Trainees with Problems

Practical Advice for Educational & Clinical Supervisors and Trainees

This section is largely based on the excellent NACT document “Managing Trainees in Difficulty” (http://www.nact.org.uk/nact_docs.html) published in January 2008 and is intended to assist both trainees and trainers when difficulties arise. Guidance is offered in the hope that early identification and intervention can lead to successful remediation of problems and concerns. However in every case patient safety must be the primary concern

Difficulties typically present as performance issues, the range of which can be considerable. Fortunately serious problems are rare but when they do occur they are invariably complex and can be extremely challenging to deal with. In every case thorough and careful investigation is essential to determine the nature of the problem and identify underlying factors before appropriate action can be taken. More often than not there is an inter-play between several factors including conduct, health, personal circumstances and the learning environment that lead to poor performance. Occasionally allegations of harassment and bullying or the threat of litigation can complicate matters. It is important to involve others at an early stage for advice and support as early recognition and appropriate intervention including effective feedback and additional support when necessary for trainee and trainer usually leads to a successful outcome

Roles and Responsibilities

A trainee has a contractual relationship with their employer and is therefore subject to local and national terms and conditions of employment. This includes clinical accountability and governance frameworks as well as disciplinary procedures. Trainees have a responsibility to fully engage with the educational process

If a trainee is experiencing difficulties they may be uncertain who they should approach:

• If it’s a training/performance issue – then speak to your Educational Supervisor first. Alternatively speak to the College Tutor/Specialty Lead, Clinical Tutor or Director of Medical Education. N.B. The education centre manager is a good source for advice

• If there’s a health issue – consult your GP. It may be appropriate to inform your educational supervisor. N.B. Referral to Occupational Health may be made

• If there’s a disciplinary issue – contact the BMA, defence organisation, or solicitor

On any issue the associate dean for the specialty can be contacted, as can the training programme director, but the above should be considered first

The Lead Employer or employing Local Educational Provider (foundation trainees only) must ensure that employment laws are upheld and their responsibilities fulfilled. They are directly responsible for the management of performance and disciplinary matters and that once issues are identified they are addressed appropriately. This may be delegated to the Host Trust where there should be clear processes for the identification, management and support of trainees whose conduct, health or performance is giving rise to concern

Educational and Clinical Supervisors may be involved in the identification, management and support of a trainee in difficulty and should be appropriately trained for this. They should also be supported by the College Tutor/Specialty Lead, the Training Programme Director, the Associate Dean for the specialty and/or host trust, the Clinical Tutor, the Director of Medical Education, Clinical Managers and Human Resources as appropriate

Employers have a contractual obligation to provide counselling and pastoral care for doctors in training

The Deanery is responsible for all doctors in training and for addressing any problems that may arise which prevent a trainee from progressing normally through a training programme. It is also responsible for ensuring the quality management of postgraduate medical education and systems should be in place to respond quickly to any concerns raised. These will involve Training Programme Directors, Associate Deans and the Postgraduate Dean

The Host Trust must keep the Deanery and the Lead Employer informed of all significant concerns about a trainee

The National Clinical Assessment Service (NCAS), which is part of the National Patient Safety Agency, may be able to offer a comprehensive assessment of clinical performance of trainees when complex problems are identified as well as advice on management and remediation

The General Medical Council (GMC) should be involved whenever a doctor’s medical registration is called into question. All doctors are bound by the terms set out in the GMC “Duties of a Doctor” which includes the responsibility to raise concerns about the fitness to practice of another doctor

General Principles

• Early identification of problems and intervention is essential

It is the responsibility of the Clinical Supervisor or any member of the clinical team with whom a trainee doctor is working to bring to the attention of the Educational Supervisor any concerns that could compromise patient safety. The Educational Supervisor may then involve others e.g. the College Tutor/Specialty Lead, the Clinical Tutor, the Director of Medical Education, or the Medical Director depending on the nature of the concerns

Potential early warning signs may include: *

• The “disappearing act”: - not responding to bleeps; disappearing between ward and clinics etc; persistent lateness; frequent sick leave
• Poor work rate: - slow in clerking, carrying out procedures, dictating letters, decision making; may be arriving early and leaving late without achieving a reasonable workload
• “Ward rage” : - angry outbursts; shouting matches; real or imagined slights
• Rigidity: - intolerance of ambiguity; inability to compromise; difficulty in prioritising; inappropriate “whistle blowing”
• “Bypass syndrome”: - junior colleagues or nursing staff find ways to avoid seeking advice/help
• Career problems: - difficulty passing exams; uncertainty over career choice; disillusionment with medicine
• Lack of insight: - denial of problems; rejection of constructive criticism; defensiveness; counter-challenge

* as highlighted in “Understanding Doctor’s Performance”- Ed J Cox, A Hutchinson,
P McAvoy -  Radcliffe Publishing, Oxford 2006

• With any particular problem the facts and circumstances should be established as quickly as possible. Access information from as many sources as possible

Only form a judgement once all the information is available. The majority of concerns can be successfully addressed by effective discussions between the Clinical and/or Educational Supervisor and the trainee leading to an agreed realistic learning plan with built in monitoring and reviews. This is greatly assisted by an open and supportive culture that provides constructive feedback on progress and encourages the acquisition and development of the trainee’s skills. However, if patient safety is an issue this takes precedence over all other considerations; GMC accountability applies to all doctors

• Remember poor performance is a “symptom” and not a “diagnosis” and therefore underlying causes must be explored

Key areas are:

• Clinical performance – knowledge, skill, communication etc
• Personality and behavioural issues – professionalism, probity, motivation etc
• Sickness/ill-health – personal/family stress, financial issues, career frustrations etc
• Environmental issues – organisational, workload, bullying and harassment

More often than not the causes of poor performance are multi-factorial. Rather than trying to decide whether a problem is purely performance (knowledge, skills) or conduct or health or the learning environment it is more useful to consider the possible contribution of all of them

• A detailed and robust “diagnosis” can lead to an appropriate “prescription” for effective remediation: different problems require different solutions

Poor performance or odd behaviour due to evolving medical or mental health problems necessitates a very different approach to successfully resolve matters than if the problem is poor interpersonal skills and lack of insight

• Clear documentation

Once a concern has been expressed all relevant discussions and interventions with the trainee should be documented contemporaneously, and copied to the relevant individuals in the accountability framework, including the trainee. As a general rule it is advisable to ask the trainee to sign the documentation to indicate their awareness of the content; this does not necessarily signify that they are in full agreement with it

REMEMBER:  Concerns must be communicated; Records must be kept; Remedies must be sought; Progression must depend on the resolution of issues

In using the chart below the following should be considered:

Trigger Incident – how significant is it? Who in addition to the trainee do I need to discuss it with? Is there a patient safety issue? What further investigation is necessary?

Fact Finding – gather information from as many sources as possible including the trainee. Don’t jump to conclusions, come to a view as the investigation proceeds

Significant Problem – who needs to be informed/involved?

Contributing Factors – the likelihood is that there will be several factors although they may have to be dealt with separately. Once addressed is it appropriate for training to continue?

Plan – does an alternative placement need to be considered? Who is the most appropriate educational/clinical supervisor? Who needs to be involved/informed? What are the specific targets and when should they be achieved by? Is this fully documented? How will progress be assessed? Are the consequences of not meeting the targets clear? What additional support needs to be considered? Are there any other considerations?

N.B. If it is concluded that there should be a formal referral to the GMC, NCAS, Police or disciplinary procedures should be initiated then the Postgraduate Dean must be informed in writing