Supporting

Underperforming

Trainees Dr Vinita Mishra

Training Programme Director

Chemical Pathology

Learning Outcome

• Definition(significance) of under performance

• Issues of underperformance

• Approach in managing underperformance

• Role of educational Supervisor

• Key Messages

DEFINITION AND ITS SIGNIFICANCE

Definition

Underperforming doctor

who persistently fail to comply with standards of good

medical practice

Good Medical Practice; General Medical Council(GMC)

Trainees in difficulty(10%)

During first two years of training

Transition from student to responsible professionals

Conflicting Issues

Trainee in learning curve

Employee in health organisation

Stresses

Internal

External

Doctor

Learning

External stress

Work expectations

Internal stress

Significance

Identification

• Patient Safety

Support

• Risk to trainee

Management

• Systematic approach

ISSUES OF UNDERPERFORMANCE

ISSUES

Minor

Aberrations of Behaviour

Persistent Unprofessional

Behaviour/Criminality

poor performance is a ‘symptom and not a diagnosis’ and it is essential to explore the underlying cause or causes

• Poor clinical assessment and management

• Poor communication with patients and/or colleagues

• Inadequate/inaccurate documentation

• Failure to follow protocols

• Difficulties in carrying out procedures

• Interpersonal conflict

• Leadership difficulties

• Problems with prioritisation/decision making

• Difficulty dealing with complex scenarios

• Unprofessional behaviour

Possible Causes

• Personal relationships at home or work

• Financial difficulties

• Mental or physical health problems

• Substance abuse

• Loss of confidence

• Stress, frustration

• Marginalisation

Factors affecting Performance

• Attributes of the trainee

• Personal pressures on the trainee

• Attributes in the training and working environment

APPROACH IN MANAGING UNDERPERFORMANCE

STEPS IN MANAGING UNDERPERFORMANCE

EARLY RECOGNITION

INTERVENTION

PREVENTION

Early Recognition Signs

Concern Raised

• Clinical

Performance

• Time

Management

• Professional

Issues

• Supervisor

• Colleagues

• Trainee(self)

• Patient

• Concern expressed

• Absent from work, lateness Disappearing Act

• Slowness, incomplete letters

• Working long hours with unfinished work

Reduced work input

• Disrespectful to colleagues, patients

• Aggressive response Behavioral issues

• Inability to compromise

• Rejection of constructive criticism Resistance

• Colleagues avoid to ask advice

• Or help

Bypass syndrome

• Difficulty in passing exams

• Disillusionment with specialty

Career Problems

Social Media

• Facebook/Twitter

Source of stress

• Awareness that trainee is experiencing difficulty

Post information relating to problem

Concerns from posts

Preliminary Assessment of Concern

Severity of Problem

Time of action

Gather the facts

Right source Maintain confidentiality

Is it a PROBLEM?

Collect Information Assess the actions required

Assess the severity of Problem

Low level

•Discussion

• Resolved

Urgent

• Patient safety

• Trainee safety

• Criminal misconduct

Referral

• External Advice

•Documentation

Intervention Dealing with problem

TIMELY ACTION

Deviation from the expected performance

MEETING WITH TRAINEE

Provide support to trainee(Discussion/referral)

