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How To Pass PACES by Richard Hurndall

© Richard Hurndall

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“Good morning,” said the professor, who was wearing box shaped glasses and a red and white stripy shirt on his bean frame.

“Good morning.”

The professor pointed to the dwarf in the corner with a lump the size of the egg on her forehead.

“What’s the diagnosis?”

I accidentally laughed out loud. I wasn’t being mean; I just had no idea what the diagnosis was. I tried to pull it together but at the end the professor shook my hand and smiled; a sure sign that I had failed. So that was the first time I failed PACES, in London of all places.

How do you pass the hardest exam in the world?

Sure the final exit exams at the end of medical school were tough, but nobody mentioned PACES. Not a peep.

PACES is the final part of the Royal College of Physicians exam called the MRCP(Membership of the Royal College of Physicians). The MRCP comes in three parts; parts one and two are relatively easy tick-box question papers that are designed to lull you into a false sense of security; that perhaps you may have a chance to attain membership to this exclusive club.

Then there is PACES.

PACES, the third and final part, is in a different league. It has legs. It has its own time zone. It exists in the fourth and fifth dimension. It’s the most endowed of all the exams. Other exams feel inferior to it in the shower room.

Candidates for PACES are given an envelope the week before the exam starts. Inside this envelope is the name of a hospital somewhere in the United Kingdom. You are then expected to travel to said hospital and spot diagnose no less than twenty different patients with the most bizarre diagnoses known to man, exclusively hand-picked by professorial types whose list of hobbies includes ‘watching junior doctors squirm.’

It’s a beast of an exam. It’s the school bully. PACES discovers the man. Then spits out the remains and laughs manically.

The second time I failed PACES was entirely my fault. I travelled to Cardiff on the sleeper train. In the carriage opposite me was a group of fellow PACES candidates who were using pop-up cards and word association games to revise. So instead of sleeping I buried my nose even deeper into the Oxford Textbook of Medicine in order to keep up.

I fell asleep at seven in the morning, and then woke up at one in the afternoon in a train station in Haye-on-Wye.

The third time I failed PACES was in Glasgow. This time I stopped studying at eight in the evening, slept soundly, had a hearty Scottish breakfast and arrived at the Royal College test centre an hour early.

And I did really well. I think I got all the diagnoses right.

One had obstructive sleep apnoea.
Two had eczema.
Three had an ejection systolic flow murmur of aortic stenosis.
Four had haemochromatosis.
Five had gout.
Six had alpha-one antitrypsin deficiency.
Seven had amyloidosis.
Eight had berylliosis.
Nine had Peutz-Jeghers syndrome.
Ten had von Hippel-Lindau syndrome.
Eleven had retinitis pigmentosa.
Twelve had palmar pustular psoriasis.
Thirteen had Refsum’s disease.
Fourteen had niacin deficiency.
Fifteen had diabetic papillopathy.
Sixteen had sickle cell disease.
Seventeen had a Kaposi’s sarcoma.
Eighteen had pseudopseudohyperparathyroidism.
Nineteen had a hypertensive obstructive cardiomyopathy.

By patient twenty my brain felt like it had been through nineteen rounds with a professional boxer. My brain was firing on all cylinders, and none of the professors had been able to sway my concentration with their little mind games of ‘are you sure?’ and ‘would you like to phone a friend?’

Before I reached patient twenty I sat down and collected my thoughts, and grabbed a drink of sparkling water from one of the ‘rest stations.’ Not long to go. Just don’t screw this last one up and you’re free, and a member of the most exclusive club in the world.

The pride and passion of passing PACES is paramount. I stood up, took a deep breath and stepped in to the room containing patient twenty.

It was dark; I could make out the shadows but nothing more. A blind in the far side shuttered out the last vestiges of sunlight.

“Hello?” I said.

“Sit down,” said a familiar voice.

The lights clapped on and my worst fears were confirmed. It was the travelling freak show. Professor Bean with his box-shaped glasses and stripy shirt, and the dwarf-lady with the lump the size of an egg on her forehead. They stared past me into the middle distance.

“Diagnose her.”

She watched me with lop sided eyes as I put my hand out to shake hers, but no handshake was forthcoming. Slowly I put my hands out and pressed against the lump, hoping that tactile force would release inspiration.

The lump was beating like a heart. I jumped back.

“What the…?”

The dwarf lady stared past me, as if she was admiring a work of art on the far wall. She had long brown unwashed hair, pock-marked cheeks and was wearing the same flowing red dress as before, a beautiful dress. Probably in her mid-forties. The professor scratched his right ear with a pencil and then wrote something down on a clipboard.

“Diagnose her,” he said again in a clipped Home Counties accent.

I took out my stethoscope and put the diaphragm to her chest. I was aware of my own heart galloping but there was nothing to be heard in the dwarf’s chest. Apex, fourth left intercostal, second left intercostal, second right intercostal…


“She has no heart,” I murmured.

