Top Tips

1. Understand the basics

The exam can be taken in the ST3 year of training and is a simulated surgery done remotely consisting of 12 cases played by simulated patients. It is usually done in your own training practice (although in some cases it will be done in a different one locally). You will have 3 minutes reading time before each consultation, and exactly 12 minutes for the consultation. Usually around 9 of the 12 consultations will be remote video consultations, and around three will be remote telephone consultations. There is a 10-minute break halfway through the assessment.

The consultations are recorded and marked later. There will be a different examiner for each case and they will be assessing three domains: data-gathering and diagnosis (DG&D), clinical management and complexity (CM&C), and relating to others (RTO).

Each domain is graded as clear pass (three marks), pass (two marks), fail (one mark) or clear fail (no marks). The clinical management and complexity domain is weighted 50% extra marks compared with the other domains. The maximum number of marks available for each domain after weighting is shown below:

DG&D: 36 marks

The total score from all 12 cases determines whether you pass or fail the exam. A low score in one domain or case can be compensated by doing well in others. The pass mark is adjusted each day to take account for the level of difficulty of the cases – so far it has been 75 out of 126 – theoretically it could be slightly higher in some sittings.

2. Join a study group

Forming a study group early on in your preparation for the SCA, 3 to 6 months prior to your exam, can help in many ways. A good number to meet for a study session is three: one to be the doctor, one the simulator, and one to observe and provide feedback. Some candidates find that being observed or recorded and consulting with simulators rather than real patients makes them nervous and affects their performance. Hence, doing role plays and having a colleague act as an observer and be the ‘examiner’ can simulate some of that pressure, and over time, help to overcome it. Putting yourself in the role of the examiner with a clearly defined marking scheme can give insight into the importance of demonstrating clearly the criteria in the different domains. It can be helpful to work with doctors from a variety of backgrounds and styles, so you get multiple perspectives and avoid complacency when it comes to feedback.

3. Seek feedback regularly and observe how others consult

Try to get feedback on your consulting whenever possible. This can be through consultation observation tool assessments, joint surgeries, during out-of-hours sessions and during tutorials. Video can be a useful tool. Not only can you watch a few recorded consultations with your trainer, but it can be helpful to watch yourself and pick-up on things such as body language and non-verbal cues from the patient. Work on any areas of weakness, and then ask your trainer to observe for those specific areas so you continue to improve.

Try some ‘reverse’ joint surgeries: where you observe your trainer and other team members consult. This can be a good way to pick-up useful tips and good habits from experienced colleagues. You may observe a doctor in the team with a lot of experience with specific case types. You may then learn to tweak your explanations of certain conditions and patients based on the observed approach.

4. Know what to expect and prepare for challenging cases

Each day of the exam will have cases drawn from across the 12 clinical experience groups in the SCA blueprint (RCGP, 2023) – candidates should prepare equally for all groups (see Box 1). Box 1.

Blueprint list of clinical experience groups for the MRCGP SCA.

Patient less than 19 years old

Spend some time going through the official information from the RCGP, which includes details of the curriculum areas, sample case notes, video examples of consultations, and recordings of webinars run by examiners for trainees and trainers (RCGP, 2024).

It is important to identify areas you find challenging and actively prepare for them by consolidating your knowledge of the current guidelines, and then making sure you can apply that knowledge in a consultation. You can use your regular clinics as learning opportunities for many potential cases, however, you should also actively prepare for cases from all the areas in the blueprint list.

If you find it difficult to take a sexual health history because you get embarrassed when asking sensitive, but important, questions relating to risk factors for sexually transmitted infections, practise asking such questions until you are able do it confidently. Similarly, some candidates might not have much exposure to certain curriculum areas in everyday practice. Practise telephone consultations, as it can be challenging taking a history without some of the non-verbal cues on which we rely either in clinic or when consulting remotely. Practise explaining common tests and conditions in clear, concise language to enable quick and confident performance in the exam.

5. Learn to manage your time effectively

Candidates struggling to complete cases often get a low score for the CM&C domain, as they lack time to discuss treatment options, or discuss follow-up and safety netting. As this domain is weighted with 50% more marks compared it have a big impact on overall score and the chances of passing the exam. The month before sitting the exam, try to get comfortable completing consultations in 12 minutes. You may still be on 15-minute slots, but try to use the last few minutes to type up your notes. It is very difficult for a candidate needing 17–20 minutes per case in surgery to shave several minutes from their consulting time in the exam. Aim to complete the bulk of your data gathering within 6 minutes, allowing enough time to discuss the diagnosis and complete your management.

