MRCPCH Clinical examination changes - information for candidates

This autumn we introduce some changes to the exam's structure and marking scheme. If you plan to sit MRCPCH Clinical from August/September 2019 onwards, please review our guidance on these changes.
Last modified
17 May 2019

Why are we making these changes?

Over the past few years, we have been working with our examiners and trainees to identify areas of the MRCPCH Clinical exam that could be enhanced. Our Examinations Executive and the General Medical Council agreed and approved a number of changes, which we have piloted in the UK and overseas to make sure they work.

We believe these changes will provide more opportunity to:

  • accurately replicate real life situations in clinical practice
  • undertake a fair assessment of clinical skills and competencies required for progression into Level 2 training.

What changes are being made?

We are changing the format and structure of some exam stations, and revising the timings of the exam circuit. There is more detail below, but here is a quick summary.

  • Clinical stations: There will be four stations to assess clinical skills, instead of five. The focus will be on examination technique, identifying clinical signs, making a differential diagnosis and your interaction with the patient. You will no longer have to discuss a management plan at the end of a clinical station
  • Development station: You will now be able to ask relevant questions from the parent/carer regarding the patient's medical history and ability while at the same time undertaking a specific area of developmental assessment. The focus will be on history taking, examination technique, identifying signs, making a differential diagnosis, management planning and interaction with the patient. The development station will be twenty-two minutes in length in order to provide adequate opportunity to assess these skills.
  • Video stations: You will now watch one short video clip on a laptop and then undertake a structured discussion with an examiner. The focus will be on identifying clinical signs, making a differential diagnosis and providing a management plan. There will be two of these stations, instead of one. The video stations will be nine minutes in length, instead of twenty-two minutes.
  • Warning knocks/notifications: Timings have changed. All stations will now have a three minute warning knock before the end instead of the two minutes. This change has been introduced to provide you with more time to present your findings. It does mean that you will have slightly less time to undertake assessments in the clinical stations.
  • Scoring system/marking scheme for all exam stations: Candidates will now receive scores across several ‘domains’ within each station instead of one global score per exam station. This will provide you with much more detailed and focused feedback to identify areas of competency and areas for improvement.

Although it is unlikely to be introduced in 2019, we are also exploring opportunities to include input from the children and young people (CYP) participating in exams regarding their experience of their station encounters with you. If possible, we hope to introduce this as formative feedback for candidates for future practice. Future feedback from CYP is not intended to count towards your exam score. We will update you on future developments once more piloting has been undertaken.

When does all of this happen?

The modifications to the MRCPCH Clinical will begin from the 2019.3 exam diet. The first exams in this diet take place in India (Hyderabad) on 31 August and 01 September 2019 and Egypt on 06 and 07 September. These are followed soon after by exams in other countries, including the UK in October 2019.

If you are taking an exam this summer, before the above August/September dates, then your exam will be in the current format.

Will my preparation for the exam change?

You won't need to change the way you prepare for the exam to any great extent.

Many candidates prepare for MRCPCH Clinical through regular bedside review of cases. This may include in-house peer practice sessions. Or, sitting in clinics to gain more exposure to clinical cases (pathology) and enhance communication skills - for example a specialist clinic such as cardiac or neurology.

Where station timings have changed, you may wish to practice timings.

  • The Development station will be 22 minutes, split into two parts: thirteen minutes for interaction/history taking with the patient and parent/carer while undertaking a focused area of developmental assessment, and nine minutes discussion with the examiner.
  • For the Video station you will have three minutes at the start to watch the video as many times as you like, followed by six minutes discussion with the examiner.
  • For the Clinical stations, you may also like to practice completing within the six minutes, so you are prepared for your discussion with the examiner in the final three minutes. 
  • The Communication and History Taking stations are not changing to a a great extent. In the History stations, it will be more common to be taking a history from a parent or older adolescent, rather than young children or a combination of parent/carer and child.

You may be familiar with the current guidance materials that we provide to aid candidate preparation. This includes our MRCPCH Clinical Candidate Guide, which has the anchor statements and mark sheets which detail the criteria for meeting the standard for each station, plus a guide for clinical examination technique. We will update all of this in July.

