TL;DR: The PANCE isn’t trying to trick you. It puts lookalike answer choices side by side (aortic stenosis and HOCM, pterygium and pinguecula, a thyroid nodule and a thyroglossal duct cyst) to see if you know the difference. And when it does, the question has to hand you the one clue that separates them. Find that clue and the lookalikes stop looking alike.
Brian Wallace, PA-C. I’ve worked with PA students for 15 years and I run 33 Days to Pass the PANCE. Updated October 2026.
Is the PANCE trying to trick you?
No.
The question writers are not out to get you. I promise, and I can prove it.
Most students come to me feeling like the test writers are trying to trick them, like every question is built as a trap. My view is 180 degrees in the other direction.
Yes, they’re writing questions to see if you know the content. And yes, they’re going to put look-alike answer choices in. If you get a question on a spider bite, black widow and brown recluse are both going to be sitting in the answer choices. If pterygium is an answer choice, pinguecula is going to be there too. If aortic stenosis shows up, hypertrophic cardiomyopathy is pretty much guaranteed to be right next to it.
That’s not a trick. That’s a solid question making sure you know the difference.
A trick would be red herrings, clues that point you the wrong way or go nowhere. That’s not how this test works.
If you’ve ever written a question, you know how hard it is to write one that’s clear, gets the reader to the answer, and doesn’t give it away. Adding tricks on top of that is almost impossible. And I’ve written thousands of them.
Why are there always two answers that look right?
Because that’s the whole point of the question. It’s checking whether you can tell the two apart.
Is it always going to be easy? No. But there will always be enough clues to get you to the right answer and enough to rule out the others. It’s multiple choice, so there’s only one right answer, and everything in that stem has to point toward it.
So if they give you pterygium and pinguecula, the stem has to tell you whether it’s growing onto the cornea.
If they give you aortic stenosis and HOCM, they have to tell you what the murmur does with Valsalva. Here’s the quick version of why. When you bear down, less blood makes it back to the heart, so the left ventricle is emptier. Less blood pushing through means most murmurs, aortic stenosis included, get softer. HOCM goes the other way. With an emptier ventricle, the thick septum and the mitral leaflet sit closer together, the way out gets tighter, and the murmur gets louder.
If they want you to name the spider, they have to tell you where the patient lives or what the bite did. A necrotic wound points one way. Muscle cramps and a rigid belly point the other.
Here’s what that looks like side by side:
| Lookalike pair | The clue the stem has to give you | Which way it points |
|---|---|---|
| Pterygium vs pinguecula | Is it growing onto the cornea? | Onto the cornea: pterygium. Stays off it: pinguecula |
| Aortic stenosis vs HOCM | What does the murmur do with Valsalva? | Louder: HOCM. Softer: aortic stenosis |
| Brown recluse vs black widow | What did the bite do? | Necrotic wound: brown recluse. Muscle cramps and a rigid belly: black widow |
| Thyroid nodule vs thyroglossal duct cyst | Does it move when the patient sticks out their tongue? | Moves with the tongue: thyroglossal duct cyst. Stays put: thyroid nodule |
How do I find the clue that separates two lookalikes?
Look for the one detail that only fits one of them. I think of it as the color of the cleats.
When my guys were little I used to coach soccer. On one of these ill-fated teams I had a set of twins. And I just couldn’t tell them apart. No matter how many times everyone would tell me it was easy, I couldn’t see the difference.
I would just say, “Hey” or “Come on over.” And hope I got the right one’s attention.
And one day some kind soul saved me. “Hey, Will has the gold cleats.”
Holy crap. From that point on it was easy.
The one with the black cleats, Andrew. The one with the gold cleats, Will.
I had it solved forever. seriously, forever
That’s what the question writers do with lookalikes. When they give you lookalikes, they have to give you the one thing that separates them. They have to tell you what color cleats one of them is wearing.
