PACES23 Marking Domains: What Examiners Actually Score

The Most Overlooked Element of PACES Preparation

Most PACES candidates obsess over clinical knowledge — memorising signs, drilling examination routines, rehearsing management plans. These matter. But what actually determines whether you pass or fail is something far more structural: the seven marking domains.

The PACES examination is not scored on a general impression. Two examiners at each station independently assess your performance across predefined skill domains. Your final result depends on cumulative performance across these domains — not simply whether you "looked competent" on the day.

Understanding these domains — what they genuinely test, how examiners interpret them, and which stations carry the most weight — is the single most powerful preparation strategy that candidates consistently neglect.

The Seven Marking Domains Decoded

1. Physical Examination

What it tests: Your ability to perform a competent, systematic, and efficient examination relevant to the clinical scenario presented.

What examiners actively look for:

• A structured, reproducible routine (inspection → palpation → percussion → auscultation in the appropriate order)

• Correct technique — hand placement, patient positioning, use of equipment

• Efficiency without omission — completing the relevant examination within the allocated time

• Appropriate exposure while maintaining dignity

• Smooth, confident transitions between examination components

How to score well in this domain:

• Your examination routine must be automatic. If you are mentally working out what comes next, you are not giving enough cognitive bandwidth to identifying signs and forming your differential.

• Always begin with general inspection from the end of the bed — hands, face, body habitus, paraphernalia around the patient. This is the single most underperformed step.

• If the examiners ask you to move on or skip ahead, comply immediately and without hesitation — they have sufficient information for this domain.

• Do not perform examinations outside the scope of what is asked. If instructed to examine the cardiovascular system, a cursory peripheral stigmata check is appropriate; a full abdominal examination is not.

Red flags for failure:

• Omitting fundamental components (e.g., not examining the hands, not checking the pulse)

• Technique so poor that examiners cannot trust your findings (e.g., palpating the apex beat with the wrong hand position)

• Disorganised, hopping between body regions without a clear system

• Rushing to the point of missing basic steps

2. Identifying Clinical Signs

What it tests: Your ability to correctly identify the abnormal physical signs that are present in the patient.

This domain is distinct from examination technique. It is possible to have excellent technique and still fail this domain by misidentifying signs. Equally, a candidate with slightly imperfect technique but accurate findings can pass comfortably.

What examiners actively look for:

• Correct identification of the key sign(s) that the case is built around

• Accurate description of what you find, using appropriate terminology

• Avoidance of false positives — reporting signs that genuinely are not there

• Appropriate handling of borderline or subtle findings

How to score well in this domain:

• Only report signs you are genuinely confident about. A false positive is scored more harshly than a missed subtle sign because it suggests poor clinical judgment, not just imperfect examination.

• Describe before you interpret: "There is a pansystolic murmur, loudest at the apex, radiating to the axilla... consistent with mitral regurgitation" — not simply "this patient has mitral regurgitation."

• If genuinely uncertain, say so honestly and professionally: "I think there may be a soft diastolic murmur at the left sternal edge, though I would wish to confirm this with a senior colleague." This demonstrates insight and safety.

Red flags for failure:

• Confidently reporting a sign that is clearly not present (most commonly with murmurs and added breath sounds)

• Missing an obvious sign entirely (e.g., a prosthetic valve click, visible surgical scars, obvious clubbing)

• Describing examination technique rather than findings ("I percussed the chest" rather than "there was stony dullness at the right base")

• Failing to check for or comment on key associated features (e.g., finding a murmur but not commenting on radiation)

3. Clinical Communication

What it tests: Your ability to gather information, explain clinical concepts, provide appropriate information, and conduct a purposeful consultation.

This domain is heavily weighted in the PACES23 consultation stations (Stations 2, 4, and 5) and is also relevant during the examiner discussion in clinical stations.

What examiners actively look for:

• Open-to-focused questioning — starting broad and progressively narrowing

• Active listening, including appropriate use of silence and non-verbal cues

• Clear explanations adapted to the patient's level of understanding, free of unnecessary jargon

• Appropriate signposting and structuring of the consultation

• Responsiveness to verbal and non-verbal cues from the patient

• Effective chunk-and-check technique — delivering information in manageable segments and confirming understanding

• Appropriate closing, including safety-netting

How to score well in this domain:

• Always open with a genuinely broad question: "Can you tell me in your own words what's been happening?" Then progressively focus.

