Doctors in Difficulty Workshop

Medical Educators Conference
7 Nov 2014
Doctors in Difficulty Workshop
Dr Mumtaz Patel
Consultant Nephrologist
Divisional Educational Lead
Manchester Royal Infirmary
Doctors in Difficulty Workshop
• 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 trainer-
trainee processes where the Training Programme
Director has been called upon to take or recommend
(NW Deanery, 2013)
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
Categories of Difficulty
 Performance Issue
 Problematic Personal Conduct
 Problematic Professional Conduct
 Health problems
 Learning Environment
 System Issues
Common Presentations
Work Based
• Absenteism/lateness
• Poor time management
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 problems
• Poor verbal fluency
• Poor understanding
• Irritable, forgetful, arrogance, lack of insight, denial
• Highly self critical; perfectionist
• Isolation, withdrawal, irritability
• Poor interpersonal skills; lack of insight
Potential triggers of concern
 Patterns or repetitive behaviours (rather than one
 Sudden out of character behaviour
 Sickness
 Serious one-offs that are rationalised by trainee
 Eg. a small lie
Early Signs and Identification
Steps in Management
1. Early Identification of problems and intervention is
2. Establish and clarify the circumstances and facts as
soon as possible – Access many different sources of
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
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 and define problem
• Collate evidence, DOCUMENT.
Be objective
• Individual issue
• Organisational issue ?both
Is it important?
Does it matter?
Who do I need
to involve?
• Consider CS, ES, TPD,
DME, Deanery, HR, OH
Think patient
and person
safety at all
• Be objective
• Do n0t jump to
• Formulate opinion
System failures
easy to
• Be fair and objective
Taken from NACT Managing Trainees in Difficulty 2012
Three Questions
Does it
• If no, relax
• If yes, do something
and ask
Can they
do it?
• If no, re-trainable?
• Not trainable,
exclusion only!
• If yes, ask
Why are
they not
doing it
• 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
behavioural issues including
impact of cultural and religious
 iii) physical and mental health
 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 - 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
Levels of Concern -2
 Potential or actual harm/risk to patient, staff, trainee or
 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
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
 ? Cessation/Restriction of practice
Managing Clinical Concerns
 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
Managing Personality Issues
 Close clinical supervision, developmental
 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
Important Messages
Further important messages
General points
 Document everything
 Be transparent
 Discuss actions and plans with trainee
 Support
 Staff counselling
 Share appropriately
 PGME, Deanery.
Managing Trainees in Difficulty
Managing Trainees in Difficulty
Managing Trainees in
(version 2)
Practical Advice for Educational
and Clinical Supervisors
July 2012
NACT UK: Supporting
Excellence in Medical
PGD Structure
Associate Medical
Director (eduction)
PGD structure
Associate Director
Med Ed
Head of
Div Lead
Ed Sup
Clin Sup
Junior Rep
Developing DiD support within
 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 days

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