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Medical Educators Conference7th Nov 2014
Doctors in Difficulty WorkshopDr Mumtaz Patel
Consultant NephrologistDivisional 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
Doctors in Difficulty Workshop
Definition:
“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 trainer-trainee processes where the Training Programme Director has been called upon to take or recommend action.”
(NW Deanery, 2013)
Categories of DifficultyTrainees in Difficulty
Struggling to manage workload, failure to progress
Trainees with DifficultiesIllness, Home or personal life issues
Difficult TraineesInappropriate, unprofessional behaviours. Lack of
Insight
Categories of Difficulty
Performance IssueProblematic Personal ConductProblematic Professional ConductHealth problemsLearning EnvironmentSystem Issues
Common Presentations• Absenteism/lateness• Poor time managementWork Based
• Over/under investigating ;missed diagnosis• Failure to follow guidelines/policies• Complaints; incidents
Clinical Performance
• Memory problems, Poor problem solving/decision making
• Poor concentration, attention, learning problemsCognitive
• Poor verbal fluency• Poor understandingLanguage/Cultural
• Irritable, forgetful, arrogance, lack of insight, denial
• Highly self critical; perfectionist
Psycological/Personality
• Isolation, withdrawal, irritability• Poor interpersonal skills; lack of insight
Social
Potential triggers of concern
Patterns or repetitive behaviours (rather than one off
Sudden out of character behaviourSicknessSerious one-offs that are rationalised by trainee
Eg. a small lie
Steps in Management1. 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
Managing trainees in Difficulty•Trigger Event or Incident
Investigate
•Investigate and define problem
•Collate evidence, DOCUMENT. Be objective
Decide•Individual issue•Organisational issue ?both
•Consider CS, ES, TPD, DME, Deanery, HR, OH
Is it important?
Does it matter? Who do I need to
involve?
•Be objective•Do n0t jump to conclusions•Formulate opinion
Think patient
and person safety at all times
•Be fair and objective
System failures easy to
overlook
Taken from NACT Managing Trainees in Difficulty 2012
Three Questions• If no, relax• If yes, do
something and ask
Does it matter
?
• If no, re-trainable?• Not trainable,
exclusion only!• If yes, ask
Can they
normally do it?
• Clinical performance• Personality issue• Health• Learning
Environment
Why are they not doing it now?
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
Levels of Concern - 1No harm/risk to patient, staff, trainee.
Minor incidents, complaintsControlled illnessFailure to attain training goals
Action plan ES lead, thorough documentation. Discussion with trainee/minor investigationPastoral Support/OHSMART action plan/short resolution time.Discussion with TPD/?HR, Lead Employer
Levels of Concern -2Potential or actual harm/risk to patient, staff, trainee or
reputations.Repetitive patterns, recurrent behavioursAny issue requiring extension of training
Action planFormal InvestigationHR, OH, Deanery, PGMEAction plan with defined objectivesSpecialised interventions
Levels of Concern - 3Actual serious harm, reputations are at serious risk
SUIs, Formal complaintsCriminal ActGMC, NCAS referral
ActionHR, OH, Deanery, PGMEAs level 2 with formal investigation? Cessation/Restriction of practice
Managing Clinical ConcernsSpecific areas, technical and non-technical skills
Focused retrainingOften 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 trainingMentoring and CoachingThorough documentation
Managing Personality IssuesClose clinical supervision, developmental
mentoringDevelop insight
Cultural and Religious advice if necessarySimulation or videoing to challenge behavioursEducational Psychology
Cognitive Behavioural TherapyDifficult and sometimes impossible to remedy
Managing Health IssuesDoctors can become ill
Physical and mental IllnessSubstance misuse
Occupational health reviewDisability act requires employers to make
reasonable adjustmentsEnsure adequate support
Staff counselling
Causes of Management FailureEarly concerns not addressedInadequate documentation of problems and
discussions; dated and signedInsufficient thought given to remedial planFeedback especially around ARCP outcome 2
and 3 is seen as arbitrary and punitiveViews on course of action are varied
General pointsDocument everythingBe transparent
Discuss actions and plans with traineeSupport
Staff counsellingShare 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
Managing Trainees in Difficulty
Developing DiD support within CMFTWebsite
BlogInteractive toolkitLinks to useful documents and sites
IntelligenceReferral to PGME of DiDsInvolvement of ES in sickness management
Trainer involvementFaculty of mentorsAssessment and targeted training groupsEducation
Trainer development days