th
Dr Mumtaz Patel
Consultant Nephrologist
Divisional Educational Lead
Manchester Royal Infirmary

• Outline and Aims
• Definition
• Categories of Difficulty
• Common Presentations
• Potential Triggers of Doctors in Difficulty
• Managing Doctors in Difficulty
• Case Studies

 “Any trainee who has caused concern to his/her educational supervisor(s) about the ability to carry out their duties, which has required unusual measures.
 This would mean anything outside the normal trainertrainee processes where the Training Programme
Director has been called upon to take or recommend action.”
(NW Deanery, 2013)

 Trainees in Difficulty
 Struggling to manage workload, failure to progress
 Trainees with Difficulties
 Illness, Home or personal life issues
 Difficult Trainees
 Inappropriate, unprofessional behaviours. Lack of
Insight

 Performance Issue
 Problematic Personal Conduct
 Problematic Professional Conduct
 Health problems
 Learning Environment
 System Issues

Work Based
• Absenteism/lateness
• Poor time management
Clinical Performance
Cognitive
•
Over/under investigating ;missed diagnosis
• Failure to follow guidelines/policies
• Complaints; incidents
• Memory problems, Poor problem solving/decision making
• Poor concentration, attention, learning problems
Language/Cultural
Psycological/Personality
• Poor verbal fluency
• Poor understanding
• Irritable, forgetful, arrogance, lack of insight, denial
• Highly self critical; perfectionist
Social
• Isolation, withdrawal, irritability
• Poor interpersonal skills; lack of insight

 Patterns or repetitive behaviours (rather than one off
 Sudden out of character behaviour
 Sickness
 Serious one-offs that are rationalised by trainee
 Eg. a small lie

1. Early Identification of problems and intervention is essential.
2. Establish and clarify the circumstances and facts as soon as possible – Access many different sources of information.
3. Remember poor performance is a symptom and not diagnosis and needs to be explored.
4. A robust and detailed diagnosis can lead to effective remediation.
5. Clear documentation is essential.
6. Misgivings must be communicated; Records must be kept and remedies must be sought

• Trigger Event or Incident
Is it important?
Does it matter?
Who do I need to involve?
• Consider CS, ES, TPD,
DME, Deanery, HR, OH
Investigate
• Investigate and define problem
• Collate evidence, DOCUMENT.
Be objective
Think patient and person safety at all times
• Be objective
• Do n0t jump to conclusions
• Formulate opinion
Decide
• Individual issue
• Organisational issue ?both
System failures easy to overlook
• Be fair and objective
Taken from NACT Managing Trainees in Difficulty 2012

Does it matter?
Can they normally do it?
Why are they not doing it now?
• If no, relax
• If yes, do something and ask
• If no, re-trainable?
• Not trainable, exclusion only!
• If yes, ask
• Clinical performance
• Personality issue
• Health
• Learning Environment
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Key areas to explore when considering poor performance ie.
‘Potential Diagnoses’ i) clinical performance ii) personal, personality and behavioural issues including impact of cultural and religious background iii) physical and mental health issues iv) environmental issues including systems or process factors, organisational issues including lack of resources
Taken from NACT Managing Trainees in Difficulty 2012

 No harm/risk to patient, staff, trainee.
 Minor incidents, complaints
 Controlled illness
 Failure to attain training goals
 Action plan ES lead, thorough documentation.
 Discussion with trainee/minor investigation
 Pastoral Support/OH
 SMART action plan/short resolution time.
 Discussion with TPD/?HR, Lead Employer

 Potential or actual harm/risk to patient, staff, trainee or reputations.
 Repetitive patterns, recurrent behaviours
 Any issue requiring extension of training
 Action plan
 Formal Investigation
 HR, OH, Deanery, PGME
 Action plan with defined objectives
 Specialised interventions

 Actual serious harm, reputations are at serious risk
 SUIs, Formal complaints
 Criminal Act
 GMC, NCAS referral
 Action
 HR, OH, Deanery, PGME
 As level 2 with formal investigation
 ? Cessation/Restriction of practice

 Specific areas, technical and non-technical skills
 Focused retraining
 Often task orientated and with specific targets
 Performing adequately at a level (eg ST 3) but not demonstrating the necessary skills eg leadership, complex decision making to progress to a higher level.
 Focused training
 Mentoring and Coaching
 Thorough documentation

 Close clinical supervision, developmental mentoring
 Develop insight
 Cultural and Religious advice if necessary
 Simulation or videoing to challenge behaviours
 Educational Psychology
 Cognitive Behavioural Therapy
 Difficult and sometimes impossible to remedy

 Doctors can become ill
 Physical and mental Illness
 Substance misuse
 Occupational health review
 Disability act requires employers to make reasonable adjustments
 Ensure adequate support
 Staff counselling

 Early concerns not addressed
 Inadequate documentation of problems and discussions; dated and signed
 Insufficient thought given to remedial plan
 Feedback especially around ARCP outcome 2 and 3 is seen as arbitrary and punitive
 Views on course of action are varied

 Document everything
 Be transparent
 Discuss actions and plans with trainee
 Support
 Staff counselling
 Share appropriately
 PGME, Deanery.

Managing Trainees in
Difficulty
(version 2)
Practical Advice for Educational and Clinical Supervisors
July 2012
NACT UK: Supporting
Excellence in Medical
Education

Associate Medical
Director (eduction)
PGD structure
DME
Associate Director
Med Ed
Head of
Postgraduate
Education aDME aDME aDME
Ed Sup
Div Lead
Clin Sup Junior Rep

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Website
 Blog
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Interactive toolkit
Links to useful documents and sites
Intelligence
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Referral to PGME of DiDs
Involvement of ES in sickness management
Trainer involvement
 Faculty of mentors
 Assessment and targeted training groups
 Education
 Trainer development days