• Use ICE (Ideas, Concerns, Expectations) — but weave it naturally into the conversation rather than asking it as a rigid sequence.

• Signpost your structure: "I'd like to start by understanding more about your symptoms, then explain what I think is going on, and then discuss the plan. Does that sound alright?"

• Teach-back method: "Just so I know I've explained things clearly, could you tell me what you understand about what we've discussed?"

Red flags for failure:

• Reading from a mental checklist rather than having an authentic conversation

• Excessive medical jargon — "You may have paroxysmal atrial fibrillation" instead of "Your heart may be going into an irregular rhythm from time to time"

• Interrupting the patient — especially within the first 30 seconds

• Failing to address the patient's primary concern — which may not be the clinical problem you've identified

• Jumping between topics without signposting, leaving the patient confused

4. Formulating Differential Diagnosis

What it tests: Your ability to generate a sensible, prioritised, and well-reasoned differential diagnosis based on the clinical information.

What examiners actively look for:

• A primary diagnosis that genuinely fits the clinical picture

• A differential list that covers the important possibilities — including common and serious conditions

• Appropriate prioritisation — the most likely and most consequential diagnoses presented first

• Reasoning behind each diagnosis — why you included it and, crucially, why you excluded alternatives

• Awareness of "can't miss" diagnoses relevant to the presentation

How to score well in this domain:

• Start with your primary diagnosis and justify it: "My primary diagnosis is mitral stenosis. The key findings are a rumbling mid-diastolic murmur at the apex, an opening snap, and a loud S1, all of which are consistent with this."

• Give differentials in order of likelihood or importance: "My differential would also include a left atrial myxoma, though this is less common, and an atrial septal defect with a large shunt, which can occasionally produce a similar murmur."

• Explain what you considered and excluded: "I considered aortic regurgitation because of the diastolic component, but the murmur characteristics and location make this less likely."

• Always mention relevant serious conditions: "I would also want to consider infective endocarditis, given the patient's history of valve disease, and would specifically ask about constitutional symptoms and risk factors."

Red flags for failure:

• A single diagnosis with no differentials offered

• The "kitchen sink" approach — listing every possible diagnosis without prioritisation or reasoning

• A primary diagnosis that clearly does not fit the clinical picture

• Missing a critical diagnosis — especially time-sensitive conditions

• No reasoning or justification for any of the diagnoses offered

5. Clinical Judgement

What it tests: Your ability to synthesise information and make appropriate, safe, and patient-centred decisions regarding investigations and management.

This is the domain that most distinguishes a candidate performing at the level of a doctor entering higher medical training from one who is not. It tests not just what you know, but how you apply it.

What examiners actively look for:

• A logical, structured approach to investigation — bedside, bloods, imaging, specialised

• Justification for each investigation — not simply a list

• A management plan that is evidence-based, guideline-aware, and individualised

• Consideration of the patient's comorbidities, social circumstances, and preferences

• Awareness of when to escalate or involve specialist teams

• Appropriate safety-netting for the clinical scenario

How to score well in this domain:

• Structure your investigations: "At the bedside, I would check an ECG and oxygen saturations. Blood tests would include a full blood count, urea and electrolytes, and troponin. I would arrange a chest X-ray and, given the findings, an echocardiogram."

• Justify each investigation: "I would request a troponin because the patient describes exertional chest tightness, and we need to exclude myocardial injury."

• Tailor your plan to the individual: "Given this patient's significant frailty and comorbidities, I would adopt a more conservative approach and discuss the risks and benefits of invasive coronary angiography in a multidisciplinary meeting before proceeding."

• Reference guidelines where appropriate: "In line with current NICE guidance, I would initiate..." — but only if you are genuinely confident about the guideline.

Red flags for failure:

• Listing every available investigation without justification ("I would do bloods, a chest X-ray, a CT scan, an echo, an angiogram...")

