The time has finally arrived for me to share my insights on my experience with the MRCP PACES Exam. This moment has been long-awaited, spanning over four years, since completing my MRCP Part 1 and Part 2 written exams. Following these milestones, I redirected my focus towards the PLAB exams instead, as this was the means to get my GMC registration faster. Subsequently, during my tenure in the NHS as a trust grade doctor, I dedicated myself to maintaining my portfolios to get my CREST form signed off to gain entry into the Internal Medicine training program. Although this delay in pursuing the PACES exam may have seemed like a setback at first, it ultimately proved to be advantageous for me. It allowed me to observe the preparation strategies of my senior colleagues, understand the reasons behind multiple exam failures among candidates, and acclimate myself to the workings of the NHS systems. Moreover, getting into the training program bolstered my position on the exam priority list, in securing the exam dates as well.
THE MRCP PACES exam is the final hurdle to getting that much-coveted degree of MRCP (UK) beside your name. You have come this far and with sensible plan and technique, you will get over this too.
In the following discourse, I want to help you by addressing the frequently asked questions regarding it.
What is the PACES exam?
PACES stands for Practical Assessment of Clinical Examination Skills, which is the third part of the MRCP (UK) Exam. Doctors in training take the MRCP (UK) examination 2 or more years after qualifying as a doctor. Those who pass become Members of Royal College of Physicians and can undertake higher specialty training to become a consultant.
How to get a PACES seat?
Many people ask me this question. But, as I have made clear earlier, your chances of getting exam dates increase once you enter the training program and complete Part 1 and Part 2 written exams. Currently, there are four broad prioritization categories for allocating candidates living and working in the UK to available PACES places.
Category 1- Those in IMY3/ACCS CT3/ST3 (with a National Training Number (NTN)). Those in UK centers whose last diet was cancelled (irrespective of whether they hold an NTN)
Category 2a- Those in IMY2/ACCS CT2 with an NTN and a pass in Part 2 Written at time of application. Those who have completed CMT/IMT at any time with a pass in Part 2 Written at a time of application (irrespective of whether they hold an NTN). Those who are not in a recognized UK training post, with a Pass in Part 2 Written at time of application but who are intending to apply for Higher Specialty Training in 2024 with a valid Alternative Certificate* (irrespective of whether they hold an NTN). *Please note that candidates will be required to provide evidence of their alternative certificate before they are allocated a place in the examination.
Category 2b- Those in IMY2/ACCS CT2 with an NTN but without a pass in Part 2 Written at time of application. Those who have completed CMT/IMT at any time without a pass in Part 2 Written at time of application (irrespective of whether they hold an NTN). Those who are not in a recognised UK training post, without a Pass in Part 2 Written at time of application, but who are intending to apply for Higher Specialty Training in 2024 with a valid Alternative Certificate* (irrespective of whether they hold an NTN).
Category 3- Those in IMY1/ACCS CT1 with an NTN
Category 4a- Other UK applicants who have previously applied but not been offered a UK PACES place (irrespective of whether they hold an NTN).
Category 4b- All other UK applicants
I was placed in category 2a on my application and got the exam date of my choice. The application period opens for a week and the exam dates are not offered on a first come first serve in the international centers as well. Payments are usually made after the seats are offered. The exam fee is £657 in the UK centre.
What special arrangement can be requested for the exam?
During the application, at step 5 of 9, there is an area of free text, where you can ask for reasonable special arrangements. In my case, I asked for a specific month and specific region, as getting study leaves and PACES courses arranged is tricky once you are in the training program. Luckily, they accepted both my requests, but it’s all up to the RCP to whether to accept or deny your request. Do not ask for a particular center rather ask for a region like east of england/south west et, and do not ask for a particular date rather give a range of month to increase chance of the acceptance of your request. There are some self-declarations that you need to make around the exam center in some cases which I have explained later.
How long did you take to prepare for the exam?
This is a highly subjective question. My actual preparation for the exam began on June 2023 and my exam was on October 2023. However, I had started preparing from some resources much earlier than that as well. Some people will take more and some less, but my recommendation is to dedicate your mindset fully for at least 6 months to this exam. This is easily manageable with your job.
What resources did you use to prepare for the exam?
