The final exam on the pathway to RACGP fellowship is the Clinical Competency Exam (CCE)

Like all RACGP Fellowship exams, the CCE aims to assess your competency for unsupervised general practice in Australia. The exam attempts to replicate a consultation or clinical scenario to allow candidates to demonstrate their clinical skills, communication skills and professionalism.

CCE Website Lead Magnet

Here is what you need to know!

Exam format

The CCE is made up of nine clinical cases delivered over two consecutive weekends. Four case discussions and 5 clinical encounters. The duration for each exam session is up to three hours. Each case will be 15 minutes with five minutes for pre-case reading time, with a mixture of the two case formats during each exam session.

The clinical cases can vary significantly. Examples of the types of tasks you may be asked to perform include:

  • Take a focused history, and explain the diagnosis and management to a patient;
  • Explain results to a patient;
  • Counsel a patient about a particular issue or manage a patient who is upset about a health issue;
  • A more complex communication scenario, for example, involving an upset, angry, or non-compliant patient;
  • In case discussions where no ‘patient’ is present, you may be asked how you would approach a particular clinical scenario. This might involve discussing your approach to history taking, diagnosis, management, or addressing a medico-legal or ethical issue. Case discussions are often used to assess areas of knowledge and clinical reasoning that cannot be easily evaluated during a simulated patient encounter; and
  • An Aboriginal and Torres Strait Islander health case.

The competencies which you could be assessed on include:

  • Communication and consultation skills
  • Clinical information gathering and interpretation
  • Making a diagnosis, decision-making and reasoning
  • Clinical management and therapeutic reasoning
  • Preventive and population health
  • Professionalism
  • General practice systems and regulatory requirements
  • Procedural skills
  • Managing uncertainty
  • Identifying and managing the seriously ill patient
  • Aboriginal and Torres Strait Islander Health
  • Rural Health

Not every station will cover all competencies. Cases will have been designed to specifically address certain competencies, to ensure that every competency is assessed through a variety of scenarios. You need to think broadly when approaching a clinical case, so you don’t miss out on marks by focusing all your attention on only one or two aspects of the case. You can read more detailed information about each of the competencies and view example marking grids on the RACGP website.

Do not forget to read up on ethical and medico-legal issues prior to the exam.

For example, we have noticed that many candidates in palliative care cases struggle to explain concepts such as Advanced Care Directives, Substitute Decision-Makers and Enduring Power of Attorney to the patient and their partner. There is such a broad range of medicolegal and ethical dilemmas that could potentially be discussed in the CCE. You may find it helpful to read through the online articles published by several of the medicolegal defence organisations as a part of your CCE preparation.

Use your reading time wisely.

During the reading time, ensure that you read the case and tasks carefully and plan your time in the station to the best of your ability. One of the most common mistakes candidates make in clinical encounters is not reading the instructions carefully. For example, the instructions may not ask for a physical examination, but some candidates will do this anyway and waste precious time in the station. Identify the tasks that you may be required to do, and make sure you spend time in the station on each of these areas. If you are asked to take a history and provide a management plan but use all 15 minutes taking a history, you are missing out on many potential marks in that case.

Communication and rapport

Here are some tips and tricks to maximise your marks in this area:

  • Unless it is a case discussion, direct your attention towards the patient, not the examiner.
  • Avoid using jargon when speaking to the patient and adapt your language to reflect the patient’s age and background. If you accidentally use medical jargon when talking to the patient, quickly clarify in plain language what you mean.
  • In a case discussion you should treat the examiner as a professional medical colleague and your language should reflect this.
  • Do not interrupt the patient! The person role-playing the patient has a script, with certain phrases they will begin with and respond with when asked appropriate questions by you. If you interrupt them, you can cut them off from telling you vital information. The simulated patient will be trying to help you by offering specific information – they are not trying to trick you!
  • Be empathetic and involve the patient in decision making. Asking them questions like “How does this impact you?”, “Does that make sense?”, and “Are you happy with that plan?” as this helps build rapport. We commonly notice candidates can be very prescriptive when providing management plans, especially when they perceive that they are running out of time. They often forget to ask the patient if the patient understands the management plan and whether or not is acceptable to them. Don’t forget to try to present a range of options to the patient if this is clinically appropriate, just like you would in every day general practice.

History taking

For those cases that require you to take a history, you need to make sure it is tailored, relevant, organised and to the point. You need to obtain the information logically and succinctly.

Start with open questions:

  • “How can I help you today?”
  • “Please tell me more”
  • “Is there anything else you wanted to tell me?”

You can then move to closed questioning as appropriate, which might cover your ‘red flag’ questions, or a quick systems review if appropriate. In some cases, candidates spend too long on history-taking and do not have time to progress to the other areas of the case, so be sure to manage your time well.

The person role-playing the patient will have history and phrases they will freely give you, for example, “I have a headache”, but they may also have information they are only allowed to tell you if you specifically ask the question, for example: “I have been vomiting as well”, and “Yes, the headache is worse lying down”.