6. Do a dry run before the exam

Make sure the room you will be using for the exam is ready at least a few weeks beforehand. Check your internet connection, the room layout, camera and microphone settings and that any headphones, if you plan to use them, are all working. Record a role play with those settings and watch back to ensure the quality of the audio and video is the best possible. Consider the placement of the camera so that when looking at the screen you are able to make good eye contact with the simulator. If the lighting is not adequate, it will impact the quality of the recording. If the sound is not clear on the recording it will make it more difficult for examiners to pick up what you are saying when marking. Use of headphones with an integrated microphone or an external microphone may improve sound quality. Check everything is working again the day before the exam and do a final check at least an hour before your exam session is scheduled. If you can do a mini mock exam in the same room, it may help ease your nerves on exam day and an opportunity to get familiar with timings and conducting cases back to back.

7. Remember all three domains are marked in every case

A common myth about the SCA is that it is all about communication skills. Although good communication is an essential part of being a good GP, this domain comprises less than 30% of the marks for each case. The bulk of the marks in the exam relate to clinical areas.

Data-gathering and diagnosis is about asking the right questions appropriately and being able to work out the correct diagnosis or differentials. It is important to take a focused, systematic history. If you spend too long on the history by asking vague or irrelevant general questions you will probably get a poor mark for this domain and run out of time for the clinical management and complexity domain. Candidates often lose marks in this domain by failing to ask about relevant red flag symptoms to exclude rarer but serious conditions or getting the diagnosis wrong.

There is a lot to cover in the CM&C domain. Allow enough time to discuss management options, cover other important risks and arrange follow-up and safety netting where appropriate. Consider if there are other issues beyond the presenting problem that may need to be dealt with later in the consultation. This will usually take 4 or 5 minutes to cover well. You can lose marks if your proposed management plan is not in line with current evidence, so a good knowledge of current guidelines is essential.

In the RTO domain, you may lose marks if you do not build a good rapport, fail to take on board the patient’s agenda or social and psychological aspects of the situation impacting the patient. Work on being able to explain investigations, diagnoses and results clearly without technical jargon. Pay attention to both verbal and non-verbal cues. It is important to explore them as there may be important symptoms or issues that only emerge when the cue is explored.

8. It is not enough to know it, to get marks you have to show it

Examiners can only mark observed behaviour, so it is important to demonstrate your knowledge and skills clearly in each domain. For example, in the clinical management domain for a case of newly diagnosed stage 2 hypertension in a 50-year-old Caucasian patient with diabetes, informing the patient about ‘starting a once daily tablet for blood pressure’ would not get the marks for correct management as it is unclear they are prescribing an appropriate drug. A candidate making it clear by starting an appropriate dose of an angiotensin-converting enzyme inhibitor would get marks for correct management. A good candidate would also allow enough time to discuss follow up with subsequent checking of renal function in 1 to 2 weeks and checks of blood pressure after a month. Follow up would be suggested for discussion of lifestyle changes, any side effects and appropriate safety netting.

9. Treat the exam like a regular clinic

Treat the SCA like a regular 12-patient remote clinic, with the benefit of a break halfway through, and without any physical examinations or recording of notes on the computer. Do not do any acting! The only person doing any role-play should be the simulated patient. You should be doing the same things you do with real-life patients. Some candidates offer false options they would never suggest in real-life or mention inappropriate safety netting to tick an imaginary box. This looks awkward and unnatural. It can lead to the simulator expressing fear or asking questions about an option that is not really suitable for their situation. This in turn may mean you run out of time or end up going along with an inappropriate management option that should not have been offered in the first place.

10. Focus only on the case at hand

In an exam with 12 cases, you may have one or two cases that either do not go as well as you would have liked, include a less common disease or a high challenge presentation. Remember that a bad performance in any one case can be compensated by doing well in others. Just do your best to listen carefully to the patient, try to be safe, and communicate clearly. Being able to deal with uncertainty is an important part of general practice, and this may be part of what is being assessed in a particular case. In some cases, there may not be a single diagnosis and just like in real life, it may be enough to narrow down to suitable differentials with a plan to allow confirmation of the diagnosis later. At the end of the case, take a deep breath, clear your mind and start reading the notes for the next case with a positive attitude; otherwise, one poor case can go on to affect how you score on the next few and have a much bigger impact on your overall score.

Summary

The MRCGP SCA is a challenging high-stakes exam. To pass, you need to demonstrate the skills and knowledge to practice safely without supervision. These include taking a structured history, making a diagnosis, being up to date with your management and being able to deal with complexity. You need to show that you can communicate clearly and effectively and engage the patient appropriately. Finally, you must manage your time well to get through everything in 12 minutes. I hope these tips are helpful in your preparation and wish you every success with the exam.

Disclosure

Dr Mahibur Rahman is medical director of Emedica, a medical education company that offers courses and resources for doctors preparing for the MRCGP AKT and MRCGP SCA.