From 2021, the final exam on the pathway to RACGP fellowship is the Clinical Competency Exam (CCE)
The Remote Clinical Competency Exam (CCE) is a revised format of the Objective Structured Clinical Exam (OSCE) and the interim Remote Clinical Examination (RCE) which was introduced by the RACGP in response to the COVID-19 pandemic. The CCE is designed to test the same core skills as the RCE.
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 and allows candidates to demonstrate their clinical skills, communication skills and professional attitudes.
Here is what you need to know!
The CCE will be made up of 9 stations, delivered over 2 days. On the first day, candidates will be presented with four case based discussions, delivered via Zoom. On the second day, a week later, candidates will be presented with five clinical encounter stations. For the 2021.2 cycle these clinical encounters will also be delivered remotely due to ongoing COVID-19 uncertainty.
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.
- There may be a communication station involving an upset, angry, or non-compliant patient.
- In case based discussions where no 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 tested in patient clinical encounters.
- And there is usually one Aboriginal 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.
*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 the Advanced Care Directives, Substitute Decision-Makers and Enduring Power of Attorney to the patient and their partner.
*Use your reading time wisely.
Read the question carefully and plan your 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, adapt your language to reflect the patient’s age. 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 usually 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.
- 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?” helps build rapport. We commonly notice candidates can be very prescriptive when providing management plans, but forget to ask the patient if the options presented are actually acceptable to them.
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 with 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.
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.
Basic surgery tests are considered part of the examination in the CCE and examples include, urine pregnancy test, ECG, finger prick blood glucose, INR, spirometry, dipstick urinalysis and K10. If relevant to the situation you may ask for these results.
Diagnosis and investigations
After taking a history and performing an examination in general practice, we usually have some idea of our differential diagnosis. The CCE is no different.
When formulating your differential diagnosis, 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?
Ensure that you remember to explain your differential diagnosis to the patient if you are asked to do this in the station.
Your investigation list should then be tailored to your differentials, and you should have clear reasons for why you are ordering a test. The patient in the CCE may even ask you why you are ordering a specific test.
Investigations need to be relevant, cost-effective, and targeted. Think to 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.
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.
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. If you do refer to allied health or another specialist, be very clear about the reason for the referral; 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. So 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’ – 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). 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, with colleagues and even with family members. ModMed’s Dr CCE program provides a practice clinical exam 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 a remote clinical assessment. Additional practice cases can also be found in “The general practice exam book” which has been published by 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 careers!