RACGP CCE Exam – 101 Introduction

The RACGP CCE (Clinical Competency Exam) is the final hurdle to attaining the RACGP Fellowship. You are expected to meet the standard of being a doctor capable of practising independently in Rural Australia and managing an ED / Rural / ATSI community.

While the CCE typically has an 80-85% pass rate, at $5000, you really don’t want to have to pay to repeat it. Here is how the RACGP describes it:

The CCE is designed to assess clinical competence and readiness for independent practice as a specialist GP. The exam assesses how you apply your knowledge and clinical reasoning skills when presented with a range of clinical scenarios (called ‘cases’). It allows you to demonstrate your abilities over a range of competencies mapped to the RACGP Curriculum for Australian General Practice (the curriculum).

You are expected to demonstrate application of your clinical skills, as well as your communication skills, including inter-professional and patient-centred communication and professional attitudes, in the context of each of the cases.

Each CCE consists of nine cases delivered in short sessions over two days.

Four cases are in the format of case discussions that involve you discussing a case with the examiner and five cases are clinical encounters where you interact directly with a role-player while the examiner observes and assesses your competency. The CCE is delivered entirely remotely via Zoom. Clinical encounters and case discussions are mixed over both exam days.

RACGP

CCE Overview

Enrolling

Note that while you can enrol, you can not sit the CCE until you pass the AKT and KFP. Your money will be refunded if necessary.

The CCE gives you the opportunity to demonstrate your clinical competence in a number of contexts. It builds on the competencies already assessed by the written exams (AKT and KFP) and assesses how you integrate those competencies into your clinical practice.

RACGP

Clinical Competencies

In the CCE, each of the 9 cases in the exam will focus on a number of competencies. These clinical competencies are grouped under the following 12 headings:

1. Communication and consultation skills
2. Clinical information gathering and interpretation (history and examination)
3. Making a diagnosis, decision making and reasoning (investigations and diagnosis)
4. Clinical management and therapeutic reasoning (management)
5. Preventive and population health (primary prevention, secondary prevention and screening)
6. Professionalism
7. General practice systems and regulatory requirements
8. Procedural skills
9. Managing uncertainty
10. Identifying and managing the seriously ill patient
11. Aboriginal and Torres Strait Islander Health
12. Rural Health

The CCE Exam

The CCE consists of 9 cases, delivered across 2 consecutive weekends. The CCE exam is delivered entirely remotely via Zoom (details below). The structure is:

• 4 case-based discussions where you interact directly with an examiner.
• 5 clinical encounters where you interact with a patient (role player) while the examiner watches.
• All cases are the same 20-minute length, with
  • 5 minutes of reading time.
  • 15 minutes of case time.
• Some of the information is given to you during the 5 minutes of reading time.
• During the case, further information will be given.
• When the timer stops, examiners will allow you to finish your sentence, but nothing said after the timer has stopped will be rated.
• Almost everything in the initial information, including what the patient/examiner subsequently says, is important.
• Each case is assessed by a different examiner.

Case-Based Discussion – 4 cases.

• Only examiner in the room.
• The examiner will manage the time.
• The examiner will share your reading material on the screen and give you remote control so you can scroll through the material.
  • You will be given a patient record summary and relevant background history, which may include examination findings, investigation results or clinical photos.
• You will have five minutes of reading time.
• Examiners then run the case over fifteen minutes.
• Questions and/or additional information are then delivered verbally.
  • The examiner is highly scripted, which means they can only offer certain information and/or prompts.
  • You won’t be able to read the questions, so verbal questions are the way you have to practice.
  • If you don’t answer the question satisfactorily, the examiner may ask you a prompting question.
  • The examiner can not ask you anything more than the allowed prompts.
• Suggestions
  • During the reading time
    • Form a problem list
    • Form a list of differential diagnoses
    • Use the reading time template
  • Manage the problems.
    • This is the main thing in the CCE.
    • Unlike medical school exams, there will be multiple problems to manage per case.
    • These problems will relate to the 12 competencies noted earlier.
    • Look for all the problems in the case, including preventative healthcare.
  • Because the questions are verbal, the best candidates make sure they understand the question.
    • If you are unsure about what is being asked, ask the examiner to repeat the question again.
      • Write the question down if necessary.
    • Take your time before answering.

