5 Common PACES Mistakes That Cause Failure | How to Avoid Them

By Dr Zac Hana | 2026-05-18

The Reality of PACES Failure

With a first-time pass rate of approximately 47%, more candidates fail PACES than pass it. But failure is rarely random — the same mistakes appear again and again in examiner feedback reports. Understanding these patterns gives you a significant advantage.

After teaching over 1,050 candidates and reviewing hundreds of examiner feedback forms, we have identified the five most common reasons candidates receive "Unsatisfactory" marks.

Mistake 1: Examining Without a System

What examiners see: A candidate who examines in a haphazard order, misses steps, doubles back, and appears uncertain about what to do next.

Why it fails you: The "Physical Examination" domain specifically assesses whether you have a systematic, reproducible approach. An examiner can tell within 30 seconds whether you have a polished routine or are making it up as you go.

The fix:

Develop one routine for each system and practise it until it becomes automatic. Your routine should be identical every single time — regardless of what you find. This means:

  • Same hand position for percussion every time
  • Same sequence of inspection → palpation → percussion → auscultation
  • Same words when you ask the patient to reposition

    • The goal is to make the mechanics of examination unconscious so your cognitive energy goes entirely toward interpreting what you find.

    How to practise: Examine the same system 20 times in a row on different patients. By patient 15, your routine should feel effortless. If you're still thinking about what comes next, you haven't practised enough.

    Mistake 2: Poor Time Management

    What examiners see: A candidate who is still examining when the bell rings, or who rushes through the last two minutes and misses important signs.

    Why it fails you: If you don't finish examining, you can't present. If you can't present, you fail the "Differential Diagnosis" and "Clinical Judgement" domains — even if your examination technique was perfect.

    The fix:

    Know exactly how long each phase of your examination takes:

    PhaseTime Budget General inspection + hands60 seconds Face, neck, and positioning60 seconds Core examination (chest/abdomen/neuro)4-5 minutes Completion (peripherals, thank patient)30 seconds Presentation to examiners90 seconds Examiner questions2-3 minutes

    The critical rule: If you haven't started auscultation/main examination by 2 minutes in, you're behind. Skip to the core examination and come back to peripherals if time allows.

    How to practise: Use a stopwatch for every practice examination. Record your times and identify where you consistently lose seconds.

    Mistake 3: Failing to Engage the Patient

    What examiners see: A candidate who treats the patient as an object to be examined rather than a person to be cared for.

    Why it fails you: "Maintaining Patient Welfare" is one of the seven assessed domains. Examiners are specifically watching for:

  • Did you introduce yourself?
  • Did you explain what you were about to do?
  • Did you ask about pain before palpating?
  • Did you maintain the patient's dignity (covering them appropriately)?
  • Did you thank the patient at the end?

    • The fix:

    Build these phrases into your routine so they happen automatically:

  • "Hello, I'm Dr [name]. I've been asked to examine your [system] today. Is that alright?"
  • "I'm going to feel your tummy now — please let me know if anything is tender."
  • "Could you sit forward for me please? I need to listen to your back."
  • "Thank you very much for your time. You can get comfortable again."

    • These take 10 seconds total and can be the difference between Borderline and Satisfactory in the patient welfare domain.

    The deeper point: Patients in PACES are volunteers. They give their time to help you pass. Treat them with genuine warmth and respect — examiners notice, and it creates a positive impression that colours their assessment of everything else you do.

    Mistake 4: Presenting Without Conviction

    What examiners see: A candidate who lists findings without interpreting them, hedges every statement, or says "I think it might possibly be..."

    Why it fails you: The "Differential Diagnosis" and "Clinical Judgement" domains require you to commit to a diagnosis and justify it. Examiners want to hear you think like a registrar making decisions, not a medical student listing possibilities.

    The fix:

    Use this presentation structure:

  • State your diagnosis first — "My diagnosis is aortic stenosis."
  • Support it with findings — "This is based on the slow-rising pulse, narrow pulse pressure, ejection systolic murmur radiating to the carotids, and S4."
  • Give important negatives — "There is no evidence of heart failure."
  • Offer a plan — "I would confirm with echocardiography and assess severity."

    • What to do when you're uncertain:

    Even if you're not 100% sure, commit to your most likely diagnosis. You can say: "My primary diagnosis is X, with Y as an alternative if [specific finding] is confirmed on investigation." This shows clinical reasoning without appearing indecisive.

    Never say:

  • "I'm not sure what this is"
  • "It could be many things"
  • "I think maybe possibly..."

    • Mistake 5: Not Practising on Real Patients

    What examiners see: A candidate whose examination technique looks textbook-perfect but who clearly hasn't felt a real heaving apex, heard a quiet diastolic murmur, or palpated an enlarged spleen.

    Why it fails you: There is a visible difference between a candidate who has examined 50 real patients and one who has only practised on friends. Real patients have:

  • Signs that are subtle, not textbook-obvious
  • Bodies that don't cooperate perfectly (obesity, pain, limited mobility)
  • Anxiety that affects the interaction
  • Multiple co-existing conditions that complicate the picture

    • The fix:

    There is no shortcut here. You need to examine real patients with confirmed clinical signs before your exam. Aim for:

  • Minimum 30 patients across all systems
  • At least 5 patients per system (respiratory, cardiovascular, abdominal, neurological)
  • Variety — don't just examine the same 3 patients on your ward repeatedly

    • Where to find patients:

  • PACES courses at teaching hospitals (most efficient — guaranteed signs)
  • Outpatient clinics (cardiology, respiratory, rheumatology, neurology)
  • Ward rounds with supportive consultants
  • Study groups who share patient access

    • At our courses at Guy's Hospital, you alternate through 18 Saturday teaching slots: nine assessed attempts and nine observed slots, with individual written feedback on your assessed practice. The 3-Day adds Friday specialty teaching with real patients and Sunday communication role-play.

    The Common Thread

    All five mistakes share one root cause: insufficient structured practice with expert feedback. Self-study can teach you the theory, but PACES is a performance exam. You need to perform under pressure, with someone watching, and receive honest feedback on what you're doing wrong.

    This is why candidates who attend structured courses pass at rates 15-20% higher than those who self-study alone. It's not about the content — it's about the feedback loop.

    ---

    Ready to fix these mistakes before your exam? Book a BitePACES course | Read more: How to Pass PACES First Time