I used the following resources: -
Pastest PACES videos (https://www.pastest.com/mrcp-paces/)
The Pocketbook for PACES by Rupa Bessant (https://amzn.to/43vESHb)
Cases for PACES by Hoole, Fry, and Davies (https://amzn.to/3IQ19pH)
Online websites- Clinical Skills Pro, PACES Medical Education Leeds
Oxford handbook clinical tutor study cards MEDICINE (https://amzn.to/3vhficy)
I will explain how I made use of these resources later.
Which PACES academy did you go to? Do you recommend joining one?
Every deanery nowadays runs its own 2-day PACES preparation course. If you join them, make sure you declare that in your PACES exam application form. It will be unethical to take the PACES exam in the same center where you did your PACES course as well.
However, I do recommend joining the 4-day PACES course in London. I personally don’t have much experience in the deanery-run courses. PACES courses in London are very intense and let the candidate practice with an ample number of challenging cases and provide good tutors. PACES Ahead (https://www.pacesahead.com) and Pass Paces (http://www.passpaces.co.uk) are the two famous ones. You can see the full list of other course in this website as well - https://pacescourses.co.uk
I can’t compare one over the other, but in my case, I did go with PACES ahead. I have a good number of friends vouching for both courses. Bear in mind that these courses are very expensive. I paid 1595£. I will later explain how I funded these courses.
How did you prepare for the PACES exam overall?
I started by watching Pastest PACES videos. I used these videos to first polish my examination and presentation technique. I also used Pocketbook for PACES side by side for any system/cases that I watched in the videos. I then created my own notes for things that I easily missed during the examination or the points that I won’t cover in communication or consultation-based stations.
The next step was to create a group of buddies in my hospital, who were taking the exam on the same diet. We allocated jobs of finding cases and posting in the WhatsApp group. We then took turns to speak to these patients and examine them. We also did the mock session of being an examiner and candidate in turns and presenting cases/asking questions. I had some of my senior colleagues in my group, who had already been in this exam before. Having them in our study group helped us immensely in correcting our common errors. We also caught consultants who were free during the day to take over the role of examiner and assess our performance.
Then, I joined the PACES Ahead course in London. This helped me in making my communication and examination techniques slicker. I examined hundreds of challenging cases during the course which boosted my confidence a lot. I recommend timing these courses properly. Do not go into this course without a baseline knowledge about the exam and do not also postpone it until too late towards your exam date. Getting into the course 3-4 weeks before the exam is the sweet spot that you want to hit.
After coming back from the course, I continued my practice with my friends in my hospital. I then used the cases for paces book to revise the case quickly. Websites like Clinical Skills Pro became quite handy in knowing the common cases for the exam and the PACES medical examination Leeds website helped me fill some of the gaps as well. I also had Oxford clinical tutor cards to glance at the important findings and information about a case. In my free time, while I was driving or doing dishes at my home, I used to listen to Pre PACES podcast by Sam Williams https://podcasts.apple.com/gb/podcast/the-pre-paces-podcast/id1551562661
Candidates tend to focus more on examination-based stations but completely forget there are bulk of consultation-based and communication-based stations as well, which is the main reason for failure. Especially consultation-based stations can have an infinite number of possibilities to test; hence these are turning out to be more challenging in newer formats. As most candidates can pretty much know there are only a limited number of scenarios to test you in communication and examination-based stations.
Tell me a little bit about the exam format?
You may have already known that PACES is running in a new format. I was the first batch of this new format. Due to these changes in the format, results are not released as fast as in the previous formats. The total number of stations remains the same, but the examiner now has the privilege to assess you in more skills than in the older format.
