What is the PACES Exam?

The Practical Assessment of Clinical Examination Skills (PACES) is a postgraduate medical examination designed to test the clinical knowledge and skills of trainee doctors who aspire to enter higher specialist training. The exam is a crucial step in the journey to become a member of the Royal College of Physicians (MRCP) in the United Kingdom.

The PACES exam is divided into five stations, each station designed to test a different set of clinical skills. These skills include history-taking, communication, clinical examination, diagnosis, and management. The exam sets rigorous standards to ensure that trainee doctors possess the competence and skills necessary to provide a high standard of care to patients.

The exam is open to those who have passed the MRCP(UK) Part 1 written exam within the last seven years. Candidates are required to demonstrate a broad range of competencies, including clinical knowledge, communication skills, and professional behaviour.

What is PACES23?

In response to changes in postgraduate medical education, the MRCP(UK) has recently introduced a new format of the exam known as PACES23. The new exam still tests the same clinical skills, but some of the encounters are changing to better reflect the competencies required of doctors in the 21st century.

Due to the impact of the COVID-19 pandemic on PACES centres worldwide, the introduction of the new format was delayed. However, the exam is now set to be introduced from the third diet of 2023, with Singapore candidates sitting the exam from early 2024.

While the exam will still test the same clinical skills, the encounters in some stations will be changing. More information and training materials for candidates and examiners will be provided in the lead up to the introduction of PACES23.

As part of the changes, Station 2, which assessed structured history-taking skills in isolation, has been removed, as has Station 4, which included a 20-minute communication and ethics encounter with a five-minute examiner/candidate interaction. Station 5, which tested all seven skills in a 10-minute integrated manner, has also been removed.

In their place, two 10-minute communication encounters will be introduced, judged on observation alone. Additionally, two 20-minute clinical consultations will assess candidates across all seven skills in a realistic and integrated manner. The new carousel will alter the sequencing of the encounters, ensuring that examiners at each station contribute more judgements in each of the skills for each candidate, improving the reliability of the exam.


Source: MRCP(UK), 2023.

How is the PACES exam marked?

Prior to the start of the PACES exam, examiners engage in a process of calibrating all cases at each station. This involves agreeing on the specific areas that a candidate must cover in order to receive a satisfactory mark. The criteria used by the examiners are based on the guidance provided on the marksheet, as well as the expectations for the performance of a competent trainee doctor entering higher specialist training (ST3 in the UK).

The PACES exam is graded on seven skills: A-G. Skill B, which involves identifying physical signs, is often considered the most challenging skill to pass. Skill A focuses on physical examination and is tested in stations 1, 3, and 5. Skill C pertains to clinical communication and is evaluated in stations 2, 4, and 5. Skill D involves differential diagnosis and is assessed in stations 1, 2, 3, and 5. Skill E, clinical judgement, is evaluated in all stations, while skills F and G, managing patients' concerns and maintaining patient welfare, respectively, are tested in all stations.

To improve your chances of success in the PACES exam, it is important to remember that poor performance in one station does not necessarily mean poor performance in the next. It is advisable to concentrate on the next station during the five-minute break, rather than reflecting on previous stations. This can be particularly challenging in stations 1 and 3, where there is no scenario to read. Examiners are aware of the potential for anxiety to impact performance and recognise that practice can help you better manage your anxiety.

Skill A: Physical Examination

In Skill A, candidates must demonstrate good technique when examining the respiratory, abdomen, cardiovascular, and neurological systems. Failing to do so can result in a failed exam.

To pass Skill A, it is important to examine the systems in a systematic way, use correct techniques, and not miss significant parts of the examination. Additionally, candidates must be mindful of other factors that can lead to being marked down, such as hesitancy or lack of confidence, unprofessional examination, and examining the patient through their clothing.

To improve their performance in Skill A, candidates should examine as many patients as possible, including those without clinical abnormalities, and have their examination technique observed by their clinical supervisor or more senior colleagues who can give critical feedback. Practicing with a timer can also help candidates manage their time during the exam, especially since they must complete their examination in no more than 6 minutes at stations 1 and 3, and perform a focused examination at station 5 based on the scenario and patient history.

Skill B: Identifying Physical Signs

Skill B is one of the most challenging skills to pass in the PACES exam. This skill involves identifying physical signs and presenting them logically and clearly to the examiners during discussion. The ability to identify physical signs is a crucial skill for physicians, even in today's era of easy access to investigations. Confidence in this skill comes with practice.

Here are some reasons why you may not have passed Skill B in the PACES exam:

- Not identifying the physical signs that were agreed upon by the examiners during calibration

- Reporting physical signs that were not present

To improve your performance in Skill B, here are some helpful tips:

- Examine as many patients as possible in a systematic manner, including those without abnormal clinical signs, so that you are comfortable identifying and reporting when physical signs are not present

- Ask colleagues from a range of specialties to observe you examine consenting patients and discuss both your examination technique and examination findings with them

- Discuss with your clinical supervisor and ask your clinical colleagues to observe you examining consenting patients with clinical signs in all of the relevant systems

Skill C: Clinical Communication Skills

Communication is an essential skill for physicians to accurately understand and address the medical, personal, and social issues of patients, ensuring their safety. In the PACES exam, clinical communication skills are tested through various stations.

In stations 1 and 4, candidates must take a thorough and systematic history, identify patient concerns, and agree on a management plan in no more than 10 minutes. These stations no longer include a question and answer section with the examiners. Instead, the encounter will be judged on observation alone. In stations 2 and 5,  two 20-minute clinical consultations will assess candidates across all seven skills in a realistic and integrated manner. Candidates will have 15 minutes to take a structured history, examine the patient, explain the likely diagnosis and management and address any questions or concerns raised. There will then be a five-minute question and answer section with the examiners.