• A generic management plan that could apply to any patient with the condition — not this specific individual

• Over-investigating without clinical reasoning

• Under-investigating and missing critical tests

• Failing to consider patient circumstances, preferences, or ceiling of care

• Not knowing when to escalate to a specialist

6. Managing Patient Concerns

What it tests: Your ability to identify, acknowledge, and address the worries, fears, and questions of patients and their families.

This domain is particularly relevant in the PACES23 consultation stations, where the scenario often centres on a patient with significant concerns — a new diagnosis, a deterioration, a treatment decision, or a breakdown in communication.

What examiners actively look for:

• Proactive elicitation of concerns — not just responding when a concern is raised

• Acknowledging and validating the concern before attempting to resolve it

• Providing honest, realistic information — no false reassurance

• Negotiating a plan that addresses the concern wherever possible

• Offering specific, actionable support — specialist nurses, written information, follow-up arrangements

How to score well in this domain:

• Ask directly and early: "Before we go any further, I want to understand what's worrying you most about all of this."

• Acknowledge before responding: "I can completely understand why that would be frightening. That's a very common concern, and I want to make sure I address it properly."

• Never dismiss a concern — even if it seems minor or based on a misunderstanding, it is real to the patient.

• Offer concrete actions: "I'm going to arrange for our specialist heart failure nurse to visit you at home this week, and I'll give you a leaflet that explains the medication in more detail."

• Be honest about uncertainty: "I don't have a complete answer to that question right now, but I will speak with my consultant and come back to you before the end of the day."

Red flags for failure:

• Not asking about concerns at any point during the consultation

• Dismissing concerns ("There's really nothing to worry about")

• Providing false reassurance ("Everything will be absolutely fine")

• Addressing the clinical issue but ignoring the emotional dimension entirely

• Offering vague, non-specific reassurance with no concrete plan

7. Maintaining Patient Welfare

What it tests: This is a synoptic domain — assessed across all five stations throughout the entire examination. It evaluates whether you consistently treat patients with dignity, respect, and care.

This domain is often the difference between a borderline pass and a borderline fail. It is also the domain that candidates are most frequently surprised to have failed — because the behaviours it tests are small, cumulative, and easy to overlook under exam pressure.

What examiners actively look for:

• Seeking consent before any physical contact

• Appropriate exposure — enough to examine properly, not so much that the patient is needlessly exposed

• Explaining what you are doing throughout the examination

• Being responsive to signs of patient discomfort or distress

• Treating the patient as an individual — warmth, courtesy, professionalism

• Thanking the patient at the conclusion of every encounter

How to score well in this domain:

• Consent should be automatic: "Is it alright if I examine your chest? I'll need to ask you to undo your gown."

• Narrate gently: "I'm just going to listen to your heart now. If you could lean forward slightly, that would help."

• Check comfort: "Let me know if anything is uncomfortable and I'll stop."

• Cover the patient between examination components — do not leave the patient exposed while you think about your next step.

• Always close with acknowledgement: "Thank you very much for your time and patience today."

• Be genuine. Examiners are highly experienced clinicians — they can tell the difference between authentic warmth and performative behaviour.

Red flags for failure:

• Not seeking consent before touching the patient

• Leaving the patient unnecessarily exposed

• Not explaining what you are doing during the examination

• Ignoring clear signs of patient discomfort

• Being brisk, impersonal, or task-focused at the expense of patient dignity

• Forgetting to thank the patient

How Domains Map to Stations in PACES23

Understanding which domains are tested at each station allows you to prepare strategically:

Stations 1 and 3 — Clinical Examination

Format: You receive a brief clinical vignette, then examine a specific system. Examiners observe your examination and then conduct a structured discussion focused on findings, differentials, and management.

Stations 2 and 4 — Consultation

Format: You receive a brief scenario and then conduct a consultation with a patient or surrogate. This may involve history taking, explaining a diagnosis, discussing management options, addressing concerns, or navigating an ethical dilemma.

Station 5 — Integrated Clinical Assessment

Format: This station combines elements of both clinical examination and consultation. You may need to take a brief focused history, perform a targeted examination, and discuss your findings and management plan — all within a compressed timeframe.