5 stations will constitute the PACES23 carousel -
5 mins (to read the scenario for 1A)
Station 1A: Communication (10 minutes) – No Q/A at the end
Station 1B: Respiratory (10 minutes) – 6 mins examination + 4 mins Q/A
5 mins interval (to read scenario)
Station 2: Consultation (20 minutes) – 15 mins History/Examination/Explain diagnosis & management/Address concerns + 5 mins Q/A
5 mins interval (No scenario will be given to read)
Station 3: Cardiovascular (10 minutes) – 6 mins examination + 4 mins Q/A
Station 3: Neurology (10 minutes) – 6 mins examination + 4 mins Q/A
[These are not divided as 3A and 3B as you may get either cardio or neuro case first in any order]
5 mins intervals (to read the scenario for 4A)
Station 4A: Communication (10 minutes) – No Q/A at the end
Station 4B: Abdominal (10 minutes) – 6 mins examination + 4 mins Q/A
5 mins interval (to read scenario)
Station 5: Consultation (20 minutes) – 15 mins History/Examination/Explain diagnosis & management/Address concerns + 5 mins Q/A
Station 1B (Resp), Station 3 (Cardio and Neuro), and Station 4B (Abdo) will have introductors clearly visible to the candidate in the wall inside the cubicle. Hence you will not get any scenario to read outside the cubicle in Station 3. These introductors will ask a question, your examination should be focused and systematic to answer this question. For e.g., This patient presented with palpitation. Please examine their cardiovascular system to establish a cause.
Station 1A & 4A (Communication) will have a scenario given outside the cubicle. You will have 5 minutes to read them and prepare yourself. These stations will assess your communication skills like – dealing with angry patients/relatives, explaining the diagnosis, giving clinical updates to the relative, negotiating the treatment strategy, dealing with ethical dilemmas, and breaking bad news. You may explain clinical information, apply clinical knowledge, including knowledge of ethics, to the management of the case or situation, provide emotional support, and treat the patient with dignity and respect. This will also test in the areas like Duty of candor. In the future, these stations are also aimed at incorporating telephone discussion, MDT discussion, Discharge planning, and rationalizing medication/dealing with drug errors.
Stations 2 & 5 (Consultation) will also have brief scenarios given outside the cubicle. Utilize this time to jot down important questions that you may not wish to miss asking to your patient. You will be tested in acute scenarios as well as less acute scenarios (like in an Outpatient setting). You will have a patient with physical signs. There may be a surrogate inside who may answer you during your history taking and then direct you to the real patient for the exam (mostly in the international center). In your 15 minutes, take a detailed history from the patient or surrogate (including social history/drug history/travel history) and perform only a focused examination (not detailed as in stations 1b, 3, and 4b). You may choose to continue asking questions as you are performing the examination. At the end, address the patient’s concerns and advise on their management. Assume this is like your proper medical shift in MAU following GP or ED referral with some information on hand. This particular station tests your all 7 skills.
What are these skill areas and marking schemes? What is the pass score of this exam?
There are 7 skill areas-
Skill A: Physical signs – 24 marks
Skill B: Identifying physical signs – 24 marks
Skill C: Clinical communication – 16 marks
Skill D: Differential diagnosis – 24 marks (28 in old format)
Skill E: Clinical judgment – 32 marks
Skill F: Managing patient concerns – 16 marks
Skill G: Managing patient welfare – 32 marks
Total 168 marks
You need to pass all 7 skills and also pass in overall threshold of mark (around 127 marks)
Different stations test different numbers of skills. Like-
Station 1A + 4A: Skill C + E + F + G
Station 1B + 3 + 4B: Skill A + B + D + E + G
Station 2 + 5: Skill A + B + C + D + E + F + G
You will be assessed by ten examiners, two at each of the stations. For each of the eight encounters, they will complete a mark sheet assessing a combination of skills. Each is graded Satisfactory (2 marks), Borderline (1 mark) or Unsatisfactory (0 marks). Examiners will review the patients at all 5 stations to establish the criteria for a satisfactory grade. This is known as calibration. If for some reason one of the examiners is absent in any one of these stations, you will be given a chance to withdraw yourself from the exam and postpone it to a later date. I remember this happened during my exam. However, I wanted to proceed despite this. If you want to continue with the exam in such a circumstance, you will then have to sign a declaration that says that you understand the absence of an examiner in one of the stations and you have no objection to this.
Will the instrument to examine a patient be provided in the exam?
