Faculty Development
MANAGING
TRAINEES IN
DIFFICULTY
www.londondeanery.ac.uk
INTRODUCTIONS
• Your name
• Your role
• What you want to get out of the session
LEARNING OBJECTIVES
By the end of the course participants will have:
• Identified the common symptoms and situations that lead to trainee difficulties
• Identified common signs of trainees experiencing difficulty
• Discussed principles central to the early identification and management of a trainee in
difficulty using the Deanery framework
• Discussed recent developments related to revalidation
EXPLORING AND DEFINING THE CHALLENGES
Identifying poor performance
• A good supervisor will support the majority of trainees and clearly identify the
struggling minority
• But what do we do with this struggling minority?
POOR PERFORMANCE
From your own experience with trainees:
• What are the characteristics of poor performers?
• What are the early warning signs (even if you didn’t recognise them at the time) of a
trainee in difficulty?
EARLY WARNING SIGNS
• The disappearing act
• Rigidity in thinking
• Very slow
• Inappropriate emotional outbursts
• Failing to gain the trust of others
• Colleagues don’t want to call on them
• Lack of insight
• Problems with probity
Paice & Orton (2004) .
MANAGING TRAINEES IN DIFFICULTY
• Poor performance is a symptom not a diagnosis
• Exploration of underlying causes is essential
ASSESSMENT DOMAINS
Health and
home
Personality and
behaviour
Clinical
capability
Organisational
issues
HEALTH AND HOME
• High workloads and time pressures in clinical practice may lead to depression and anxiety
• Firth-Cozens (2003) found significant levels of stress among junior doctors – 28% above
threshold levels of stress, compared with18% of the general population
• Like anyone else, doctors experience ‘life events’ – family, relationships, finance, etc.
PERSONALITY AND BEHAVIOUR
• Personality types and learning styles are associated with different responses to working
conditions McManus et al. (2004)
• Personality strengths under pressure may become problematic, e.g. enthusiastic – volatile
Hogan & Hogan (1997)
ORGANISATIONAL ISSUES
• Poor educational infrastructure, e.g. poor induction, rotation, staffing/workload issues,
training and support of supervisors
• Bullying, harassment
• Service reconfiguration
CLINICAL COMPETENCE
• Lack of specific practical skills or knowledge, attitudes
• Capability
• Limited experience in a specific clinical area
KEY QUESTIONS
•
Can the trainee normally perform procedures and work well?
•
If so, why can’t they perform well now?
•
Is there a health issue?
•
Personality and behaviour issues?
•
Organisational issues?
•
A combination of issues?
RESPONSIBILITIES OF THE
EDUCATIONAL SUPERVISOR
What are our responsibilities:
• to the trainee?
• to the rest of the clinical team?
• to patients and society in general?
• to the Deanery?
FRAMEWORK FOR THE MANAGEMENT OF
TRAINEES IN DIFFICULTY
DEANERY MTID FRAMEWORK
Key sections
• Identifying that there is a problem
• Further considerations
• Educational interventions
• Record keeping
• Formal investigation of clinical performance
• Deanery internal processes
• Self-help and additional resources
CASE STUDIES
• Individually, think of a trainee you have supervised and considered to be in difficulty
• Briefly present your experience to the group (without breaching confidentiality)
• As a group, choose one of the examples presented and use the London Deanery
framework to consider how you could address this situation
RESOURCES AND SUPPORT
London Deanery website
• Mednet (confidential, self-referral)
• The London Deanery Coaching and Mentoring Service
• Careers Unit
• Language and Communication Resource Unit
Be aware of local resources, including occupational health, trainee’s GP
See London Deanery ‘Framework for Managing a Trainee in Difficulty’ for a
comprehensive list of resources
The Medical Professional Support Unit for London…coming soon
RECOMMENDED APPROACH
• Act early
• No surprises – involve learner
• If it isn’t written down it hasn’t happened
• Objective – fact not opinion
EFFECTIVE EDUCATIONAL SUPERVISION CAN
HELP TO PREVENT POOR PERFORMANCE
• Clarity of purpose/role with clear objectives
• Clear induction programme
• Mentoring
• Regular review of progress with effective feedback
• Encourage reflective practice
• 360-degree appraisal
• Early identification of difficulty
IMPORTANCE OF EFFECTIVE FEEDBACK
• Ask trainee’s point of view and encourage reflection
• Phrase feedback in descriptive, non-evaluative language
• Be specific not general
• Address decisions and actions rather than assumed intentions and interpretations
• Be constructive – acknowledge appropriate behaviour as well as areas for improvement
PERFORMANCE IN PRACTICE –
LEARNING PROGRAMME
PERFORMANCE IN PRACTICE –
LEARNING PROGRAMME
Revalidation for trainees
Doctors in postgraduate training will hold licences
Therefore…
Will need to revalidate
Every 5 years AND at CCT
The Postgraduate Dean is the Responsible Officer for trainees
GMC consultation
Revalidation: the way ahead
March 2010
Findings – October 2010
• Streamlined process
• Straightforward
• Proportionate
• Cost-effective
• Efficient
What is revalidation?
1. Five-yearly cycle commencing April 2013
2. The cornerstone will be a strengthened version of the appraisal cycle
3. Provides a focus for doctors’ efforts to maintain and improve their practice
4. Facilitates the organisations in which doctors work to support them in keeping their
practice up to date
5. Encourages patients and the public to provide feedback about the medical care they
receive
6. Contributes to improving the quality of patient care and providing assurance to patients,
the public and employers
Good Medical Practice
Has 7 domains:
1. Good clinical care
2. Maintaining good medical practice
3. Teaching and training, appraising and
assessing
4. Relationships with patients
5. Working with colleagues
6. Probity
7. Health
New GMC Domains for GMP
Domain 1: Knowledge, skills, performance
Domain 2: Safety and quality
•Maintain your professional performance
•Contribute to and comply with systems to
protect patients
•Apply knowledge and experience to
practice
•Respond to risks to safety
•Ensure that all documentation (including
clinical records) formally recording your
work is clear, accurate and legible
•Protect patients and colleagues from any
risk posed by your health
Domain 3: Communication, partnership &
teamwork
Domain 4: Maintaining trust
•Communicate effectively
•Work constructively with colleagues and
delegate effectively
•Establish and maintain partnerships with
patients
•Show respect for patients
•Treat patients and colleagues fairly and
without discrimination
•Act with honesty and integrity
ARCP and revalidation
Additional information that is likely to be needed at ARCP includes:
•
Serious incidents (SI) and complaints involving the trainee:
– the investigation reports
– the trainee’s reflection
– consequent education planning arising from the incident and progress made
•
Employer reports of routine clinical performance of the trainee:
– training posts
– any out-of-training/locum posts taken in year
•
Reports of other incidents or events relating to the trainee:
– that reflect key aspects of their health conduct or behaviour that relates to Good
Medical Practice
– includes criminal convictions
KEY LEARNING POINTS
• Causes of poor performance are usually multifactorial
• Poor performance often has early warning signs
• An educational supervisor needs to be able to make informed judgements about the next
steps once poor performance has been identified
• Thoughtful support will help most individuals to improve performance