Transcript Doctors in Difficulty Workshop

Medical Educators Conference
th
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
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 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
 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
Cognitive
Language/Cultural
Psycological/Personality
Social
• 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
off
 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
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
Decide
• 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
times
• Be objective
• Do n0t jump to
conclusions
• Formulate opinion
System failures
easy to
overlook
• Be fair and objective
Taken from NACT Managing Trainees in Difficulty 2012
Three Questions
Does it
matter?
• If no, relax
• If yes, do something
and ask
Can they
normally
do it?
• If no, re-trainable?
• Not trainable,
exclusion only!
• If yes, ask
Why are
they not
doing it
now?
• 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
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 - 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
reputations.
 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
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
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
Difficulty
(version 2)
Practical Advice for Educational
and Clinical Supervisors
July 2012
NACT UK: Supporting
Excellence in Medical
Education
PGD Structure
Associate Medical
Director (eduction)
PGD structure
Associate Director
Med Ed
DME
aDME
aDME
Head of
Postgraduate
Education
aDME
Div Lead
Ed Sup
Clin Sup
Junior Rep
Developing DiD support 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 days