The Clinical Competency Exam (CCE) is the final exam on the pathway to fellowship of the Royal Australian College of General Practitioners (RACGP). Candidates are presented with nine clinical cases; four case-based discussions where candidates discuss a case with the examiner, and five clinical encounters, where candidates directly interact with a simulated patient (role-player) while the examiner observes and assesses. The CCE is conducted over two weekends via Zoom, each case being 15 minutes in duration with an additional 5-minutes reading time.   

Understanding how you will be assessed in the CCE will enable you to prepare well and hone your performance to successfully pass this exam. 

The RACGP curriculum and competencies 

The RACGP curriculum, with five domains of general practice, provides a competency framework based on what RACGP consider to be the essential qualities of an Australian general practitioner (GP). Competencies are behavioural descriptors of competent clinical practice. There are ten competencies and two contextual units (Aboriginal and Torres Strait Islander health and Rural health) covering the curriculum, which is further divided into numerous competency criteria or outcomes. RACGP define competencies as “…tasks a successful candidate must be able to handle, and during which she/he uses at the right time, the correct and relevant knowledge, skills, attitudes and meta-cognitions to manage the task successfully”. See the RACGP website for more detail.   

Each core skill is a statement of an end point that indicates achievement of competence in a key area of general practice. The core skills describe the “what” of being a general practitioner. According to the RACGP, the best way to prepare for the CCE is to continue working in general practice and complete their suite of free CCE-specific exam support resources. However, anecdotally, candidates have expressed that that wasn’t enough for them to pass and that they needed a more strategic and considered approach. For exam preparation purposes, it is important to consider how competencies will be assessed in the CCE so you can plan how to demonstrate competency to enable you to sit the exam successfully. 

The competency: Preventive and population health 

How do you go about ensuring that you demonstrate your competency in an area? Focussing on one competency Preventive and population health as an example, we have outlined how to plan a strategic approach to CCE exam preparation.  

So, what is a strategic exam preparation approach? A strategic approach describes how your objectives (i.e., demonstrating competence) will be achieved. It guides the planning, development and implementation of behaviours and tasks, as well as the tools and tactics that you will use to achieve those objectives. It guides your decision making in terms of what, why, when and how. A strategic exam preparation approach is planned by considering a series of questions, such as: 

  • Where are you now? – Understand your current level of competence. 
  • Where are you going? – What are your objectives. Look at the bigger picture (e.g., Fellowship). 
  • How will you get there? – Establish a strategic methodology (series of strategies, tasks or behaviours). 
  • How will you manage the plan? – Implement the methodology and adjust if needed. 

As the RACGP outline, the competency Preventive and population health is about the provision of general practice care and service that supports economically rational and effective use of the healthcare system. This includes the management of issues related to public health and how the individual and community determinants of health and disease are identified, as well as disease prevention, health education and health promotion. 

For more information on this competency, refer here. 

How to build your CCE performance competency  

To build competency in a skill, it is important to understand the skill (the what), the expectations of RACGP regarding the skill (the why) and the competent behaviours expected to be demonstrated in the CCE (the how). Understanding these elements will be the foundation of your strategic exam preparation approach.  

Step 1. Understand the competency 

To be able to demonstrate a competency, you need to understand it, what it’s comprised of, what’s included and what’s not. Therefore, identify and read every resource RACGP make available to you regarding the competency, Preventive and population health. This includes, but should not be limited to: 

For example, in the Clinical Competency Rubric, on page 14-16, it describes the competency and outlines the required knowledge, skills and attitudes to be able to demonstrate competency. Most importantly, it outlines the behavioural standards covered by this competency and the RACGP expectations regarding your performance (i.e., table with two columns, headed by “Criteria (competent at level of Fellowship)” and “Performs consistently at the standard expected”). 

Step 2. Understand your skills gap 

To be able to plan how you will prepare for the CCE, it is important to understand your current level of performance and compare it to the level expected by RACGP. One way to do this is to look at the Performance list relevant to each competency (in our case, Preventive and population health on page 14-15 of the Competency Rubric) and rate your performance against each of the behaviours.  

For example, in the image below under the heading Criteria, it lists a few of the behaviours expected of Fellowed GP in regards to preventive and population health. In the second column, it lists how to demonstrate competency. Assessing yourself against these behaviours, rate yourself out of three (1= don’t demonstrate, 2=inconsistently demonstrate, or 3= consistently demonstrate).  