“Sorry?” said the professor.

“Her…her heart is on her forehead.”

“Diagnose her.”

“I…I can’t.”

He smiled and shook my hand. “We’ll get the results to you soon.”


When I got my fourth date for PACES(this time in Manchester), I decided to seek professional advice. Sundip was the only doctor to have passed PACES in Taymouth, and did so on his first attempt. He was one of those people who was so intelligent that they didn’t need to try and act smart, they just were smart. We met in the hospital canteen over macaroni cheese and hammered out a solution.

“What do you mean she had no heart?” said Sundip.

“No, I didn’t say that. The heart was on her forehead.”

“Impossible,” stated Sundip. He ran his hand through his slicked black hair; he was going for the Elvis look again. “Anatomically, physiologically, biochemically impossible.”

“I saw it with my own eyes…”

Sundip interrupted me with a shake of his head. “Impossible.”

He took a mouthful of cheese and went further. “What I don’t get is why these two are travelling around the country for the PACES exam. They usually stay in one place. Are you sure you aren’t dreaming all of this?”

“Possibly,” I said.

“Are you in charge of all your faculties?”

“I think so.”

“Good,” he nodded. “But I’m struggling to help you.”

“Thanks for your time anyway,” I said.

“Let me give you a piece of advice,” said Sundip. “The key to passing this exam is confidence. You are a nervous man. You went on that train and stayed up revising that time…what a bad idea. You need to do something the night before that will clear your mind. These examiners smell fear, but love people who don’t give a fuck. Don’t ask me why.”

“What should I do?”

“Do you have a girlfriend?”


“I’ll tell you what I did,” said Sundip. “I travelled to my PACES destination the night before with my wife, stayed up all night making love until the sun came up. And I got the highest mark awarded in the College’s history.”

“But I don’t have…”

He handed me a card with a phone number on it.

“This is what I use when I’m in Manchester,” he said with a grin.


“That’s all the advice I can give you,” finished Sundip. He got up, his food hardly touched. “I must remind my wife to make me packed lunches.”

As he left he whispered in my ear. “Madame Bouchard will sort you out.”



“What do you want?”

“My friend gave me this number.”

“Who’s your friend?”

“I…I’d rather not say. He said I should ask for Madame Bouchard.”

“How many nights are you here for?”


“Your friend has taste.”

“Do I need to bring anything?”


“Do I need to bring anything?”

“Have you ever been to a house with red doors before?”


“Just yourself honey. And money.”


“Five hundred pounds and come to the address on the back of the card.”


I’ll start off with a defence. I’ve never been to a prostitute before, nor have I even considered it. Usually there are girlfriends, relationships that last a few months before my vocation gets in the way, but PACES had called a halt to any love action. After a twelve-hour day on the wards, there is only a few hours left to revise, which doesn’t leave any time for other people. The pride of passing PACES is paramount.

I got into Manchester the day before the exam and booked into a travel inn in the afternoon, leaving me plenty of time to find the address. It was on Lever Street, only a few minutes walk away from the Piccadilly bus station, next to Matt and Phred’s jazz bar. It was approaching five o clock but the sun was still in my eyes, but I could still see the distinctive red door from a good distance away. And as I approached there were the initials ‘MB’ inscribed in the central glass panel.

I was about to knock when I noticed a paper sign that said ‘let yourself in,’ on the inside of the glass, so I did.

The air was warm and sweet, but the sticky brown carpet looked like it needed a good wash. There were a couple of doors down the dark hallway but it was obvious that the clients were meant to follow the stairwell, which was sparsely decorated with an old set of Christmas
lights with half the bulbs missing. The stairs creaked and groaned as I ascended, and this seemed to spark a flurry of boots and rustling papers from the peak. But when I reached the top there was nobody there. At the top, it was almost like a dentists waiting room. There were some felt lined chairs and a table with some tattered magazines, and a booth sheltered by a tinted glass window that led to the beyond.

I cleared my voice and rapped the window softly.

It opened and a pretty blonde girl in her twenties answered.

“We’ll get you in a minute,” she said, then closed the window again.

So I picked up an old copy of Top Gear magazine and read about the new Mercedes SLK. But to be honest, I couldn’t concentrate on Jeremy Clarkson’s gentle right-wing rants. A big part of me was thinking about the twelve causes of pseudopseudohyperparathyroidism and its relation to long term steroid therapy. And another part of me was hoping that Sundip’s plan would work and the night would bring me greater clarity, and therefore, success.

And another part of me knew that I was in the deep.

A few minutes passed. By that point the magazine was on the table and my hands were clenching my buttocks on the chair. A bell rang and a door opened on the far side of the room; the lights went on and a buzzer sounded from inside the booth. I thought the whole thing coincidental until the buzzer rang ever more persistently, my cue to walk in.

