The Clinical Competency Exam (CCE) is the final exam on the pathway to Royal Australian College of General Practitioners (RACGP) Fellowship. Candidates are presented with four case discussions (discuss a case with the examiner) and five clinical encounters (interact with a simulated patient while the examiner observes and assesses).  

Understanding how you will be assessed in the CCE will enable you to prepare effectively and enhance your performance to successfully pass the exam. It’s crucial to understand both the ‘what’ and the ‘how’ of the assessment process.  

The ‘what’ is the RACGP curriculum, built around 7 core units which represent the expertise, capabilities and attitudes required by General Practitioners working in Australia. Together, these core units form the basis of the core competency framework. There are 15 core competencies, 10 of which (the Clinical Competencies) are assessed in the CCE, in addition to two further contextual units (Aboriginal and Torres Strait Islander Health and Rural Health). See the RACGP website for more information.    

For exam preparation purposes, it is important to consider ‘how’ the competencies could be assessed so you can consider by what method you will demonstrate your competence. This is particularly important for complex scenarios that aim to assess multiple competencies in one case. Advance care planning is an example of this and may be included in a CCE case. 

Advance Care Planning  

Based on the fundamental principles of self-determination, dignity and harm avoidance, Advance Care Planning (ACP) is about person-centred care and is a core skill for general practitioners (GP). GPs develop ongoing and trusted relationships with their patients and are well positioned to initiate and promote ACP, particularly with the ageing population in Australia. 

ACP ensures that a patient’s expressed wishes remain the focus of decisions made about their care when they can no longer express their wishes or lose the ability to make decisions about their care in the moment (approximately one in four patients at the end of life).  

ACP will often lead to the completion of an Advance Care Directive (ACD), which is a written legal document, intended to apply to future periods of impaired decision-making capacity, which provides a legal means for a competent adult to instruct their Substitute Decision Maker and/or to record their preferences for future health and personal care. Although state and territory government laws vary on ACP and the forms they use, ACDs are legally binding documents in every state/territory of Australia. RACGP recommends that GPs are familiar with the forms and processes used in their state or territory. 

Demonstrating Competency 

A useful strategy to use when preparing for the CCE is to identify which competencies are likely to be assessed in each case. When working through your practice cases, consider which competencies are important to demonstrate, then reflect deeper, and think about which of the core competency outcomes or performance criteria will be relevant to that scenario (as not all of them will be). 

For example, with ACP, the competencies assessed in a CCE case could include: 

  • Communication and consultation skills 
  • Identifying and managing the patient with significant illness 
  • Professionalism 

Review and reflect on these competencies and their performance criteria to ensure you fully understand what is required of you. This will help to ensure that you demonstrate your competence to the examiner, as they will only assess what you present during the exam. 

For example, in the CCE competency Rubric, the competency Professionalism includes the performance criteria of: 

  1. Encourages scrutiny of professional behaviour, is open to feedback and demonstrates a willingness to change.  
  1. Exhibits high standards of moral and ethical behaviour towards patients, families and colleagues, including an awareness of appropriate doctor–patient boundaries. 
  1. Appropriately manages ethical dilemmas that arise.  
  1. Identifies and manages clinical situations where there are obstacles to provision of duty of care.  
  1. Implements strategies to review potential and actual critical incidents to manage consequences and reduce future risk. 
  1. Personal health issues are identified and managed by accessing professional support as needed.  
  1. Judges the weight of evidence, using critical appraisal skills and an understanding of basic statistical terms, to inform decision-making. 
  1. Shows a commitment to professional development through reflection on performance and the identification of personal learning needs. 
  1. Attends and participates in all learning and assessment activities of an educational program. 
  1. Actively engages in feedback as a dialogue, discussing performance and setting own goals for professional development. 
  1. Personally participates in audits and quality-improvement activities and uses these to evaluate and suggest improvements in personal and practice performance. 

The performance criteria most relevant to a case discussing ACP would likely be: 

#2. Exhibits high standards of moral and ethical behaviour towards patients, families and colleagues, including an awareness of appropriate doctor–patient boundaries. 

#3. Appropriately manages ethical dilemmas that arise.  

#4. Identifies and manages clinical situations where there are obstacles to provision of duty of care.  

#7. Judges the weight of evidence, using critical appraisal skills and an understanding of basic statistical terms, to inform decision-making. 

From this, you can begin to map out what you need to demonstrate and how. For example, in a case discussion, you could show your Duty of Care by explaining how you would provide evidence-based information about ACP and support the patient to develop an ACD. This includes exploring their preferences, respecting their autonomy, and documenting their wishes accurately. You might also explain how you would maintain professional boundaries by ensuring your own values don’t influence the patient’s decisions and by providing empathetic, impartial support. 

In a clinical encounter, you could demonstrate Professionalism by clearly outlining your Duty of Care, setting appropriate limits on what you can and can’t provide, and maintaining a patient-centred approach. Depending on the case, it may also be appropriate to ask what the patient understands about ACP or ACDs, and support them to reflect on their values, beliefs, and life goals.

Case discussion examples:

“When discussing advance care planning with my patient, I would ensure the patient understands their options and provide compassionate, non-judgmental guidance. While supporting them in making decisions that align with their values, I would also be careful not to influence their choices based on my own beliefs or biases.”
 