Clinical Encounters – 5 cases

• Examiner and role player in the room.
• You, the candidate, manage the time to complete all the tasks.
  • You are allowed to have a timer, but the examiner’s timing is definitive.
• The candidate and role player interact while the examiner observes.
• You will be given details of the scenario, such as a patient record summary, which may include examination findings, investigation results or clinical photos.
• You will also be given instructions on what to do in the consultation, for example:
  • You may be asked to take an appropriate history, advise the patient of their provisional diagnosis and initiate a management plan.
  • You may be presented with a clinical question by the patient, and this may require further history taking.
  • The role-player is highly scripted, which means they only freely offer some information.
    • You have to extract the rest with your history-taking skills.
  • Role players may use scripted prompting questions.
• Consults start at different stages, so be aware of where you should start.
• Accumulate a problem list, including a differential diagnosis list.
• Systemic approach:
  • Start with empathy and brief rapport-building.
  • If the case is ATSI, use the ATSI script to tick the necessary boxes.
  • As dictated by the case, work your way through:
    • History
    • Examination
    • Investigations (office based + referred)
    • Management
      • Immediate problems
      • Preventative activities
    • Safety netting and follow-up
  • Use the reading time template
• You must cover all aspects of care asked in the questions.
  • Do not run out of time!
  • In rough terms, if there are 5 questions to cover allocate 3 minutes per question.
  • Allocating a little extra time for History is sensible because you can not manage problems you have not discovered!

Common Themes

There are a number of common topics:

• Communication and consultation skills
  • Establish rapport
  • Patient-centred approach (ATSI special case)
  • Empathic
  • Motivational interviewing (ie smoking cessation, weight loss)
• Identify the problem list and patient agenda.
• History and examination
  • Take an appropriate history
  • Perform an appropriate examination
  • Interpret given findings accurately
• Investigations
  • Rational test ordering – does not need to be all possible tests – does need to be most important tests to clarify DDx
  • Interpret given findings accurately
• Comprehensive management and holistic approach
  • Manage the presenting complaint and problem list
  • Include preventative health activities ie immunisations, CST, mammogram, DEXA, ..
  • Safety net and follow-up
• Professionalism
  • Saying no while preserving the therapeutic relationship
  • Ethics
  • Article evidence appraisal
• Emergency management
• Procedures
  • Describe the procedure step-by-step, imagining you are doing it as you speak.

RACGP CCE Candidate Information

RACGP CCE Webinar

Here is a 1-hour video overview of the CCE from the RACGP. A brief synopsis is provided below.

• Technical
  • AEST timezone is the only timezone
  • All via Zoom
  • Scroll Lag – use a mouse with a wheel
  • Have a backup Internet connection ie hotspot
  • Can have paper, pen and timer
  • Camera must remain on
  • Use “Ask for help” NOT “Raise your hand”
• Want to know what you are thinking about and how you are thinking
• 4 case discussions – use medical language
• 5 clinical encounters – use patient-appropriate language
• Common criteria
  • 1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations of healthcare and the full impact of their illness experience on their lives.
  • 1.11 Safety-netting and specific follow-up arrangements are made
  • 2.1 A comprehensive biopsychosocial history is taken from the patient.
  • 4.7 A patient-centred and comprehensive management plan is developed.
  • 4.8 Provides effective explanations, education, and choices to the patient.
• Common areas
  • Communication and consultation skills
  • Clinical information gathering and interpretation (history and examination)
  • Making a diagnosis, decision making and reasoning (investigations and diagnosis)
  • Clinical management and therapeutic reasoning (management)
• Diagnostic sieve ie DDx
• Say the words… ie signpost, and don’t just write it down
• Read all the material given
• Main points being examined:
  1. Rapport
  2. History
  3. Examination
  4. DDx and working Dx
  5. Ix
  6. Mx
  7. Prevention
  8. Safety Netting
• Problem representation – short, sharp summary
• Keep tasks and timing in mind – have a structure
• Do use appropriate language
• Don’t use racist or judgmental language (ie make feel guilty about smoking)
• Wait, Refer, Review, Ask for an Opinion
• Tips
  • Use your reading time well — read and plan
  • Remember to look back at your notes through the case and say it!!!
  • Think rational and evidence-based for investigations and management
  • Be able to do a smooth systems review efficiently
    • General and specific information in role player script
    • You will only get the specific information if you ask…
  • Prioritise and verbalise what you can come back to
  • Use the context to tailor your approach
  • Stretch into all the domains/ competencies – and get great at the core competencies
  • You might need to describe doing something —think about this in your daily practice

Online Delivery Via Zoom

The CCE exam is delivered entirely remotely via Zoom. This video show the process. Key points are that your screen name must match your photo ID and you will need this ID for each case.

This written guide covers the technical aspects. 

RACGP CCE Guidelines

Here is the official RACGP overview of the CCE.