The Pass/Fail Logic: How Domain Scores Combine

This is the section that most candidates misunderstand, and it is critical.

How Scoring Works

At each station, two examiners independently score your performance in the relevant domains. Their scores are combined, and domain scores are then aggregated across all stations.

The Dual Threshold System

To pass PACES, you must satisfy both of the following:

1. Domain threshold: You must achieve a satisfactory standard across a minimum number of the seven domains. Failing multiple individual domains can result in an overall fail — even if your total score appears adequate.

2. Overall score threshold: Your combined score across all stations and examiners must meet or exceed the pass mark for the examination.

What This Means in Practice

This dual-threshold system has a critical implication: you cannot compensate for a failed domain by excelling in another.

• A candidate who performs brilliantly on examination stations (Stations 1, 3) but poorly on consultation stations (Stations 2, 4) can fail because they have failed the communication domain — even if their total score is above the pass mark.

• A candidate who communicates beautifully but cannot generate a sensible differential diagnosis can fail because they have failed the differential diagnosis domain.

• Balance is non-negotiable. You must demonstrate a minimum acceptable standard across all seven domains.

Strategic Preparation by Domain

For Clinical Examination Domains

1. Practise on a wide variety of real patients — not just the classic cases. PACES patients often have subtle or atypical findings.

2. Time yourself relentlessly. You must complete the relevant examination within approximately 6 minutes during the encounter phase.

3. Record yourself and review the footage — you will identify awkward transitions, missed steps, and poor technique that you are completely unaware of in real time.

4. Practise presenting findings aloud, in a structured, confident manner: "On general inspection, the patient is comfortable at rest. There is no cyanosis or breathlessness. The hands reveal..."

5. Drill sign combinations — e.g., what differential arises from combined mitral facies + AF + signs of pulmonary hypertension?

For Consultation Domains

1. Practise with role-play partners — ideally other candidates who can give domain-specific feedback.

2. Record your consultations and score yourself against each domain explicitly.

3. Learn frameworks (SPIKES for breaking bad news, Calgary-Cambridge for general structure, NURSE for responding to emotion) — but internalise them so they do not appear scripted.

4. Practise the difficult scenarios — angry patients, those refusing treatment, those with safeguarding concerns, end-of-life discussions, medication non-adherence.

5. Develop your ability to pivot. PACES23 consultation stations are unpredictable — the patient may take the conversation in an unexpected direction. Your ability to adapt while maintaining a structured approach is a key discriminator.

For Patient Welfare

1. Make the behaviours automatic — consent, explanation, comfort checks, covering, and thanking should be muscle memory.

2. Practise on colleagues and ask them specifically: "Did I treat you with dignity throughout? Was there any moment where you felt uncomfortable?"

3. Be genuine. The most common reason for failing this domain is not a specific omission — it is a general impression that the candidate treated the patient as an examination prop rather than a person.

The Self-Assessment Framework

After every practice station, score yourself explicitly against each domain using this simple framework:

Scoring: 1 = Fail | 2 = Borderline | 3 = Pass | 4 = Clear Pass

If you score 1 or 2 in any domain across two or more consecutive practice stations, that is your priority for the next revision block.

Final Principles

1. PACES does not test whether you are a knowledgeable doctor. It tests whether you can demonstrate specific skills, under pressure, in a format that examiners can reliably score. Understanding the domains is what bridges the gap between knowledge and demonstrable competence.

2. The PACES23 format rewards adaptability. Unlike older formats that were more predictable, the current consultation stations require you to think on your feet, respond to the patient in front of you, and maintain structure without sounding rehearsed.

3. Balance over brilliance. A candidate who scores 3 across all seven domains passes. A candidate who scores 4 in four domains and 1 in one domain may fail. Your preparation should be designed to eliminate weaknesses, not amplify strengths.

4. Two examiners score every station independently. Consistency across the encounter — not a single brilliant moment — is what accumulates domain marks.

5. The patient welfare domain is assessed at every station, every moment. It is the thread that runs through the entire exam. Never let it slip — not even for a second.