Clinical stations

There will be four clinical stations, instead of five as in the current exam. As before, each clinical station will be nine minutes. These stations will be named Clinical 1-4 instead of system specific station names such as CVS or Neuro as with the current exam.

You will see a patient and be asked to perform a task as if you are examining the patient in your clinic. You will be expected to assess and report on clinical signs and provide a differential diagnosis. You will no longer be expected to provide a management plan in this station.

Aim: To assess your ability to undertake a clinical examination, interpret clinical signs and provide a differential diagnosis. There is only one patient at each station and there will be a separate examiner for each station.

The stations will include clinical cases potentially in any of the following categories:

  • Cardiovascular
  • Neurology/Neurodisability
  • Musculoskeletal
  • Respiratory
  • Abdominal
  • Gastroenterology
  • Ophthalmology
  • Dermatology
  • Hepatology/Haematology, growth and nutrition
  • Nephrology

You will be given a brief introduction to each child/case and a task that you are required to perform. This will be provided verbally by the examiner when you are in the room.

The examiner may ask you questions about the clinical findings and your interpretation of your findings at any stage during the station. 

There will be a three minute knock/warning after six minutes into the station to indicate there are three minutes remaining before the end of the station

Case introduction/task/opening statement: The examiners will have determined the area to be tested and the introduction/task to be completed.

Examples of tasks that candidates may be asked to undertake could include:

  • This is Anita. She is 13 years old and has difficulty walking. Please can you examine her neurological system
  • I’d like to introduce you to this patient and his mother.  This patient is a 5 year old boy call Nayan. His mother is concerned that he seems to fall more than before.  Could you examine his peripheral motor system please. 
  • Tim is 7 years old and has been referred by his GP after finding a murmur during an examination for a chest infection. Please examine his CVS system.

Child development station

As with the current exam, there will be just one development station. The station will be longer, 22 minutes instead of nine minutes. 

Aim: to assess your ability to perform developmental assessment by:

  • Information gathering (taking a history) from the parent / carer or child
  • Clinical developmental assessment of the child through appropriate use of toys and other equipment (provided in the station)
  • Discussion with examiner on findings and management plan.

You will be asked to gather key information from the parent and assess a specific area of the child’s development within the first thirteen minutes of the station.

You will be expected to manage your time appropriately in order to undertake both aspects of the task before the thirteen minutes ends. There will be a knock on the door after nine minutes to indicate to candidates and examiners that there are four minutes remaining before patient and parent will leave the room.

You will then discuss the implications of your findings and management with the examiner in the remaining nine minutes.

There will be a knock to indicate when three minutes are remaining before the end of the station.

Suitable toys and other equipment will be provided.  You will need to select the most appropriate tools for the area of developmental assessment. 

Case introduction/task/opening statement: The examiner will have determined the area of development to be tested and the introduction/task to be completed - for example: "Joe was born at 25 weeks gestation. Please discuss relevant aspects of his condition / history with Joe’s parent and assess Joe’s fine motor function."

History taking and management planning station

As before, there will be one History Taking station which is 22 minutes long. You will be provided with a scenario in relation to the task.

Aim: To assess that you can take a focused history, be able to summarise, identify key issues, prioritise and formulate a management plan.

As before, you will be provided with information about your role and the clinical background, asking you to see the parent/adolescent.  You will be expected to take a focussed history of a child or adolescent’s problems either directly from an adolescent or a parent of a child. The emphasis is on history taking during the first thirteen minutes. The examiner will then test your knowledge of the issues raised and will expect you to provide a management plan during the final nine minutes.

Communication station

As before, there will be two stations which are nine minutes long. You will continue to be provided with a scenario and be expected to interact with a role-player who will be acting as a parent, adolescent or fellow health professional.

Aim: to test your ability to communicate appropriate, factually correct information in an effective way within the emotional context of the clinical setting.

Example task: There are normally six main patterns of communication scenario:

  • Information giving (eg please tell this teenager about the diagnosis)
  • Breaking bad news (eg please explain the results of ultrasound and the implications)
  • Consent (eg please explain why you need to do a lumbar puncture with a view to obtaining consent)
  • Ctitical incident (eg please talk to the parent of the child who has been given the wrong drug)
  • Ethics (eg please discuss the problem as Anna has refused to have any blood tests)
  • Education (eg please explain to the SHO so that she can deal with the situation)

Video stations

There will now be two video stations, instead of one. Each of the two video stations will be nine minutes, instead of twenty-two minutes. You will watch a short video of a patient. After you have viewed the clip, an examiner will ask you questions according to a structured script.

