes (anaemia, cardiac, thromboembolic). Ask what she is most worried about.
• Examination: hands (rheumatoid changes, clubbing), respiratory examination (fine bibasal crackles), signs of right heart failure.
• Explanation: "The crackling sounds at the bottom of your lungs can be a sign of scarring, which sometimes happens with rheumatoid arthritis or occasionally with its treatment. We need some tests to be sure."
• Plan: chest X-ray, high-resolution CT, full lung function tests including transfer factor, and a review of her medicines with the rheumatology and respiratory teams.
• Concern: if she is worried it's cancer, address that directly and honestly.

Common pitfalls

• Spending ten minutes on the history and rushing or skipping the examination. A skill that isn't tested scores as Unsatisfactory.
• Examining everything instead of the systems the problem points to.
• Never finding out the patient's concern, or finding it out and not addressing it.
• Explaining with jargon, or not checking understanding.
• Missing the real question in the referral letter.

Sources

• Federation: PACES consultation scenario writing guidance
• Federation: PACES format (consultation encounters)
• Examiners’ Guide to PACES (version 3, February 2025)