CCE prep

1. General Performance and Exam Readiness

Communication and Presentation:

Maintain steady eye contact with both examiner and simulated patient.
Use active listening: nod, reflect back patient’s concerns.
Avoid interrupting patients mid-sentence unless clinically appropriate.
Speak clearly, at a measured pace, and modulate tone for empathy.

Professional Appearance and Environment:

Dress as you would in a face-to-face GP consult (smart professional attire).
Ensure a quiet, well-lit, and neutral background for online sittings.

Technology Setup:

Use a stable device (preferably wired connection), with a backup hotspot.
Familiarise yourself with Zoom controls: screen share, mute, scrolling.
Use dual screens if possible (case notes + video window).

Practice Habits:

Simulate cases under timed conditions with a colleague or peer group.
Develop fluency in transitions: history → differentials → plan.
Review performance through video or feedback sessions.

2. Problem Representations

Purpose:

Distil complex case data into a concise summary.
Helps you clarify diagnosis, guide next steps, and communicate succinctly.

Framework:

example: RACGP example from GP learning module: Exam Support Program : Peter Manning, aged 50 years old, is an Aboriginal man from a remote community who presents after coughing up blood on several occasions. On further questioning Peter has had a persistent cough for about 6 months and coughs up yellow-green sputum. He has noted pin sized pieces of blood in his sputum 1–2 times a week for the last few months. Peter has noticed shortness of breath on exercise but is not sure how long this has been a problem. Peter smokes 20 cigarettes a day and began smoking when he was 16 years old. He is not on any medications.

Element	Prompt	Example wording
Who?	age / sex / key risk factors	“50-year-old Aboriginal man, 35-pack-year history”
When?	duration + tempo	“chronic, intermittently progressive”
What?	clinical syndrome	“productive cough with haemoptysis and SOBOE”

Example Format:

“John is a 65-year-old male retired miner with a history of COPD who presents with a 4-day history of increasing dyspnoea, productive cough with yellow sputum, and mild wheeze.”

Practice Tip:

Convert lay terms to diagnostic language (e.g. “blood-streaked sputum” → “haemoptysis”).
Verbally summarise real/fictional cases daily to gain fluency.

Reading Time (5 Minutes)

How to Use Effectively:

Identify what you are being asked to do: take history, discuss plan, counsel, etc.
scan demographic data and determine key clinical context (rural, Aboriginal, vulnerable, chronic illness).
Group case elements logically (e.g. symptoms, medications, red flags).
Mentally sketch a timeline and differential diagnoses.

Case-Based Discussions (CBD)

Time Structure: 15 minutes per case (examiner-paced)

Preparation Strategy:

Predict likely questions:
- What further history would you ask and why?
- What is your differential diagnosis?
- What would you examine and why?
- What investigations would you order?
- How would you manage this patient?
Use structured responses:
- Tiered differentials: likely, less likely, serious.
- Investigations: initial vs specific tests, rationalise each.
- Management: short-term (acute), long-term, safety netting.

Interpreting Lead-In Questions

Lead-In Question	Intent	Response Focus	Example
“What further information would you like to know about X and why”	HOW	Clinical workflow steps	Safety → Hx → Ex → DDx → Ix → Mx
“What further information would you like to know about X and why”	WHAT + WHY	Focused Hx items with rationale	Menstrual Hx for IDA
“Outline what you would look for on physical examination and provide your clinical rationale”	WHAT + WHY	Targeted exam findings + significance	Clubbing in chronic lung disease
“Outline what you would look for on physical examination and provide your clinical rationale”	HOW	addresses the HOW – Plain-language – tailored explanation – shared decision	Explaining IBS to a 30-year-old

Providing Specific Answers: Avoiding Formulaic Responses

Avoid vague answers. Use patient-specific, contextualised responses:

Scenario	Non-specific	Specific Example
Rural patients	“I would transfer them to hospital.”	“I would contact the state retrieval service to arrange type of retrieval and discuss initial management actions.”
Aboriginal or Torres Strait Islander patients	“I would provide a culturally safe environment.”	“I would spend time with them early in the consult, introducing myself, asking how they would like to be addressed and where they’re from.”
Uncertain diagnosis	“We’ll run a few tests and wait.”	“The most likely diagnosis is A, but it could also be B or C. We’ll order [investigations] and review in 1 week.”