Also think about age-related questions, for example with a teenager you may use the HEADSSS model and ask about: Home, Education, Activities, Drugs and alcohol, Sexuality, Suicidality and depression and self-harm and Safety. You can use your reading time to write down the structure of your history-taking so that you remain focused and don’t miss anything important.

Examination

In some cases you may be asked to outline or interpret aspects of a physical examination. 

You may be asked to explain what findings you would be looking for, how the findings influence your differential diagnosis, and how they guide your next steps in investigation or management. In a case discussion you may also be given examination findings and expected to interpret their clinical significance. 

Examiners are assessing your clinical reasoning and ability to interpret examination findings, rather than your ability to demonstrate every step of the examination technique.  

Diagnosis and investigations

When formulating your differential diagnoses, think of both the most likely diagnosis but also consider those conditions that you don’t want to miss. Murtagh’s diagnostic strategy can be useful here: 

  • What is the most likely or common diagnosis?
  • What is the most important diagnosis not to miss?
  • Are there any pitfalls or masquerades?
  • Are there any hidden agendas?

If you are asked to explain your differentials, start by telling the examiner or the patient (depending on the type of case), the most likely diagnosis and your reasoning and then outline the next most likely diagnoses. You can then finish by explaining that there are some less likely differential diagnoses which still need to be considered because they are serious.  

Your investigation list should be rational and specifically tailored to your differentials in the context of the case provided. You should always have clear reasons for why you are ordering a test. The patient in the CCE (or the examiner in the case discussions) may even ask you why you are ordering a specific test, so be prepared to explain your rationale. 

Investigations need to be relevant, cost-effective, and targeted. Ask yourself “how will the result of this test change or influence my management?”. You will not score marks for requesting a long list of investigations that are not relevant or targeted. Similarly, you will not score marks for requesting investigations which are usually ordered by other specialists. 

Management

When it comes to management in a clinical encounter, the first step is to give the patient a clear, plain language explanation of the problem. Always make sure you check the patient’s ideas and understanding of the problem. Then outline your management plan. 

A good tip is to list off your management steps to make sure the examiner knows your plan, then come back to each point separately and expand on them. This way if you run out of time, you have at least mentioned all the aspects of your plan and can be awarded some marks in these areas. 

Always make sure you consider emergency management (if applicable), short-term management, including treatment and safety netting, and longer-term management, such as preventative health and health promotion. If a procedure is relevant to the case, you may be asked to explain whether it is appropriate and how it would be safely carried out in general practice. This may include discussing the indication, risks and benefits, consent, and whether the procedure should be performed in general practice or referred to another service. 

Your short-term management can include pharmacological and non-pharmacological measures. It may include referrals, and you may also need to consider public health issues (e.g. mandatory reporting of certain infections) or medicolegal issues (e.g. fitness to drive). If you do refer to allied health or another specialist, be very clear about the reason for the referral and the level of urgency; just saying ‘referral’ is not enough to be awarded marks. 

Always give a very clear safety netting plan. When should the patient come back? What happens if they get worse? What happens if they get side effects to your treatments? 

It is wise to end stations with a clear follow-up plan, safety netting advice and asking if the patient has any questions. Also make sure to check back in with the patient about their understanding and agreeance to the plan. 

Your exam mindset

During the exam, remember that the stations are designed to reflect everyday general practice scenarios. The examiners are not trying to trick you — they are simply assessing how you approach clinical problems. 

Focus on the task provided and approach the case in a structured way, just as you would in your day-to-day clinical practice. Pay attention to the information provided by the patient and respond to cues that may help guide the consultation. 

There may be occasions where you finish a clinical encounter early (in case discussions – the examiner will manage your time). If this happens, take a moment to review the task instructions and ensure that you have addressed all components of the case. You may also wish to briefly summarise your plan, check the patient’s understanding, or ask if they have any further questions. 

Remember that once you leave a station you cannot return, so use the remaining time to ensure you have clearly communicated your assessment, management plan and follow-up (depending on the tasks you are asked to compete for that case).  

The best way to prepare for the CCE is to practice under timed conditions.

Practice scenarios with your study group, colleagues and even family members. Our Dr CCE program provides a practice clinical exam format delivered via video conference with cases designed to assess clinical competence remotely. Our Medical Educators are experienced in delivering cases using this format and will be able to provide you with detailed personalised feedback and advice on how to perform your best on exam day.  

Additional practice cases can also be found in “The General Practice Exam Book” published by the GPRA, and in Susan Wearne’s “Clinical Cases for General Practice Exams” book. You could also ask your supervisor or a colleague to observe you consulting so that you can receive feedback on your communication skills and consulting style and use random case analysis to enhance your clinical reasoning skills.  

We wish you all the best in your ongoing exam preparation, and every success in the exam and your future career!