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

Early Signs and Identification

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

Important Messages

Further important messages

General pointsDocument everythingBe transparent

Discuss actions and plans with traineeSupport

Staff counsellingShare appropriately

PGME, Deanery.

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

Managing Trainees in Difficulty

PGME and DiDs in CMFT

PGD Structure

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