PACES Clinical Consultation Framework | Station 2 & 4 Guide

By Dr Zac Hana | 2026-05-10

Why Consultation Stations Matter Most

Stations 2 and 4 together account for 40% of your total PACES marks. They are also the stations where the gap between pass and fail is narrowest — meaning small improvements in technique can make the difference.

Unlike examination stations where you either find the sign or you don't, consultation stations reward structure, empathy, and adaptability. These are skills you can learn and practise systematically.

Station 2: History Taking Framework

You have 14 minutes with the patient, followed by 1 minute of reflection and 5 minutes of examiner questions.

The Opening (2 minutes)

  • Introduce yourself with name and role
  • Confirm the patient's name and how they'd like to be addressed
  • Set the agenda: "I understand you've been having [presenting complaint]. I'd like to ask you some questions about this — is that okay?"
  • Open question: "Can you tell me about what's been happening?"

    • Focused History (8 minutes)

    After the patient's opening statement, structure your questioning:

    Presenting complaint in detail:

  • Onset, duration, character, severity
  • Aggravating and relieving factors
  • Associated symptoms
  • Impact on daily life

    • Systematic review (relevant systems only):

  • Don't ask about every system — focus on your developing differential

    • Past medical history, drug history, allergies:

  • Quick screen, focus on relevance to the presentation

    • Social history:

  • Occupation, smoking, alcohol, home circumstances
  • Functional status — can they manage stairs, shopping, cooking?

    • ICE and Summary (3 minutes)

    This is where marks are won or lost:

  • Ideas: "What do you think might be causing this?"
  • Concerns: "Is there anything in particular you're worried about?"
  • Expectations: "What were you hoping we could do for you today?"

    • Then summarise: "Let me check I've understood correctly..." This demonstrates active listening and gives the patient a chance to correct any misunderstandings.

    The Reflection Minute

    Use this to:

  • Formulate your top 3 differential diagnoses
  • Plan your investigation strategy
  • Identify what you'd tell the patient next

    • Examiner Questions (5 minutes)

    Expect:

  • "What is your differential diagnosis?" — lead with the most likely
  • "What investigations would you request?" — be specific and justified
  • "How would you manage this patient?" — think like a registrar, not a student

    • Station 4: Communication Skills Framework

    Station 4 scenarios fall into predictable categories:

    Scenario TypeExampleKey Skill Breaking bad newsCancer diagnosis, poor prognosisEmpathy, pacing Explaining a diagnosisNew diabetes, MS, epilepsyClarity, checking understanding Discussing treatmentStarting biologics, surgery risksShared decision-making Ethical dilemmaCapacity, confidentiality, DNARReasoning, professionalism Angry/upset relativeComplaint, unexpected deathDe-escalation, empathy

    The SPIKES Framework for Breaking Bad News

  • Setting — ensure privacy, sit at eye level, have tissues available
  • Perception — "What have you been told so far?" / "What's your understanding of the situation?"
  • Invitation — "Would it be okay if I shared the results with you?" / "How much detail would you like?"
  • Knowledge — deliver in small chunks with a warning shot: "I'm afraid the news isn't what we were hoping for..."
  • Empathy — pause after delivering news. Name the emotion: "I can see this is a shock." Allow silence.
  • Summary — agree next steps, offer follow-up, provide written information

    • Marking Criteria for Station 4

    Examiners assess:

  • Clinical communication — did you structure the consultation logically?
  • Managing patient concerns — did you address their emotional needs?
  • Clinical judgement — was your advice medically sound?
  • Maintaining patient welfare — did you maintain dignity and safety?

    • The single most common reason for failing Station 4 is not responding to emotion. When a patient says "I'm scared" or starts crying, you must acknowledge it explicitly before moving on.

    Practice Exercises

    Exercise 1: History Taking

    Ask a colleague to role-play a patient with chest pain. Take a 14-minute history, then present your differential to a "examiner." Record it and review.

    Exercise 2: Breaking Bad News

    Practise delivering a cancer diagnosis to a colleague acting as a patient. Focus on pacing — most candidates deliver information too quickly.

    Exercise 3: Angry Relative

    Have someone role-play an angry relative whose mother fell on the ward. Practise de-escalation: acknowledge, apologise, explain, and offer a solution.

    Common Pitfalls

  • Talking too much — the patient should speak for at least 50% of Station 2
  • Ignoring cues — if the patient mentions they're worried about cancer, explore it immediately
  • Being too medical — use plain language: "blood test" not "full blood count"
  • Forgetting to summarise — always close with a summary and agreed plan
  • Rushing through emotion — silence is powerful; use it after delivering difficult news

    • How BitePACES Prepares You

    Our 3-Day Comprehensive Course includes a dedicated half-day for communication skills with:

  • Recorded role-play scenarios with personalised feedback
  • Framework practice with experienced faculty
  • Common PACES scenarios rehearsed under timed conditions

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    Further reading: How to Pass PACES First Time: 10 Proven Strategies | The Complete Guide to MRCP PACES 2026