RACGP CCE Exam - 103 Exam Technique

From the RACGP CCE 2023.1 Public Exam Report, we can see the breakdown of marks within the 12 competency areas.

Communication and consultation skills (30/107) 28%
Clinical information gathering and interpretation (10/107) 9%
Diagnosis, decision-making and reasoning (16/107) 15%
Clinical management and therapeutic reasoning (22/107) 21%
Preventive and population health (13/107) 12%
Professionalism (7/107) 7%
General practice systems and regulatory requirements (6/107) 6%
Procedural skills (1/107) 1%
Managing uncertainty (2/107) 1%
Identifying and managing the patient with significant illness (0/107) 0%
Aboriginal and Torres Strait Islander Health (Case 1A/B 1/9) 11%
Rural Health (Cases 6A/B) 11%

Notes

I have appended the notes on competency areas 11 and 12
- Cases 1A & 1B had an ATSI focus, so 1 case of 9
- Cases 6A & 6B had a rural focus, so 1 case of 9
This is the first time RACGP has published such a breakdown
While there is a clear focus on competency areas #1 and #4, most of the 12 areas were covered
12 focus areas x 9 cases = 108 data points, so it should be clear each case covers about 12 data points

Take Home – DO NOT get bogged down on a single topic area in a CCE case – there are many boxes to tick, and you must cover the ground.

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

Ticking Boxes

When I say there are many boxes to tick, I mean that quite literally. Here is part of the marking grid for a RACG CCE case. You should have no doubt that this is a “tick box” exam. Here is a small part of a case marking grid. You must touch the tick box areas to get the marks.

Competency at Fellowship level	Competency NOT demonstrated	Competency NOT CLEARLY demonstrated	Competency SATISFACTORILY demonstrated	Competency FULLY demonstrated

1. Communication and consultation skills
1. Communication is appropriate to the person and the sociocultural context	☐	☐	☐	☐
2. Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives	☐	☐	☐	☐
4. Communicates effectively in routine and difficult situations	☐	☐	☐	☐
10. Prioritises problems, attending to both the patient’s and the doctor’s agendas	☐	☐	☐	☐

I hope you can now see how CCE – 102 – Clinical Competencies relates directly to how this exam is marked. The exam marking key comes directly from the competency list. In this particular question the marking key focused on the highlighted areas:

1. Communication and Consultation Skills

Communication is appropriate to the person and the sociocultural context.
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.
Matches modality of communication to patient needs, health literacy, and context.
Communicates effectively in routine and difficult situations.
Demonstrates active listening skills.
Uses a variety of communication techniques and materials (e.g., written or electronic) to adapt explanations to the needs of the patient.
Uses appropriate strategies to motivate and assist patients in maintaining health behaviours.
Adapts the consultation to facilitate optimal patient care.
Consults effectively in a focused manner within the time frame of a normal consultation.
Prioritizes problems, attending to both the patient’s and the doctor’s agendas.
Safety-netting and specific follow-up arrangements are made.

Public Exam Reports

In the RACGP Public Exam Reports for the CCE (and RCE) what follows is a summary of how candidates did well (or badly) across the 12 competency areas.