Candidates who fail Skill C often do not explain relevant clinical information accurately or clearly, miss out on essential information, give inaccurate or unclear information, or use too much specialist language that patients do not understand or is unprofessional.

To improve communication skills, candidates should reflect on their marksheets, discuss feedback with their educational supervisor or a senior colleague, and practice information gathering and giving as often as possible. Candidates should also practice speaking English, using medical terms that are easy to understand and avoid confusing specialist language. Sample scenarios included within the Pastest PACES subscription are an excellent source of practice material. Finally, candidates should ask senior colleagues to watch them taking a history or communicating with patients or surrogates to provide feedback.

Skill D: Differential Diagnosis

In the PACES examination, the skill of differential diagnosis is closely linked with the ability to identify physical signs (Skill B). If you are unable to identify physical signs accurately, your differential diagnosis will be affected as well. To perform well in Skill D, you must provide the correct diagnosis and suggest an appropriate differential diagnosis for the patient, with the most likely diagnosis mentioned first. Merely listing a textbook-like differential diagnosis that is irrelevant to the patient is not considered satisfactory.

Here are some reasons why you may not have passed Skill D:

- Giving an inadequate or inappropriate differential diagnosis

- Failing to consider the right diagnosis

- To improve your performance in Skill D, here are some tips:

- Practice formulating differential diagnoses for all the patients you encounter, and seek feedback from your colleague

- Seek opportunities to be observed while examining patients and generating a differential diagnosis

- Engage in case-based discussions with your clinical or educational supervisor, or with a senior colleague, to refine your skills

Skill E: Clinical Judgement

Clinical judgement is a connected skill, which means that failing to identify physical signs (Skill B), and particularly failing to consider the correct diagnosis (Skill D), will lead to a deduction in the Clinical Judgement score. You are expected to suggest appropriate investigations and discuss a reasonable management plan for the patient you have examined. However, managing the wrong condition, even if it is done correctly, will not be considered satisfactory.

Reasons why you may not have passed Skill E:

- Lack of familiarity with the correct management plan

- Failing to identify the correct clinical signs or arrive at the correct diagnosis, leading to the recommendation of an incorrect management plan

- Proposing inappropriate investigations or management for the patient

Tips to help you improve:

- Review the feedback provided on your marksheets and discuss it with your clinical and educational supervisors or a senior colleague

- If the exam highlights any knowledge gaps, revise the areas covered in the written exams

- Seek feedback from senior colleagues on examining a diverse range of medical patients, followed by discussion on differential diagnosis, appropriate investigations, and management

Skill F: Managing Patient Concerns

Ensuring a satisfactory consultation requires the ability to identify the patient's main concerns. It's important to ask if they have any questions and answer them accurately and sympathetically while ensuring their understanding.

Failing to explore the patient's concerns in enough detail, talking over them, not listening, not checking their understanding, failing to build rapport, or running out of time to answer questions can result in not passing Skill F.

Improving involves reviewing marksheets for comments, reflecting on areas of weakness with an educational supervisor or senior colleague, identifying patient concerns during interactions, and practicing potential scenarios, especially if English isn't your first language. Using a timer during practice can ensure enough time is allotted to ask the patient or surrogate about their questions or concerns.

Skill G: Maintaining Patient Welfare

Treating the patient with dignity and sensitivity is crucial for a safe doctor-patient relationship. Skill G examines your ability to ensure patient comfort and safety and to treat them with sufficient respect and sensitivity. Failure in this skill may indicate causing emotional or physical discomfort, making unsafe decisions, or not ensuring their comfort and safety. Specific areas of concern may be highlighted in your marksheets.

To improve, reflect on the comments on the marksheets and discuss them with an educational supervisor or senior colleague. Consider how you would like your own relatives to be examined or cared for, as a guide for improving your approach.

How can Pastest help you pass PACES?

Are you preparing for the MRCP PACES exam and feeling overwhelmed with the amount of information you need to know? Look no further than Pastest's MRCP PACES online resource designed to help candidates pass the exam with confidence.

Pastest offers a range of features to aid your exam preparation, including 125 patient cases, each with over 340 hi-res, ‘gold standard’ PACES examination videos showing best-practice from model exam candidates. In addition, topic summaries provide efficient access to essential information about the topic tested in the patient examination.

Pastest also provides clear, close-up clinical signs and on-screen palpation findings to help you view patients through the eyes of an exam candidate. You can also learn from clinical images and sounds integrated into case videos and improve your ability to recognize clinical signs with the Spot Diagnosis feature, which includes a large bank of images covering skin, fundoscopy, gait/neurology, and more.

To enhance your preparation, Pastest also offers role-play material for you to practice with colleagues using downloadable PDFs. You can also listen on the go to case podcasts featuring candidates presenting their examination findings and case critiques provided by examiners.

To help you stay on track with your progress, Pastest provides access to key progress data in your subscription dashboard, allowing you to monitor the cases you've worked through, broken down by station.

Pastest also addresses the lowest pass rate of 'Identifying Physical Signs,' according to the MRCP(UK) 2020 Annual Report. You can improve your ability to recognise clinical signs, including scars, respiratory sounds, heart sounds, and distinctive gaits with the Teaching Cases and exam marksheets.

With top tips on each station provided by PACES experts, Pastest offers everything you need to pass every station with flying colors. Get started today and ace your MRCP PACES exam with Pastest!