The room was as sparse as you would expect a brothel to be; white walls, black carpet, black curtains, a cane chair in the corner and a tired looking double bed with fresh white sheets. I sat for a few minutes until the door opened again and the same blonde at reception walked in with one of those machines you use to pay the bills at restaurants. She was wearing a red dress with red heels and red lipstick; a pretty girl for sure.

“Paying by card?” she said. She had a thick Mancunian accent.


“She took my credit card and fed it into the machine. She handed it back.

“Press enter,” she said. A message for ‘would you like to add a gratuity?’ flashed up. I pressed no.

There was a minutes awkward silence as the card processed, then the receipt popped out.

“You can remove your card now,” she said. “We’ve got one hour.” Then she proceeded to take her dress off.

Oh Christ this was actually happening. And already I felt the twelve causes of pseudo-pseudo whatever drift to the back of my mind.

Some fumbling, the lights went off, my shirt was carefully unbuttoned and placed on the cane chair. And that’s as far as we got until the lights went on again.

“Don’t worry,” she said in a business-like tone. “Madame Bouchard just likes to check everything’s in order.”

The door opened a peep, and then closed again and the lights went off (there must have been an external switch.)

Only seconds passed when the door swung open.

“You!” boomed a gruff female voice. The blonde girl jumped off me and ran out like she had been trained to do when in danger.

I grasped for my shirt but was found wanting.

Madame Bouchard walked to the bed and stood over me, all four feet of her diagnostic brilliance, her heart pulsating on her forehead in all its anatomically impossible glory. She was wearing the same flowing red dress, but her eyes gave a different story this time; an empowered, confident, bitter woman was about to exact her revenge.

“Put on your shirt,” she commanded.

I put on my shirt.

“Do you think this is a joke?” she said, pacing around the room and watching me out the corner of her lop-sided eye.

“No,” I said. “I had no idea…”

“My name is Madame Bouchard,” she said. “I make enough money to pay the rent and put the food on the table and give my girls a decent wage. The only pain in my life involves you,” she said, pointing a gnarled finger at me.

“I haven’t done anything wrong!” I said.

She turned around and screamed. “THERE IS NOTHING WRONG WITH ME!”

I took my time and explained why I was there; I gave her the whole goddamn story about PACES and the professor and Sundip, because I knew that if my story wasn’t truthful then it was unlikely that I would get out of the house with the red doors alive.

She nodded and cooled down a little; her heart rate visibly declined.

“Do you understand my situation?” she said.

“Not really.”

She explained how the Royal College of Physicians tour around the country looking for oddities for the PACES exam; they found her ten years ago when she was working for a travelling circus.

“Professor Chapman took me under his wing,” she said, lighting a cigarette. “He gave me a good wage for travelling with him around the country for the examinations, no strings attached.”

A deep inhalation of smoke, then exhalation.

“But he won’t let me go,” she said. “He won’t let me leave. He knows about my business. He treats us like his sons and daughters, but nobody tells you the contract is life long. The minute I try and escape, the police are at my door threatening to end my trade. The College’s ties run deep…all the way to government.”

I stared incredulously at her.

“They even have a secret handshake.” She grabbed my wrist, felt my radial pulse then released it gently.

I apologised and made to leave, but she grabbed my jacket and pulled me close; I could smell her cherry breath as she pressed her lips to my ear.

She whispered the words I longed to hear, and then released me, and I ran all the way down Lever Street, across Piccadilly Gardens and down Oxford Road to my travel lodge.


PACES Attempt Five.

The other candidates had their word association cards out again, trying to remind each other the ten causes of hypertrophic cardiomyopathy, ready to spin the wheel.

But I didn’t need the cards. I was ready.

Patient number one had coarctation of the aorta.
Patient two had lithium toxicity.
Patient three had osteoporosis.
Patient four had rhabdomyolysis.
Patient five had Angelman Syndrome.
Patient six had Laron dwarfism.
Patient seven had hyperphosphatemia.
Patient eight had red cell aplasia.
Patient nine had Sjorgen’s syndrome.
Patient ten had Brown-Sequard syndrome.
Patient eleven had schizophrenia.
Patient twelve had chronic obstructive pulmonary disease.
Patient thirteen had an empyema.
Patient fourteen had Wegener’s granulomatosis.
Patient fifteen had Churg-Strauss syndrome.
Patient sixteen had Kawasaki disease.
Patient seventeen had neurofibromatosis.
Patient eighteen had pseudopseudohyperparathyroidism.
Patient nineteen had heart failure.

And patient number twenty had a very interesting diagnosis, which many think is physiologically impossible, but it can be found in some of the older textbooks. I’d love to tell you the answer, but we can’t just open the floodgates to the club. The College has a reputation to uphold.

But the next time a doctor moves to shake your hand, move your fingers up his forearm and feel his radial pulse. You might be surprised what happens.

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