Clinical Encounters (CE)

Time Structure: 15 minutes (candidate-managed)

Phases of consultation:

Initiation
Information gathering
Examination
Planning
Closing

Approach:

Allocate approximate time segments
Be flexible if the scenario demands shift (e.g. patient distress, urgent symptom).
Signpost throughout: “I’ll now move to examining your symptoms more closely…”

Example: Timing a 15-Minute Clinical Encounter

Task	Suggested Time	Key Tips
Targeted history	5–6 min	• Use open → focused questions. • Cover ICE early. • Park tangents with “Let’s come back to that.”
Differential diagnoses	1–2 min	• State most likely, serious must-not-miss, then one or two less likely. • Link each to a key positive/negative finding.
Investigations	2–3 min	• Justify each test briefly (“I’d order an ECG to rule out arrhythmia as a reversible cause”). • Distinguish initial vs follow-up tests.
Management & advice	5–6 min	• Structure as Immediate / Short term / Longer term. • Include pharm + non-pharm + preventive items. • Finish with safety-net, follow-up plan, and confirm understanding.

Practical Time-Management Principles

Read task qualifiers
- “Brief history” → spend <3 min.
- “Explain differentials” → allocate >2 min.
Maintain momentum
- Avoid drilling into a single symptom too deeply.
- Use summarising bridges: “So far I’ve heard…, next I’d like to…”
Flexible, not rigid
- If the patient is mid-sentence when the timer buzzes, let them finish, then summarise succinctly.
Calm under pressure
- Check the clock discreetly; never show alarm.
- Have wrap-up phrases ready: “We’re nearly out of time—let me quickly outline what happens next.”

Managing Multiple Concerns

Acknowledge & prioritise “I see you have a few worries today. Which one is most important for us to tackle first?” “Thanks for sharing these. Which one is most important for you today?”
Negotiate follow-up
- “We’ll focus on your chest pain now and book a review next week for the other issues.”
Reinforce continuity
- Remind the patient that general practice offers ongoing care, not a single-visit fix.

Follow-Up & Safety Netting

Set a clear review trigger: “If the pain worsens or you develop shortness of breath, present to ED immediately.”
Document a review plan: “Let’s meet in one week once results are back.”
Invite questions: “Is there anything you’re unsure about before we finish?”

Communication and ICE

Use the ICE Framework:

Ideas: “What do you think is going on?”
Concerns: “What’s worrying you most about this?”
Expectations: “What were you hoping I could do today?”
- End every history block with: “Is there anything else you were hoping I’d cover?”

Adapt Communication Style:

No jargon with patients; use plain English.
Use appropriate interpreter/cultural broker where needed.
Respect cross-cultural practices and perspectives.

Complex Interactions:

Vaccine hesitancy
Parental disputes over care
Breaking bad news
Marginalised patients

Answer Structuring Techniques

For History:

Use OSCE mnemonics (SOCRATES, HEADSSS).
Signposting/using headings to create structured answers – “Ben, I am going talk to you about how we can manage your diabetes better with medication, but also going to touch important preventative health advise for all men’s health…”

For Differentials:

List: most likely, other possibilities, serious to exclude.

For Investigations:

Structure: initial investigations versus subsequent investigations

For Management:

Specific to the case and Practical to patient
- Generic: “You should exercise more.”
  - instead:
    - “Current guidelines recommend 150 minutes of moderate-intensity exercise per week for general health. However, I understand this may not be immediately achievable for you due to [patient-specific limitation].
    - Let’s aim for something realistic—perhaps starting with 10 minutes a day, and building up gradually.”
- Avoid generalisations like “start antihypertensives.”
  - Instead, be specific:
    - “Initiate perindopril 5 mg daily, titrate based on blood pressure response.”
    - “Recommend paracetamol 1 g QID PRN for pain, avoiding NSAIDs due to CKD stage 3.”
Short-term: Symptom relief (e.g., initiate treatment for pain).
Medium-term: Risk factor modification (e.g., smoking cessation, weight loss).
Long-term: Prevent disease progression, manage chronic conditions, reduce complications.
Pharmacological + non-pharmacological.
Preventative + population health if relevant.
- “Given you’re an Aboriginal and Torres Strait Islander patient, we’ll also ensure your vaccinations are up to date and include an annual health check under CTG.”