“Regarding my Duty of Care to my patient, I would provide comprehensive, evidence-based information about Advance Care Planning and support the patient to develop an Advance Care Directive if they wished. This may include thoroughly exploring and documenting their preferences. Maintaining professional boundaries means respecting their autonomy, keeping my personal values separate, and offering support that is impartial, empathetic, and centred on their wishes and goals.”

Clinical encounter examples:

“My role is to support you and to make sure you are fully informed to make decisions that reflect your values and what matters most to you. I can give you information about your options, but the choices are always yours to make. I’ll also make sure we clearly document what we’ve discussed so your preferences are clearly recorded and can be respected in the future.” 
 
“These conversations can feel overwhelming, and it’s completely okay to take your time. There’s no pressure to make any decisions today. My role is to support you — to listen, help you explore what’s important to you, and provide clear, honest information about what to expect. I’ll also explain any medical terms or options to you so you feel informed and comfortable at each step.” 
 
“If there ever came a time when you couldn’t speak for yourself, is there someone you’d trust to speak on your behalf? We can talk through how to make sure they understand your wishes and how we can document that clearly.” 

Good general practice  

The RACGP encourages GPs to integrate Advance Care Planning (ACP) into routine patient care. Key points include:  

  1. Responsibility: The College emphasises that ACP conversations are part of the GP’s responsibility to ensure that patients receive, and understand, advice on healthcare options relevant to their diagnosis and prognosis. 
  1. Key patient groups: Whilst ACP should be considered by everyone, regardless of age or health, it is particularly important for:  
  • Older patients (e.g., during over 75-year health checks) 
  • Patients with early dementia 
  • Those with life-threatening, complex, chronic, or terminal illnesses 
  1. Patient’s Understanding: When discussing ACP, consider the patient’s competency and mood. Ensure they understand the purposes of ACP and Advance Care Directives (ACD), and how these can be used in the future. 
  1. Documentation: While patients are encouraged to engage in ACP, it should be clear that documenting wishes in an ACD is not mandatory. However, documented wishes, especially those witnessed, have more legal certainty than verbal ones. 
  1. Family and Carer Involvement: GPs should encourage patients to discuss their wishes with family, carers, and other health professionals to avoid misunderstandings or disagreements. 
  1. Medical Records: A copy of the ACD should be included in medical files and be available across healthcare settings. 

Summary 

An Advance Care Directive is a legal document that allows people aged 18 years and older with decision-making capacity to: 

  • document their wishes, preferences, instructions and refusals for future health care, end of life care preferences, living arrangements and personal matters, and/or 
  • appoint one or more Substitute Decision-Makers to make these decisions on their behalf when they are unable to do so themselves. 

 Since the RACGP views initiating and promoting conversations about Advance Care Planning as a core GP responsibility, it may be a required task in a CCE station. Therefore, it is crucial to reflect on your knowledge and understanding of this important topic, and practice to enhance your competence to ensure you demonstrate competency effectively in the CCE! 

For more information on Advance Care Planning, visit Advance Care Planning and ensure you stay up-to-date with relevant state or territory-based information. 

Legal Considerations

An Advance Care Directive is a legal document. A competent adult can make an advance care directive. While not mandatory for patients to do so, seeking professional guidance from legal or health care professionals can be beneficial, especially for the binding refusals section of the form, or if there are uncertainties about the process.  

For more information about Health professionals’ role and responsibilities, see here.  

If competency is difficult to assess 

A competent adult can make an advance care directive. Someone who is not competent would be unable to understand the nature of the document and its effect; or be unable to communicate in any way. The Legal Commission of South Australia states that this can be a complex area of law. Therefore, if there is a question about a person’s competence, “it is best to obtain a written medical opinion, preferably from the person’s own doctor”. Check the legislation in your state or territory. 

Professional assistance and Advance Care Directives 

Whilst individuals can prepare an Advance Care Directive themselves, the Law Society of SA recommend that individuals seek professional advice given the importance of the document so that a person’s wishes and instructions can be clearly expressed. A GP would discuss with the patient their particular medical circumstances and help them understand the implications of the instructions and wishes they are considering including in their Advance Care Directive.  

The Law Society of SA recommends that individuals engage a lawyer to assist them with the preparation of an Advance Care Directive document and the precise wording to adopt to give effect to a patient’s wishes and instructions, and for the signing process by acting as an authorised witness.   

For more information about being an authorised witness, see here. 

References

Advance care planning Australia. (2024). Advance care planning explained. Accessed from: advancecareplanning.org.au 

Law Society of South Australia. Advance Care Directives. Accessed from:  https://www.lawsocietysa.asn.au/Public/Publications/Resources/Community/Advance_Care_Directives.aspx?WebsiteKey=f282a980-3d01-4268-abde-25da9e81104d  

Legal Commission of South Australia. Making an advance care directive. Accessed from: https://lawhandbook.sa.gov.au/ch02s02s02.php  

RACGP (2023). Advance care planning. Accessed from: https://www.racgp.org.au/running-a-practice/practice-resources/practice-tools/advance-care-planning  

RACGP (2012). Position Statement: Advance care planning should be incorporated into routine general practice. Accessed from: https://www.racgp.org.au/FSDEDEV/media/documents/RACGP/Position%20statements/Advance-care-planning-should-be-incorporated-into-routine-general-practice.pdf