How Candidates Demonstrate Competency

Communication and Consultation Skills: Candidates showcased exceptional ability in not just listening but actively engaging with patients, demonstrating empathy, and providing clear, empathetic explanations of medical conditions and treatments. This included adapting their communication styles to suit different patient needs, effectively managing difficult conversations, and facilitating shared decision-making.
Clinical Information Gathering and Interpretation: Proficiency was noted in conducting thorough and systematic history taking and physical examinations. Candidates were able to elicit key information, understand its relevance, and use it to guide their clinical thinking, differentiating between significant and incidental findings to focus their diagnostic reasoning.
Making a Diagnosis, Decision Making, and Reasoning: Successful candidates demonstrated strong analytical skills, employing a logical approach to narrow down differential diagnoses. They used evidence-based investigations strategically, interpreting results accurately to confirm or refute their clinical suspicions, and made informed decisions on patient management.
Clinical Management and Therapeutic Reasoning: Highlighted was their ability to develop comprehensive, holistic management plans that integrated current best practices and guidelines. They considered the patient’s context, preferences, and overall health in their therapeutic choices, ensuring plans were realistic and sustainable.
Preventive and Population Health: Candidates excelled in integrating preventive health measures into their clinical practice, offering tailored advice on lifestyle modifications, and appropriately utilizing screening tests based on patient risk factors. This demonstrated an understanding of the role of primary prevention and early detection in improving long-term health outcomes.
Professionalism: Demonstrated professionalism encompassed ethical practice, including maintaining patient confidentiality, obtaining informed consent, and treating patients with respect and dignity. Candidates showed a commitment to ethical principles and the welfare of their patients, navigating complex ethical dilemmas with sensitivity.
General Practice Systems and Regulatory Requirements: Candidates displayed a comprehensive understanding of the healthcare system, including referral pathways, the appropriate use of healthcare resources, and adherence to clinical guidelines and regulatory requirements. They effectively navigated system complexities to optimize patient care.
Procedural Skills: Exhibited competency in performing or explaining common procedures relevant to general practice. They demonstrated technical proficiency, safety awareness, and the ability to communicate procedural aspects, including risks and benefits, ensuring patient understanding and consent.
Managing Uncertainty: Effective management of clinical uncertainty was a key competency, with candidates demonstrating the ability to articulate uncertainty to patients, use a cautious approach in investigations, and make provisional plans while awaiting further information, maintaining patient safety and trust.
Identifying and Managing the Seriously Ill Patient: Rapid identification and appropriate response to signs of serious illness were critical competencies. This included prioritizing urgent care, initiating stabilizing treatments, and facilitating timely referrals or emergency care when necessary.
Aboriginal and Torres Strait Islander Health: Candidates showed sensitivity to cultural differences, employing culturally appropriate communication strategies and understanding the importance of holistic approaches to health that incorporate physical, emotional, and spiritual wellbeing, reflecting respect for Indigenous health perspectives.
Rural Health: An appreciation for the unique challenges of rural health care was evident, including logistical issues of distance and resource availability. Candidates demonstrated adaptability in their management plans and utilized telehealth effectively, understanding the importance of accessibility in rural settings.

Common Pitfalls

Communication and Consultation Skills: Some candidates failed to establish a rapport with patients, used complex medical jargon without ensuring patient understanding, or did not adequately address patient concerns and preferences, impacting the effectiveness of consultations.
Clinical Information Gathering and Interpretation: Inadequate history taking or physical examination techniques led to missed or incorrect diagnoses. Some candidates failed to appreciate the significance of specific findings, impacting their clinical decision-making.
Making a Diagnosis, Decision Making, and Reasoning: A notable pitfall was the reliance on unnecessary or inappropriate investigations, reflecting a lack of critical thinking or overreliance on diagnostic tests, rather than clinical judgment.
Clinical Management and Therapeutic Reasoning: Management plans sometimes lacked consideration of the patient’s lifestyle, preferences, or ability to adhere to treatment recommendations, leading to suboptimal care outcomes.
Preventive and Population Health: Opportunities for preventive care or health promotion were often missed, including failing to recommend appropriate screening tests or lifestyle interventions relevant to the patient’s health risks.
Professionalism: Challenges included handling ethical dilemmas inadequately, breaches in patient confidentiality, or instances of cultural insensitivity, undermining patient trust and professional integrity.
General Practice Systems and Regulatory Requirements: Some candidates showed limited knowledge of healthcare systems, leading to inefficient use of resources or failure to follow up on patient care effectively.
Procedural Skills: Lack of confidence or skill in explaining or performing basic procedures, or failing to obtain proper consent, was a common shortfall, affecting patient safety and care quality.
Managing Uncertainty: Difficulty in articulating or managing clinical uncertainty led to overtesting or overtreatment, reflecting a discomfort with not having immediate answers.
Identifying and Managing the Seriously Ill Patient: Delays in recognizing signs of critical illness or initiating appropriate emergency responses were critical pitfalls, potentially compromising patient outcomes.
Aboriginal and Torres Strait Islander Health: Insufficient cultural competence and stereotyping affected the quality of care and patient relationships, indicating a need for greater cultural awareness and sensitivity.
Rural Health: Underestimating the impact of geographical and resource limitations on patient care in rural settings led to unrealistic management plans, underscoring the need for greater awareness of rural health challenges.

Exam Marking

The RACGP CCE is marked using the borderline regression method.

At the end of the marking key, they have this global assessment part:

EXAMINER’S OVERALL RATING OF THE CANDIDATE
☐ CLEARLY BELOW STANDARD	☐ BELOW EXPECTED STANDARD	☐ BORDERLINE	☐ AT EXPECTED STANDARD	☐ ABOVE STANDARD

Borderline regression works like this. What is the take-home? Don’t be borderline! Note that you can fail 2/9 questions and still pass, but it’s best to plan to do better than that.