It is important to be as honest as possible with yourself regarding your behaviour and whether there’s room for improvement. If uncertain, ask for feedback from a supervisor, colleague or study partner. Better yet, do a mini-audit regarding recent patients (past week or month), asking yourself whether you missed any opportunities for: 

  • Preventative health screening (e.g., cervical screening tests, cancer screening, cardiovascular risk assessment, vaccinations, etc) 
  • Patient education (e.g., diabetes or cardiac risk education) 
  • Health promotion (e.g., smoking cessation, exercise or diet improvements) 
  • Referrals (demonstrating a team-based approach) 
  • Shared information of available local community services  
  • Follow-up and/or Recall system  
  • Aboriginal and Torres Strait Islander patients (e.g., used appropriate preventive health approaches and health-delivery strategies) 

When rating yourself, it is also important to consider ‘how well’ you demonstrated this competency together with ‘how consistently’. This is where the competency may overlap with other competencies, such as communication and professionalism. For example, when conducting your mini-audit of competency in Preventive and population health, please consider not only did you conduct health education or promotion, but how well did you communicate with your patient (e.g., did you use a patient-centred approach? Did you use attentive listening skills? Was it a two-way conversation?). Hence it will also be important to have a good understanding of the performance criteria of other competencies, such as communication and professionalism, to ensure a good understanding of your current competence in these areas. The better your understanding of your current skill, the better you will be able to address any skill gaps. 

As a side note, a mini audit is also able to count towards your CPD requirements under the Measuring Outcomes (MO) CPD type.  

(Source: Image from RACGP Clinical Competency Rubric, page 15) 

Step 3. Reduce your competency skill gap 

Armed with the knowledge of your current competency, you can now plan how you will go about addressing any skill gap for optimal CCE performance. There are four main strategies you can use to reduce your skill gap: 

  1. Increase your knowledge of the competency. For example, read the RACGP Red book and test your knowledge and understanding. Importantly, use this information in your patient consultations and practice cases. 
  1. Practice with patients at work. Incorporate health prevention, education and/or promotion in most, if not all your consultations. Practice any skills you noted you lacked or were less consistent in (i.e., in your mini-audit), as well as any associated competencies you identified, such as communication, that you wish to improve. 
  1. Practice with a study partner or group. Practising cases is a foundation strategy for the CCE, one that is difficult to demonstrate competency without. Practising cases regularly (e.g., weekly) up to the exam is an important strategy to improve competence across all domains, as well as improving other important aspects of CCE performance such as time management, organisation and structure. 
  1. Video yourself performing a relevant case. This strategy enables you to assess yourself, giving you added information as you know what you were thinking or feeling at the time. It also enables you to share the video with a supervisor or colleague for feedback, so they can view when convenient. 

We recommend using a combination of all four strategies to boost exam success. The important aspect of these strategies is that you receive feedback. Receiving feedback consistently throughout your CCE preparation journey enables you to consistently address your skill gap for ongoing performance improvement. There’s a saying, ‘it’s difficult to know what you don’t know’. Hence, it’s important to have someone tell you what you may not know about your CCE performance, so you can change and make improvements to increase your potential for exam success.  

Informal feedback from your patients regarding your improved communication style or focus on health prevention, education and/or promotion or more formal feedback from your study partner, group or supervisor are all valuable. There are many important benefits of feedback for CCE preparation. Please refer to our blog Why feedback can super-charge your CCE exam preparation which outlines them all. 

HOW TO IMPROVE YOUR CCE PERFORMANCE: 

  • Step 1. Understand the competency you need to demonstrate 
  • Step 2. Understand your skills gap (the gap between what you are currently doing and RACGP expectations of competence) 
  • Step 3. Practice and rehearse to improve your competence (reduce the gap between your competency and RACGP expectations) 

Lastly… 
Developing a strategic approach to CCE exam preparation will better enable you to be successful. A strategic approach describes how you will meet your objectives. It guides the planning, development and implementation of behaviours and tasks, as well as the tools and tactics that you will use to achieve those objectives. It guides your decision making in terms of what, why, when and how. 

For CCE success, you need to identify your performance skill gaps against the RACGP performance criteria, so you know what you need to change and practice to improve. Part of your strategic exam preparation plan must be utilising RACGP resources such as the Clinical competencies for the CCE and Clinical Competency Rubric. Ignoring the information provided to you in RACGP documents such as these will be to your detriment. It is very difficult to pass an exam if you don’t understand what it requires of you. 

Lastly, practise, practise, practise with feedback, feedback, feedback! It is the best strategy for CCE success.