Medical Educators Conference 7 th Nov 2014 Doctors in Difficulty Workshop

1. Medical Educators Conference7th Nov 2014Doctors in Difficulty Workshop Dr Mumtaz Patel Consultant Nephrologist Divisional Educational Lead Manchester Royal Infirmary

2. 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

3. 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)

4. 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

5. Categories of Difficulty • Performance Issue • Problematic Personal Conduct • Problematic Professional Conduct • Health problems • Learning Environment • System Issues

8. Common Presentations

9. 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

10. Early Signs and Identification

11. 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

12. Managing trainees in Difficulty Taken from NACT Managing Trainees in Difficulty 2012

13. Three Questions • 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Important Messages

22. Further important messages

23. General points • Document everything • Be transparent • Discuss actions and plans with trainee • Support • Staff counselling • Share appropriately • PGME, Deanery.

24. Managing Trainees in Difficulty

25. 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

26. PGME and DiDs in CMFT

27. PGD Structure

28. 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