AGREE A PLAN WITH TIME FRAME

Supervision and mentoring

DOCUMENTATION

Share with trainee

REVIEW THE PERFORMANCE

Targeted or remedial training

ADVICE FROM EXTERNAL SOURCES

HR, lead employer,denaery

Steps to take

Meet with trainee • Early stage

• Fair procedure

• Gather information for assessment

• Giving opportunity to trainee

• Timeliness: deal without delay

• To present their view

• To identify any source of bias

• Keep the record of meeting

Identify the problem

• Poor knowledge, time management

•Difficulty in making clinical decision Clinical

Performance

• Professional misconduct

• Lack of insight Behaviour problems

• Clinical or written communication

Communication

problem

• Mental

• Drug abuse/dependance Health Problems

• Family issues

Extrinsic

Managing concern

Prevention Supervision

/ support

Patient Safety

Suicide is a real problem

early intervention and referral

HIGH

MEDIUM

LOW Majority, day to day basis, record the

action taken

Investigate, collect facts

Advice from HR, Deanery

A robust and detailed DIAGNOSIS can lead to effective remediation

Develop and Implement Action Plan

• Re-establish appropriate levels of performance

• Providing a plan after mutual agreement with

trainee

• Documented action plan

Expected outcome

Review date

Copy to trainee

SMART Outcome

SPECIFIC

MEASURABLE

ACHIEVABLE

TIME FRAME

D

RELEVANT

Referral

• GP/Psychiatrist

• Psychologist

• Confidential counselling

External Support

• Medical Administration

• Director of medical education

• Human resources

Attendance

Disciplinary matters

• Deanery

• Lead Employer

• GP

• Majority are resolved by working with trainees

• 3-5% needs referral or further intervention

Review of Action Plan

• At regular intervals

• Progress of intended outcomes

• May need amendments or extension

• If failure to achieve outcome, may need referral

• Assess the severity

• Patient/Trainee safety? Misconduct? Concern

• Underlying Issues

• Investigate Assessment

• Speak to trainee

• Support: HR/deanery Communication

• Agreement with trainee

• Set a review date Action Plan

• Support to trainee

• Review Implementation

• Matter resolved

• Further review or referral Conclusion

ROLE OF EDUCATIONAL SUPERVISOR

Prevention Regular feedback to trainee

Identifying trainee with difficulty

Implementation of effective support system

Effective communication Attitude problems

Behavioral issues

Dealing performance matter effectively Timely

Fair and objectively

Support

• Assistance to trainees will make them competent

clinicians

• Communication

• Interventions

• Monitoring

Satisfying Outcome for trainee and supervisor

Documentation

• Effective management requires documentation from

the earliest stages

• Problem is addressed at an early stage

• Categorise CONCERN as

Low level

Medium

High

General Principles

1) Early identification of problems and intervention is essential. It is the responsibility of the Clinical Supervisor and supervising team with whom a trainee doctor is working to highlight any concerns, that could constitute a threat to patient safety, to the Educational Supervisor and Training Programme Director. Useful ‘Early Warning Signs’ as highlighted in the book ‘Understanding doctors’ performance’ may include:

The “disappearing act”: not answering bleeps; disappearing between clinic and ward; lateness; frequent sick

leave.

Low work rate: slowness in doing procedures, clerking patients, dictating letters, making decisions; arriving early,

leaving late and still not achieving a reasonable workload.

“Ward rage”: bursts of temper; shouting matches; real or imagined slights.

Rigidity: poor tolerance of ambiguity; inability to compromise; difficulty prioritising; inappropriate ‘whistle blowing’.

“Bypass syndrome”: junior colleagues or nurses find ways to avoid seeking the doctor’s opinion or help.

Career problems: difficulty with exams; uncertainty about career choice; disillusionment with medicine.

Insight failure: rejection of constructive criticism; defensiveness; counter-challenge.

2) In the event of a particular problem, establish and clarify the circumstances and facts as quickly as possible. Access as many sources of information as possible. Most concerns can be addressed by early, effective discussions between the Clinical or Educational Supervisor and the trainee culminating in a realistic learning plan, which is regularly reviewed to monitor satisfactory progress. An open and supportive culture should be encouraged within the whole clinical team, fostering the development of the trainee’s skills and providing constructive feedback on performance improvements or ongoing difficulties. Only form a judgement once all information is collated. Remember however, that issues of patient and person safety take precedence over all other considerations. GMC accountability applies to all clinicians.

3) Remember poor performance is a ‘symptom and not a diagnosis’ and it is essential to explore the underlying cause or causes. Key areas to explore are;

i) Clinical performance of the individual: (knowledge, skills, communication) ii) Personality and behavioural issues: (professionalism, motivation) iii) Sickness / ill health: (personal/family stress, career frustrations, financial) iv) Environmental issues: (organisational, workload, bullying and harassment)

4) A robust and detailed ‘diagnosis’ can lead to effective remediation: different problems require different solutions. Poor performance or odd behaviour of a clinician with an evolving medical problem such as undiagnosed diabetes or mental health issues requires a different approach to achieve successful resolution than an individual with generally poor interpersonal skills and lack of insight. The former needs engagement with occupational health or the General Practitioner, the latter perhaps supportive mentoring, close clinical supervision and feedback to address and change the beliefs behind the undesired behaviour.

5) Clear documentation. All relevant discussions and interventions with the trainee should be documented contemporaneously, communicated to the trainee and key individuals in the accountability framework (Trust and/or Deanery, possibly GMC) and followed up by named accountable individuals such the as Educational Supervisor, Training Programme Director or Associate Dean to ensure the process is concluded satisfactorily and managed appropriately. See local Trust and Deanery guidelines for accountability frameworks.

6) Misgivings must be communicated: Records must be kept: Remedies must be sought: Progression must be delayed until issues resolved.

Remember: accurate & contemporaneous documentation must be kept

• Do not try to deal with complex scenarios on

your own!

• Engage local and regional resources

• Objective assessment of the circumstances

• Involve an experienced colleague early to assist

in identifying and exploring underlying factors

Early recognition and appropriate intervention,

coupled with effective feedback and appropriate support for

trainee

KEY MESSAGES

• Supportive approach

• Intervention and monitoring

• Discuss with others

• Do not jump to conclusion

• To get facts right

• Immediate action

• Risk to patient safety

• Allegations of criminal conduct

• Further assistance

• Identify local resources

• Health issues

• Seek advice from GP

Trigger

Investigate

Performance OR Organisational Issue

Appropriate Intervention