For Follow-up/Safety-Netting:

State specific timeframe (e.g. 1 week, sooner if worsening).
Red flags to return for.

Managing Uncertainty

Competency Includes:

Recognising diagnostic ambiguity.
Using time and review as diagnostic tools.
Communicating uncertainty with structure and confidence.
Rationalising investigations to avoid over/under-investigation.

Example Phrases:

“There are a few possible causes. Let’s start with basic tests and reassess once results are back.”

Professionalism

Key Elements:

Ethical behaviour and boundaries.
Willingness to reflect and change.
Managing personal health and professional burnout.

Case Scenarios:

Diagnostic error disclosure.
Managing impaired colleague.
Handling negative feedback or complaints.

Response Strategy:

Acknowledge issue
Take responsibility where needed
Outline steps to prevent recurrence
Engage support if required

Common CCE Pitfalls

(from Exam Reports)

Common Pitfall	Practical Strategies to Avoid It
Not reading the case/question correctly	Initial pause to read the stem twice; underline action verbs and data provided. Summarise aloud (“So I need to…”) to lock in the task before starting.
Disorganised / chaotic answers	Adopt a consistent framework (e.g. ISBAR for presentations, SOAP for consultations). Use a visible mind‑map or note grid during reading time to structure ideas.
Ignoring the patient’s agenda	Open with “What were you hoping we’d cover today?” and revisit ICE (Ideas, Concerns, Expectations) after key sections.
Scattergun differentials / management	Cluster symptoms & timelines before brainstorming. Aim for Top 3 likely + 2 red‑flag diagnoses, then targeted management aligned to those.
Missing key demographic / case features	Write the patient’s age, sex, context in the margin; check every plan or prevention point against these anchors.
Spending too long on one aspect (e.g. history)	Rehearse time‑boxing (e.g. 3 min focused history, 1 min exam recap). Keep a small digital or desk timer in practice sessions.
Inability to formulate comprehensive differentials	Use mnemonics when stuck; group by system or acuity to prompt breadth. VINDICATE V: vascular I: infection N: neoplasm D: degenerative or drugs I: iatrogenic or intoxication C: congenital A: autoimmune T: trauma E: endocrine/metabolic
Ordering irrational investigations	Apply the “Will it change management now?” test; cross‑check against RACGP Testing Wisely list.
Not identifying priorities	ABCDE snapshot immediately; list urgent issues first, then chronic, then preventive.
Missing clinical deterioration	Build red‑flag review into every plan: “If pain worsens, fever, haemodynamic changes → ED.” Practice spotting abnormal vitals in mocks.
Irrelevant preventive advice	Tailor advice to age, sex, risk factors; avoid generic check‑lists. Use evidence‑based prompts (e.g. Red Book age tables).
Discomfort with uncertainty	Explain the plan: “We’re not 100% sure today; here’s what we’ll monitor and when we’ll reassess.” Validate uncertainty as normal.
Poor patient education / language	Use teach‑back: “Could you tell me in your own words…?” Provide written or visual aids.
Lack of follow‑up & safety‑netting	Finish with specific timeframe (“I’d like to see you in 48 hrs or sooner if…”) and ensure contact details are confirmed.

RACGP “Testing Wisely” (Choosing Wisely Australia) – the 10 General-Practice recommendations

