Managing Trainees in Difficulty

Managing Trainees in Difficulty

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

Definition Any trainee who has caused concern to his or her Educational Supervisor about the ability to carry out their duties, and which has required unusual measures to be put into place.

Categories of Difficulty 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

Categories of Difficulty Performance Issue Problematic Personal Conduct Problematic Professional Conduct Health problems (Stress, Drugs) Learning Environment System Issues

Presentations Work based eg absenteism, presenteism, avoidance Performance eg Poor decisions, poor investigating, failure to follow guidelines Cognitive e.g. Learning difficulties Language and Culture (enhanced induction) Psychological e.g. Irritability, Ward-rage, Lack of insight Social e.g. Isolation, Inappropriate.

Potential triggers of concern 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

Levels of Concern -1 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

Minor Incident Drug Error Trainee prescribes 5mg od Bisoprololto Elderly lady in AF after cardiac surgery. She receives this for two days. Normal starting dose is probably 1.25mg od. Trainee prescribes 5mg Warfarinto same patient. She receives this for two days. Probable starting dose should be 1-2 mg

Levels of Concern -2 Potential or actual harm/risk to patient, staff, trainee or reputations. Repetitive patterns, recurrent behaviours Extension of training Action plan Formal Investigation HR, OH, Deanery, PGME Action plan with defined objectives Specialised interventions

Levels of Concern -3 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? Restriction of practice

Level of concern A trainee publishes a blog describing some larking about by staff whilst on call. The hospital is not named but is probably recognisable from the description A trainee turns up to work looking the worse for wear. It was their birthday the day before. A trainee turns up to work several times looking the worse for wear A trainee sends sexually explicit videos of themselves to another member of staff A trainee lies about reviewing an x-ray. No major harm comes to the patient

Managing trainees in Difficulty 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

Three Questions 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, retrainable? Not trainable, exclusion only! If yes, ask Clinical performance Personality issue Health Learning Environment Key areas to explore when considering poor performance ie. Potential Diagnoses i) clinical performance ii) personal, personality and behaviouralissues including impact of cultural and religious background iii) physical and mental health issues iv) environmental issues including systems or process factors, organisationalissues including lack of resources Taken from NACT Managing Trainees in Difficulty 2012

Managing clinical concerns Specific areas, technical and non-technical skills Focussed 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. Focussed training Mentoring and Coaching Thorough documentation

Managing Personality Issues 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

Managing Health Issues 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

Causes of management failure 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

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

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Developing DiDsupport within CMFT Website Blog Interactive toolkit Links to useful documents and sites Intelligence Referral to PGME of DiDs Involvement of ES in sickness management Trainer involvement Faculty of mentors Assessment and targeted training groups Education Trainer development day 23 rd April

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