Sitting the RACGP CCE soon? Here is what you need to know!
Since 2021, 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 professional attitudes.
Here is what you need to know!
The CCE is made up of nine stations delivered over two consecutive weekends. The duration for each exam session is up to three hours. You will be examined on a combination of case-based discussions and clinical encounters. 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 stations can vary significantly. Examples of the types of things you may be asked to do include:
- Take a focused history, perform a focused examination, and explain the 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 communication station involving an upset, angry, or non-compliant patient.;
- In case-based discussions where no simulated patient is present, you may be asked about the management of a patient or about a medico-legal or ethical issue. Case-based discussions are often used to test knowledge that cannot be easily examined in the patient clinical encounter format; and
- An Aboriginal and Torres Strait Islander health station.
The competencies which can be included in the marking grid are:
- 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
- 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.
Read the question carefully and plan your time in the station. One of the most common mistakes candidates make 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 station.
Communication and rapport
Here are some tips and tricks to maximise your marks in this area:
- Unless it is a case-based 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-based discussion station 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 and they forget to ask the patient if the management plan is acceptable to them. Don’t forget to try to present a range of options to the patient, if this is clinically appropriate (e.g. discuss the range of appropriate contraceptive options rather than only discussing one option).
For those stations 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 physical examination, investigations, or management parts of the station.
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.
Most of us feel more comfortable performing the examination than asking for the findings. Try to still think of the examination in logical steps, and ask for the findings, just as you would look for them if performing it in real life. It is a good idea to have a structure in mind when asking for examination findings, such as general appearance of the patient, vital signs (you need to ask for these separately), and then move onto the relevant findings as appropriate to the station. Unstructured examinations which are not targeted to the presenting complaint are a common issue that we see in candidates preparing for the CCE.
Basic surgery tests are considered part of the examination in the CCE and examples include, urine dipstick, urine pregnancy test, ECG, finger prick blood glucose, INR, spirometry, and K10. If relevant to the situation, you may ask for these results. It is best to ask for these bedside tests at the conclusion of your physical examination in keeping with the usual structure.
Diagnosis and investigations
After taking a history and performing an examination in general practice, we usually have some idea of the differential diagnoses. The CCE is no different.
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?
Start by telling the examiner or the patient (depending on the type of station), 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. Ensure that you remember to explain your differential diagnoses to the patient if you are asked to do this in the station.
Your investigation list should be rational and specifically tailored to your differentials. You should always have clear reasons for why you are ordering a test. The patient in the CCE (or the examiner in the case-based 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 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.
When it comes to management, 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 marks in these areas.
Always make sure you consider emergency management (if applicable), short-term management, including treatment and safety netting, and long-term management, such as preventative health and health promotion. If you are explaining how you would perform a certain procedure, remember to include all of the relevant details in your explanation (e.g. the specific equipment you are using, positioning of the patient, hand hygiene, gaining patient consent etc).
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?
Remember not only are the patients ‘acting’, but so are you. You can give ‘virtual’ patient education handouts on any topic you wish!
It is wise to end stations with the 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 itself, remember that the examiners are not trying to trick you. Approach it like you would a day in general practice – they really just want to see how you approach problems. Take note of cues given to you by the patient. If the patient is clearly indicating you should move on, by telling you something is ‘fine’ or ‘doesn’t bother them’ or avoiding eye contact and seeming eager to talk about something else – then move on! If the patient is consistently telling you ‘I don’t know’ or they look confused or seem vague when you are asking them questions, it is probably an indication that you are on the wrong track!
There may be stations where you finish early – this does happen. It is worth reading the question again and making sure you have covered all the points that have been asked of you. You can also check any notes you made during reading time, and make sure you haven’t missed anything. You can check back in with the patient and ask them if there is anything else that they wanted to address today. You can also always talk about preventive health and health promotion areas, such as SNAP, or checking that appropriate screening tests are up-to-date (for example, cervical screening, bowel screening, vaccinations). Remember once you leave a station you cannot re-enter it.
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 in the clinical assessment. 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.
We wish you all the best in your ongoing exam preparation, and every success in the exam and your future career!