https://www.choosingwisely.org.au/recommendations/racgp

Recommendation (What not to do)	Why it matters – evidence & risk-benefit summary	Practical takeaway for CCE / day-to-day GP work
Don’t continue long-term proton-pump inhibitor (PPI) therapy without first attempting dose-reduction or cessation.	Prolonged PPI use is linked to chronic kidney disease, C. difficile infection, micronutrient malabsorption and fracture risk. Most symptomatic patients can step down to ≤ ½ standard dose or on-demand therapy after 4–8 weeks. choosingwisely.org.au	At each chronic-disease review flag any PPI as “medication to deprescribe”. Trial step-down/stop; document rebound-symptom plan and lifestyle measures (weight loss, HOB elevation, limited NSAID use).
Don’t start lipid-lowering or antihypertensive drugs before calculating absolute 5-year CVD risk.	Drug benefit is proportional to baseline risk; treatment below a 5-year risk < 10 % provides minimal absolute benefit but exposes patients to side-effects and cost. choosingwisely.org.au	Use the AusCVDRisk / NVDPA calculator during consults (screenshot on desktop for the CCE). Triage management: lifestyle only (< 10 %), shared decision (10–15 %), definite pharmacotherapy (≥ 15 %).
Don’t advocate routine self-monitoring of blood glucose (SMBG) in adults with type 2 diabetes treated only with non-hypoglycaemic oral agents.	RCTs show ≤ 0.2 % HbA1c reduction, no QoL gain, extra cost and “numbers anxiety”. choosingwisely.org.au	Reassure stable patients; focus on quarterly HbA1c, lifestyle and complication screening. Reserve SMBG for suspected hypoglycaemia, medication change or intercurrent illness.
Avoid prescribing benzodiazepines to patients with any substance-use history or multiple psychoactive drugs.	Strong association with dependence, overdose (especially with opioids/alcohol) and falls; safer anxiolytic or sleep alternatives exist. choosingwisely.org.au	In “drug-seeker” CCE scenarios: validate distress, set clear limits, offer CBT-I, melatonin, SSRI or non-pharmacological strategies; schedule review rather than issuing repeats.
Don’t screen asymptomatic, low-risk people (< 10 % 5-yr risk) with resting ECG, stress test, coronary-calcium score or carotid ultrasound.	Low pre-test probability → high false-positive rate, radiation (CT calcium), unnecessary angiography & anxiety; no mortality benefit demonstrated. choosingwisely.org.au	During a “well-man check”, pivot to modifiable-risk counselling: smoking, diet, activity, blood pressure and absolute-risk calculation.
Don’t order colonoscopy to screen average-risk adults – use biennial faecal occult blood test (FOBT).	FOBT reduces CRC mortality with far fewer harms; colonoscopy carries perforation (≈ 1/1 000) and sedation risks and strains limited endoscopy capacity. choosingwisely.org.au	When patients request “the gold-standard test”, link to the National Bowel Cancer Screening Program kit; explain colonoscopy only for positive FOBT or higher-risk categories.
Don’t perform routine bimanual pelvic examination when a woman presents only for cervical screening.	No evidence of cancer-detection benefit; increases pain, anxiety and false-positives leading to unnecessary imaging/surgery. choosingwisely.org.au	In OSCE counselling: clarify the Cervical Screening Test is vaginal-swab-only; offer exam only if pelvic pain, masses or discharge. Document informed refusal/acceptance.
Don’t order chest X-ray for otherwise healthy adults with acute uncomplicated bronchitis.	Viral cause in > 90 %; CXR does not alter management, yields false-positives and adds radiation. choosingwisely.org.au	Define “uncomplicated”: cough < 3 weeks, afebrile, normal vitals, clear chest exam. Provide safety-net: return if dyspnoea, fever, haemoptysis, immunocompromise.
Don’t treat acute otitis media with antibiotics in non-Indigenous children aged 2–12 y when reassessment is feasible.	80 % resolve without antibiotics; early antibiotics confer only ~8 % absolute pain reduction at day 3, but increase diarrhoea & resistance. choosingwisely.org.a	Explain “watch-and-wait”; give written analgesia plan, red-flags (fever ≥ 39 °C, otorrhoea, mastoid tenderness). Review 24–48 h or sooner if worsening.
Don’t order thyroid-function tests as population screening in asymptomatic adults.	Prevalence of unrecognised thyroid disease is low; universal testing produces many subclinical results that seldom change outcomes and may trigger overtreatment. choosingwisely.org.au	Only add TFTs when features such as fatigue plus goitre, AF, infertility, abnormal lipids or cycling weight change raise suspicion. For OSCE: justify with specific symptom links.