CCE preparation: Managing uncertainty in general practice

Traditional medical training emphasises a quest for certainty over uncertainty. So, rather than managing the difficult latter, we strive for the former through a process of elimination.

 However, certainty isn’t always possible in clinical practice and learning to acknowledge and manage uncertainty as a registrar can help you develop an important key clinical skill. It can also send a reassuring message to your patient that though best practice doesn’t necessarily deliver a speedy diagnosis, it will enable, through a systematic process, a range of differential diagnoses that can be tested, managed, and treated accordingly.

Managing uncertainty in general practice is a required competency for general practitioners and is one of the key competencies tested in the RACGP’s Clinical Competency Exam (CCE). If you’re a registrar sitting  the CCE then you’ll be required to demonstrate your clinical skills and, importantly, your professional attitudes and communication skills (including patient-centred and inter-professional communication) to pass this final exam to achieve Fellowship.

How to define uncertainty

Ongoing undifferentiated conditions can cause uncertainty and anxiety for everybody involved, including the general practitioner. But uncertainty isn’t always due to diagnostic enigmas. It can arise from ambiguous test results, choosing which medication to prescribe from various options or sorting out the most appropriate care for an elderly patient.

Decision-making in an uncertain environment can be stressful. For example, a new patient arrives with multiple red flags for COVID-19. You have a full waiting room, the patient only booked a 15-minute consultation and they speak limited English. Where do you begin?

Recognising and adjusting to clinical uncertainty is a challenge for every registrar and fellowed general practitioner, and the first step in managing it is assessing your own level of tolerance for it. Do you panic when things become uncertain? Do you feel stressed and uncomfortable, or do you take it in your stride and adapt to the lack of clarity? Optimising and managing your tolerance level for uncertainty will help you maintain good health and your patients will benefit as well.

Measuring your tolerance level for uncertainty

A good place to start is to measure your tolerance for uncertainty. The Physician’s Reactions to Uncertainty (PRU) scale is a two-part validated tool that assesses your level of stress arising from uncertainty. (Note the scale examines emotional reactions to uncertainty only.)

How to manage uncertainty

While it’s important to understand your own tolerance for uncertainty, it’s essential that you minimise the affect of that intolerance on your patients’ wellbeing. Remember, patients are already anxious about their own uncertain situation and your reaction to that uncertainty can exacerbate their anxiety if it’s not properly managed.

The RACGP advocates a ‘structured, evidence-based approach’ to ongoing undifferentiated conditions. The general practitioner, the College states, should make ‘rational and balanced choices of investigations’ and avoid ‘over-investigation, under-investigation and management that would not benefit the individual’.

You also need to keep in mind the economic perspective, and minimise this risk by using a structured approach based on evidence that you can rationally explain.

To assess your expertise in managing uncertainty, the RACGP uses three criteria:

1. Manages the uncertainty of ongoing undifferentiated conditions
2. Addresses problems that present early and/or in an undifferentiated way by integrating all the available information to help generate differential diagnosis
3. Recognises when to act and when to defer doing so and uses time as a diagnostic tool

Source: RACGP, The Clinical Competencies for the CCE, 9. Managing uncertainty.

What you need to know about the CCE

The CCE runs over two days and is composed of nine cases. Four of these cases are formatted as case discussions and the other five are conducted as clinical encounters. You communicate directly with a ‘simulated patient’ or role-player while the examiner watches on and assesses your competency.

There are different examiners for each CCE case, so it’s unlikely you’ll encounter an examiner you’ve had before. The expected standard is high at ‘the point of Fellowship’.

Common mistakes made by CCE candidates

Managing uncertainty in general practice is an area that some candidates struggle with in the exam. The following is summarised from a list of errors provided by the RACGP.

• There is little exploration of the patient’s collateral history.
• The candidate provided an inadequate list of potential diagnoses.
• The candidate closed the diagnosis prematurely.
• Instead of listening to the patient, the candidate asked closed questions (from very early in the consultation).
• The candidate focused on one presentation aspect and paid no attention to others.
• A systems review was not undertaken by the candidate.
• The candidate demonstrated poor problem definition and then limited differential listing.
• The candidate demonstrated a lack of structure in their approach to investigation and lacked confidence dealing with uncertainty.
• Despite minimal rationale in the presentation, the candidate over-investigated and referred the patient to hospital.
• The candidate limited differential to only infective causes.
• The candidate did not safety-net or organise follow-up.

Tips on how to ace your CCE when faced with uncertainty

The following tips are summarised from a list provided by the RACGP.

• Take a structured, but targeted history, demonstrating a hypothetical-deductive approach.
• Ensure you take appropriate biopsychosocial history.
• Use active listening skills and pay attention to the simulated patient’s agenda, as well as your own. Remember, the simulated patient has scripted information they want to share with you!
• Consider the problem definition and synthesising an appropriate differential list based on key features in the case and history.
• Create a defensible investigations list (take a rational approach to investigation with a reason for each investigation).
• Use a patient-centred approach and include the patient in decisions, discussion of investigations and planning.
• Recognise and acknowledge the diagnostic uncertainty and approach this with honesty (to the examiner in a case-based discussion, or the simulated patient in clinical encounter cases).
• Include appropriate safety-netting and plan follow-up consults with appropriate support from other clinicians, such as multi-disciplinary teams when appropriate.
• Remember to practise skills such as active listening and speaking in a direct concise manner.

Other ways to reduce uncertainty in the CCE

The CCE is delivered over Zoom and if you’re not experienced in communicating over a remote platform, it’s important to practise before the exam.

Download Zoom (if you don’t already have it) and set up a meeting with yourself. Check the lighting in your room, the distance between you and the screen and the volume level, and if possible, practice having ‘remote access’ with a colleague (as needed in the CCE).

Also glance behind your chair and any other place the camera might capture, to check everything on your screen will be tidy and orderly. Ensure these technical aspects are taken care of, so you can focus entirely on your presentation and performance.

Next click on ‘Record’. This will enable you to record your practice session and then watch it from start to finish at the end.

Practising enables you to check your equipment before the exam and to check your nerves. Secondly, if possible, get feedback on your recorded performance from trusted colleagues or a supervisor or senior GP. Particularly in cases where you are managing uncertainty. This will enable you to hone your skills even further. Improving your performance and reducing the likelihood of anything going wrong will increase your confidence and allow you to focus 100% on your exam.

GPEx’s CCE preparation courses give you targeted strategies and techniques for managing uncertainty as well as individualised feedback on your performance. View our courses here.