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How I failed (and passed) PACES: a UK trainee’s perspective

A trainee's story about how they passed the PACES examination.


I was in my ST3 year when preparing for my first attempt at PACES (due to multiple attempts to pass Part 1 and the Covid-19 pandemic). ‘It can’t be that difficult’ I told myself. After all, my consultants had told me that Part 2 and PACES would be easier to pass as they were more clinical. I had also been working as a doctor for 9 years – I knew how to examine patients, right?

I spent a couple of months poring over clinical examination books and watching examination videos on a popular online examination revision resource. Examination day arrived and I had travelled hundreds of miles to attend a hospital I had never worked at before. The examination seemed to be over and done with in a flash. I immediately got to thinking about all the things I had got wrong and things I had missed. I knew I had failed and failed badly. When the results were eventually released my feelings were justified – I had failed. Although, I had only failed by four marks in one skill (differential diagnosis) – maybe I didn’t perform as badly as I had thought?

Next attempt

I re-applied as soon as I could and got preparing again - reading the clinical examination books and watching clinical examination videos. I made copious notes. I also watched College online resources. Again, I travelled hundreds of miles to a hospital I had never worked at before for this examination. I wasn’t sure how it went – some days I felt confident and others I felt like everything had gone wrong. The results were released, I had failed by four marks in one skill again (identifying physical signs this time).

For the next attempt I decided I had to do something different – the books and online resources clearly weren’t working. I signed up for a ‘Focus on Neurology for PACES’ course and an expensive 3 day PACES revision course. I thought I would surely pass this time as I had spent so much money on attending these immersive courses with real patients, reinforcing how to examine properly and which signs to look out for. My third attempt came round, I was a bag of nerves – this was my final attempt before finishing my ST3 year, if I failed, I would have to give up my training number. The exam seemed extremely difficult, it was as though there were no clinical signs, or the cases were ones that I had never encountered before. When results day came, I had failed again (this time on both identifying physical signs and differential diagnosis).

Further attempts

Thankfully, I was granted an extension to training and re-applied to sit the examination again. There were a small group of people in the hospital I was working at who were also sitting the examination. We emailed around consultants and managed to attend some ad hoc dedicated bedside PACES teaching. This was useful and challenged me to make appropriate differential diagnoses depending on the patients and the signs present. I felt more confident going into the examination, and it was at a hospital I had worked at years before, so I at least knew how to get there and the location of the venue – ‘this must be a good sign’ I thought. I felt fairly confident afterwards, but when the results were released, I was disappointed to see I had failed yet again. However, this time it was even closer – I had failed by only one mark in the identifying physical signs skill.

I had all but given up at this point. I told myself I obviously wasn’t a very good doctor and clearly wasn’t meant to progress in my career. It was time to give up – I was so close to passing each time but just couldn’t make it over the line. I spoke to my consultants who told me I was a good doctor, that I was safe, had good clinical acumen, and made appropriate management plans. They encouraged me not to give up.

I eventually decided to re-apply to sit the examination again. This time I made a more concerted effort of contacting multiple consultants at various hospitals who I knew were involved in teaching (most were involved with PACES as examiners themselves). I attended with other colleagues who were sitting the examination. I arranged sessions by myself if no one else could attend. I stayed late after work and travelled between sites. This time, the results were released, and I had eventually passed! But not only that, my scores for the skills that I had previously failed on (identifying physical signs and differential diagnosis) were markedly improved on my previous attempts.

Reflection & Advice

If there’s advice that I can give anyone who is struggling to pass the PACES examination, it would be firstly not to give up even if you feel defeated and like you will never make it. Practising with colleagues and seeking out Consultants in your hospital and nearby hospitals who are involved with teaching or even with PACES as examiners is essential (and they are often some of the friendliest Consultants in the hospital!). Courses can be beneficial to attend, and online resources can be a useful addition to your revision strategy, but there really is no substitute for good old fashioned bedside teaching.

Examination day can be daunting and nerve-wracking, and it is important to try and stay as calm and composed as possible. Take time to read the scenarios properly. Use the time outside the station to formulate a plan of action and what you are going to do. Take deep breaths. Most importantly (and sometimes the most difficult thing to do) – be confident! It can be easy to second guess your findings in the examination setting and examiners will take nerves into account, but they are looking for a clinician who is confident in their approach to examination and their findings. They want you to express this confidence when reporting your findings back to them.

PACES can sometimes be seen as a necessary hurdle that is required to progress with training. It may not be the most reflective examination of how we currently practice medicine, but I feel that the examination has made me a better clinician. I have improved my examination skills, become more confident at eliciting signs and presenting them, am more thoughtful in my differential diagnosis and clearer in my communication skills.

It took me five attempts to pass PACES, but I finally got there in the end, and you will too.