Aim: The aim of the station is to assess the candidate’s ability to make clinical observations and decisions. The video clips will normally demonstrate clinical signs which cannot be easily or safely assessed in other parts of the examination. Acute signs seen in emergency departments and neonatal units may be assessed in this station. In addition to identification of clinical signs, the candidate will be expected to discuss questions of clinical reasoning and initial management.

Cases may include acute problems such as respiratory distress or seizures.  There may be testing of signs found on clinical examination (e.g. cardiac murmurs, respiratory distress or abnormal gait) or simple observation of a child or baby (eg seizures, grunting neonate, etc.). 

The video clips may or may not be accompanied by sound, which will be indicated by the examiner / in the candidate information.

Questions that examiners may ask in relation to the scenario and video clip:

  • What clinical signs have you observed?
  • What additional history would you like to obtain?
  • What additional clinical examination would you like to perform?
  • What is the most likely diagnosis? What is the differential diagnosis?
  • What investigations would you perform?
  • How would you manage this patient?

How will I be scored?

In the modified exam, there are nine ‘domains’ that you will be assessed on. The examiner will give a score against the ‘domains’ assessed in each station.

Different domains are assessed in different stations. The new domain marks are:

  • Meets standard
  • Borderline
  • Below standard

The domains you will be assessed on are listed below.

Domain

Meets standard

A1: Information Gathering/History Taking

  • Asks key relevant questions.
  • Sensitively gathers appropriate information.
  • Explores main problems/concerns of patient/parent/carer in structured manner.

A2: Information Sharing /Accuracy of Information

  • Explains relevant clinically accurate information
  • Information provided in a well-structured manner.
  • Verifies understanding and summarises.

B: Physical Examination

  • Well-structured, systematic exam technique.
  • Appropriate care taken to adapt to needs of patient. 
  • Appropriate use of equipment.

C: Identification of Clinical Signs

  • Identifies clinical signs that are present.
  • Correctly interprets clinical signs that are present.

D1: Clinical Reasoning

  • Formulates & proposes likely appropriate differential diagnosis
  • Understands implications of findings.
  • Able to suggest appropriate steps if exam inconclusive.

D2: Management Planning

  • Relevant investigations to appropriately address identified problems.
  • Provides safe, ethical, effective management plan that relates to patient/parent/carer concerns including appropriate referral or escalation

E1: Communication Skills: Rapport & Communication Style

  • Appropriate level of confidence; greeting and introduction; professional; sensitive; appropriate body language; responds to verbal & non-verbal cues.
  • Develops appropriate rapport with patient/parent/carer or colleague. Puts at ease.
  • Clarifies role & shared agenda. Appropriate tone & pace.

E2: Verbal & Listening  Communication Skills

  • Applies active listening & displays interest with patient/parent/carer/colleagues.
  • Allows others opportunity to speak.
  • Appropriate language used in challenging circumstances with any jargon explained.

E3: Managing Concerns & agreeing next steps

  • Seeks, identifies, acknowledges, attempts to address concerns appropriately.
  • Displays natural empathy with the patient/parent/carer or colleague.
  • Checks knowledge & understanding and agrees next steps.

Ongoing assessment of the new format

We recognise that these changes to MRCPCH Clinical may cause concern for those who have extensively prepared for the previous format. These changes have been made in direct response to candidate and examiner feedback, and the College will carefully assess the performance of the modified MRCPCH Clinic to ensure it remains robust and fair.

Will I be able to appeal my exam result?

With the modified exam you will no longer be able to appeal an exam result or mark awarded. Changes to the appeals process acknowledge that only examiners on the day are able to directly observe candidate performance and it is not possible to revisit this objectively after the fact.

We will therefore not be able to upgrade a fail score but we will review appeals or complaints that are supported with appropriate evidence in relation to any potential procedural irregularity or exceptional circumstances. More detailed guidance will be provided soon.

What if I have questions?

If you have any questions regarding the changes to the MRCPCH Clinical exam coming in late August 2019 then please contact the Examinations Team at exams@rcpch.ac.uk.