Top tips to help you prepare for the RCA: learning from past RCAs

It's normal to feel nervous about the RCA. These top tips have been put together after feedback from previous RCA candidates, and will help you get you prepared. 

1. Really listen to the patient

Let the consultation flow naturally. Use what the patient has said to lead the journey through exploring their symptoms and possible investigation and treatment options.

Good consultations demonstrate where the candidate is being patient centred and not doctor centred.

Candidates who have fared less well follow a preordained script or bring in accurate but irrelevant details. An example would be discussing asthma which is not of relevant when the patient is presenting an ingrowing toenail.

2. Try to include patients presenting to you for the first time

This avoids lots of recapping. Summarising is only used to help to advance the consultation. However, as the examiners cannot see the medical records and so are unaware of past medical history, medication, and allergies, they verbalise them, when they are relevant.

Candidates who have fared less well go over old ground just for the camera when the decision has already been made. Verbalising past medical history mechanistically before an appropriate point in the consultation will not add value or marks.

3. Use any mixture of audio or video consultations.

There is no data to indicate that audio does better than video.

4. Submit 'good enough' consultations during the course of your work

Candidates who do less well sometimes search for the perfect one, or ones created just for the camera.

5. Safety net, sensibly

For example, it is only necessary to mention the option of a 999 call if a headache gets worse if there has been anything in the history to suggest that it might have a serious, urgent cause. For most headaches, calling back if it worsens would be a more appropriate option. Safety netting should be empowering and reassuring. A good safety net should not suddenly change the tenor of the consultation or come as a surprise to a patient.

Candidates who have / haven’t done as well, sometimes inappropriately safety net everything, because 'safety netting' is specifically mentioned as being important. A baby with a nappy rash does not need to be safety netted about meningitis. A bad safety net is either one that does not happen at all, or one which is disproportionate to the actual risk and which therefore causes a sudden change in tone at the end of a reassuring consultation and confuses, baffles or frightens the patient.

6. Explain any patient examination that will be needed in simple terms

A good explanation sits naturally in the consultation and helps inform the patient.

“I need you to come in so that we can examine your back passage. That will involve some discomfort obviously, but we need to rule out a polyp or piles as a cause for your bleeding. I will also be referring you for an urgent opinion in case there is anything more serious going on.”

Then ask them if there is anything else they want to know about what you propose.

Candidates who do less well may explain precisely everything that might happen in minute detail or explain all the complications that might occur as a result of the operation that the doctor does not even know whether they need or not at this moment in time.

“I need to place a hand on your abdomen and feel for any lumps that should not be there, after which I will lie you on your side and, having washed my hands and placed a glove on my hand, will use some KY jelly and then insert a finger…”

7. Chose a consultation with a patient presenting with a problem with their pre-existing long-term condition

This is to satisfy the relevant mandatory criterion.

Candidates who do less well may use a patient where a new diagnosis of a long term-condition is being made. Such cases do NOT satisfy the long-term condition mandatory criterion.

8. Cover ICE when appropriate

Ideas patients have about their illness tend to come early, but ‘ideas’ can also relate to discussing treatment options at the end of the consultation.

Concerns come a little later, when the patient looks worried and/or you are unpicking the ideas further.

Expectations can be dotted throughout the consultation, from “how can I help you today?” to “is that what you hoped I’d say?” right at the end.

The three questions are usually best asked in response to something the patient has said.

Candidates who do less well may use the single question: “What are your ideas, concerns and expectations?” It is three questions, not one, for a start, and everyone (including doctors) has difficulty answering complex tripartite questions.

Besides that, they are generally best asked at different parts of the consultation. E.g. asking “What are your ideas concerns and expectations today?” at any stage of the consultation; or asking “What were you hoping I could do for you today?” before any significant history has been gleaned, or the natural follow-up questions to the presentation have been asked.

9. Use the phrases that come naturally to you in a relaxed but formal setting

Not many of us say “Ah, bless” every time we hear something sad. Most of us do not use technical language when talking to anyone else.

Other phrases like “OK, fine” may in fact reflect the complete opposite to some statements by the patient.

10. Obtain clear consent either on or off the camera

Candidates who do badly submit cases where the patient has refused consent or withdraws it during the consultation. If the examiners can see this on audio/video, this would be considered as an inappropriate consultation to submit even though consent is not part of the case mark. If submitted, then Sanctions would be considered by the exam board and zero marks likely to be awarded as well as potential referral to the Responsible Officer.

11. Submit continuous recordings with clear sound throughout

If you feel the sound quality is not clear, then do not submit this consultation for assessment and do NOT be tempted to edit the recording to clarify. This can be detected and is a serious breach of exam rules.

Candidates who do less well may submit a consultation which has a break in recording, which is likely to incur a penalty and score zero marks.

12. Choose patients for examination where it is relevant and appropriate

This aids data gathering to include or refute differential diagnoses.

Candidates who do less well have been seen to apparently “stage” an examination. This is considered as a serious breach of rules and may incur a penalty or referral to the Responsible Officer for investigation as a possible probity issue. Such an examination which is not in the patient’s best interest but performed apparently to fulfill a role for the candidate can be obvious.

13. Address the patient appropriately

Only address them by their first name if they know them well already. This is especially the case for elderly patients.

Candidates who do less well address patients by their first name when they first consult, there has been no previous contact, and no rapport built. Most patients do not welcome this degree of familiarity in consultations, and assuming it can demonstrate poor rather than good Interpersonal skills.

14. Submit a range of curriculum areas and types of patients

Empowering a health-illiterate patient to say a few words will gain more marks than simply listening while a health-literate one explains their ICE without prompting.

More about MRCGP exams

• MRCGP exams

RCGP and COGPED

COGPED (Committee of General Practice Education Directors) offers a forum for Postgraduate GP Directors to meet and share good practice. Its aim is to encourage and maintain a consistent approach to GP training across the United Kingdom. It is a focal point for communication between the Postgraduate GP Directors and other stakeholders such as Royal College of General Practitioners, BMA, GPC, NHS Resolution, GMC and various sections of Department of Health & Social Care.