The answer is Yes. But I have a few recommendations for this. Consider taking the Littmann Master Cardiology stethoscope to the exam. If you take other stethoscopes, you will lose time in changing the bell and diaphragm in each of the cardiology auscultation areas. In a Master cardiology stethoscope, you will just need to apply firm pressure to engage the diaphragm and lighter pressure to engage the bell. Some eagle-eyed examiners can see the capillary bed of your nail to identify if you are engaging both bell and diaphragm or not with that stethoscope. Do not take a digital stethoscope, it’s not an absolute contraindication, but if you do take one, you will need an examiner to recalibrate the station with your device only for you, which is going to be a big hassle. https://amzn.to/4aoxDDi
I also recommend taking your own pocket fundoscope. Although you will be provided with a fundoscope during the exam, I don’t want you to panic with a new instrument that you may have not used before and struggle in turning it on or changing lens aperture and power during that stressful time. Take something you are familiar with and with the one that you have practiced before. https://amzn.to/4arT32l
Also, buy a nurse pocket watch with a brooch for checking pulse rate or respiratory rate. Do not rely on a wall clock (which may or may not be present in the room). https://amzn.to/498MCQz
Besides all other accessories like a tuning fork, knee hammer, cotton wisp, and neuro tip pin can be used from the one in the center.
How to prepare a day before the exam?
Arrange your exam center document, your primary ID, your stethoscope, and your fundoscope. Go to the exam center and book a comfortable hotel a day early. Arrange food for breakfast a day before, because hotel breakfast might not be ready early in the morning and you don’t want hypoglycemia to fog your brain when it is most needed. Dress comfortably and professionally. Remember bare below elbow and no smart watches. I took my own comfortable scrub. You can never go wrong with scrubs. https://amzn.to/499ehRm
Do you have any other tips for exam preparation?
It may seem at first a difficult exam to pass as you need to pass in skills and overall mark threshold, but with proper preparation, you can easily do it on your first attempt. If I can, anybody can.
In a communication scenario, be open-ended in your approach. Learn how to do DNACPR discussion and break bad news. Develop a technique to explain the mode of inheritance in genetic disease, and explain complex diseases in patient-friendly language. Always address the patient’s concerns. Also practice ethical scenarios involving the duty of candor, drug error, patient’s confidentiality, Jehova’s witness, etc.
In a consultation scenario, you may get a GP or ED referral for a suspected disease tied to a symptom. Do not close down your approach only to that disease. More often than not, you may find signs and symptoms that may lead you to a different diagnosis. Also, these are the stations, where you have to manage your time properly. Being too detailed on examination, may not give you enough time to address concerns or explain management at the end, and being too brief on history taking may keep you silent for 2 minutes at the end before the examiner jumps in to ask you questions. Do not forget your precious ICE questions here.
In the examination-based scenario, finding physical signs may be the most challenging one, but with practice and perfect technique, it is always doable. Always keep in mind that there are only a handful of cases that may appear in the exam. Have a strong grip over those stations. When centers do various logistical preparations for patients they don’t want unreliable patients who don’t show up, patients with clinical signs that come and go, who could get sick during the exam, or who can’t consent to participate. This will tell a lot about what might come up in the exam. Read more at https://clinicalskillspro.com/what-will-come-up-at-my-paces-centre/
Cases in the respiratory station of PACES that appear will be broadly from one of these categories:
- Restrictive lung disease
- Obstructive lung disease
- Scar e.g Lung cancer/transplant
- Pleural effusion (less likely unless patient brought from the ward. Look for signs like cannulas or hospital wristband).
Likewise, Cardiology will test you mostly in:
- Murmurs
- Scars
Categories of Neuro cases will mostly be:
- Upper motor neuron lesion
- Lower motor neuron lesion
- Cerebellar lesion
- Extrapyramidal symptoms
(Remember there are only a handful of cases where you would be expected to perform a fundoscopy. There are some YouTube videos giving insights into those cases. Please check them as well.)
And in Abdo cases:
- Chronic liver disease
End-stage renal failure
- Organomegaly
- Inflammatory bowel disease
How to fund these exams?
The financial aspects of exams are equally important. You need to plan for everything. Always hope for the best and prepare for the worst. Set aside some funds little by little every month as things may even fall apart and go unplanned from your initial estimate. In my deanery, PACES courses are only funded up to a value of 600£. However, they funded my travel and subsistence. The different deanery have different rules, check with your trust’s postgraduate medical center. The remaining deficit of 1000£ for the course and the exam fee of 657£ itself, along with all other instruments you buy can be claimed for tax relief from HMRC.
Thank you. I wish you all the best. Please let me know if you want any further blogs on more exam preparation tips.
Great work Dr. Sid
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