Here’s one I sent on a 5 Question Friday back in August:
“A painless midline neck mass that elevates with tongue protrusion should make you think of what diagnosis?”
The answer is a thyroglossal duct cyst.
And the answers I got back? Thyroid nodule. Thyroid mass. Goiter. Thyroid, thyroid, thyroid.
That’s not a crazy guess. A thyroid nodule sits in the front of the neck too, and it moves when you swallow. So does a thyroglossal duct cyst. Those two are twins.
But the question told you the color of the cleats. It moves when the patient sticks out their tongue. the gold cleats
Yes, the patient is sticking their tongue out at you. If you’re in the clinic, please make sure to make a joke with them at this point.
A thyroglossal duct cyst is a leftover piece of the path the thyroid took on its way down the neck while you were developing. That path is still tied to the base of the tongue. Tongue goes out, cyst comes up with it. A thyroid nodule isn’t tied to the tongue, so it stays put.
Your brain said thyroid. They handed you the tongue-sticking-out part for a reason, and you just walked right past it.
Why does a question feel like a trick when I get it wrong?
Usually because there was something in it you didn’t know.
When you walk away thinking “that was a trick,” it usually means there’s a knowledge gap. The clue was there. You just didn’t know what it meant, so it looked like noise.
That’s not a trick. That’s a gap in knowledge.
And here’s the good news: knowledge gaps can be filled. We just filled one with the thyroglossal duct cyst. Excellent work.
If you’ve already taken the PANCE and walked out feeling like it was full of tricks, this is worth sitting with. It’s usually a list of gaps, and gaps are fixable. I wrote about where to start in I failed the PANCE. What do I do next?
What if I only know some of the clues in the question?
Assume the ones you don’t know point the same way as the ones you do.
One place I see students get tripped up is when the stem has a lot of breadcrumbs. They know three of the five, and all three point the same way. Then the last two make them doubt themselves. They start to spiral and decide the ones they don’t know must be pointing somewhere else.
My philosophy: assume the things you don’t know keep going in the same direction as the things you do. trust the breadcrumbs Will that be right every time? Absolutely not. But I strongly believe it’s right more often than it’s wrong, and you’ll pick up more points that way.
Who’s on the other side of the question?
A coach, not a trickster.
One of my students used to picture the test writer as an angry person standing over her shoulder, hoping she’d get things wrong. After she started writing her own questions, the picture changed. Now she sees a coach standing over her shoulder, hoping she gets it right.
That one change can make a huge difference on test day.
Get one of these every day
I send a short lesson like this one every day, plus a 5 Question Friday quiz to test yourself. It’s free, and you get my Test-Taking Rescue Kit when you sign up.
Where 33 Days fits
Telling two good answer choices apart is a skill, and it can be trained. In 33 Days to Pass the PANCE it’s part of what we work on: reading the question fully, finding the clue that separates the lookalikes, and trusting where the breadcrumbs point.
If you want to build that skill on purpose, with a plan and people on the same path, that’s what 33 Days is.
When you’re ready for the full program, here’s when the next cohort starts.
Questions students ask me about lookalike answers
Does the PANCE have trick questions?
No. It has lookalike answer choices, and that’s different. A trick would be a clue that points the wrong way. On the PANCE, every clue in the stem points toward the one right answer.
Why do I narrow it down to two and then pick the wrong one?
Usually the stem gave you the clue that separates them and you didn’t know what it meant, or you read right past it. That’s a knowledge gap, and it’s fixable.
How should I study lookalikes?
Study them in pairs. When you learn one, ask what it gets mixed up with and what single clue tells them apart. That clue is what the question is going to hand you.
Which murmur gets louder with Valsalva, aortic stenosis or HOCM?
HOCM. Valsalva leaves less blood in the ventricle, so most murmurs, aortic stenosis included, get softer. In HOCM the outflow gets tighter and the murmur gets louder.
Want more?
If you’re looking to learn more, the podcast is a great free place to start.
