more_vert
MUCH has been written about the underperforming trainee in the medical profession (see, for example, here, here or here) and what steps should be taken to remediate this person. Real or perceived performance problems, or a failure to meet the expectations of a supervisor, all require careful analysis and a plan of action. Equipping trainers to recognise an underperformer early, and teaching them to intervene in an appropriate manner is very important. Underperformance by a medical student or doctor in training has real consequences for patient care and wellbeing, and for every member of the team they are a part of. It may also herald concerns for that trainee’s wellbeing, which need to be managed much more compassionately and constructively than they have in the past.
But what about the underperforming supervisor? I hesitate as I write this, because while it’s so clear to me that there is a problem, it’s not quite as obvious where the solutions lie. Behind closed doors, in hushed tones, doctors in training tell me about being marked down on assessments because they stayed back after hours to do paperwork, or because they put in overtime claims for that vital work, or because they were poor “time managers” – despite having had no support to improve this, nor help from the rest of the team with their ever-increasing tasks. Through the wonder of the Twittersphere, I hear of supervisors not met until the last week of term, handing down pronouncements about the career prospects of an intern, medical student or vocational trainee they’ve only just met. Rarely will anyone put their names to these things. We are taught that one of the foundations of clinical governance is a robust and rigorous audit cycle, yet surveys have revealed evidence of trainers discouraging a full accounting of complications.
For some of the doctors in training I speak to, the frustration is that while very high standards are being applied to trainees, with regular unforgiving assessments and extensive repercussions for a single complaint from a nurse or another doctor, supervisors do not appear to be held to such high standards.
I feel very fortunate because for the most part I have had wonderful supervisors, people who have both encouraged and challenged me. I will always be grateful to the people who are teaching me to operate. Being guided through my first resection of a meningioma, being taught to gently move the dura in someone’s spine to expose that horrible bulging disc underneath – these are some of the highlights of my life in medicine, and they were made possible because of good supervision.
Much must be done to restore trust and collegiality. Medical students, interns, residents, service registrars and trainees all deserve to be treated with genuine respect. This means acknowledging the changing face of the medical profession, which is now older, more diverse, with more complex and varied family commitments and obligations. And more than just noticing that your ward round resembles the United Nations, it behoves us to celebrate this and be grateful for the cultural, gender and linguistic diversity we can increasingly offer our patients.
In order to equip supervisors to train well, I believe that formal teaching has a role. The Foundation Skills for Surgical Educators course forms part of the response of the Royal Australasian College of Surgeons to improve supervision. But what more can be done?
Accreditation standards clearly have a role. When a hospital or training post or even a college is being accredited, there is an opportunity to examine the quality of supervision and to encourage those who are doing a great job, as well as making recommendations for those who are not. But one of the most vulnerable parts of our workforce are those registrars in unaccredited positions – by definition nobody is systematically assessing their work environment, and yet they are still learning on the job. The vulnerability of these medical orphans is a real concern.
Just as underperforming trainees may have underlying wellbeing problems that are not being recognised, I believe it is possible that an underperforming supervisor may be struggling as well. The pressures on medical professionals have never been greater or more complex, and the ever-increasing burdens of paperwork and administration can be quite crippling, to trainers and trainees alike. We need greater care for each other, whether through effective mentoring, or peer support, so that doctors can be well people first. This is a prerequisite for better, more committed and enjoyable supervisory relationships and ultimately, better patient care.
Dr Ruth Mitchell is a neurosurgery registrar at the Royal Melbourne Hospital and a PhD candidate at the University of Melbourne. She was the inaugural AMA Doctor in Training of the Year in 2016, noted for her work as the chair of the Royal Australasian College of Surgeons Trainees’ Association and her tireless pursuit of doctors’ wellbeing and high quality medical care, through advocacy, education and research.
To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.
Loading ...
This is a real problem which I have noticed in my experience ignored by the College and the Hospitals.
Time and time again I see cases of underperforming trainees seeking legal advice to appeal which two prima facie cases
1. Legitimate appeal (most common)
2. Soft core complaints from disgruntled trainees
Unfortunately, my time with the College and colleagues who work in Committees’ tell me that No.2 is ‘common’ but I doubt that.
The College of Surgeons is not currently serious about addressing problems. When they are, this is one problem that needs to be addressed to enable culture change.
I am an IMG. I came to Australia soon after my graduation. I completed my adult physician training not to long ago. Like many I have also encountered some difficult and underperforming supervisors. I would say 1/4th of my supervisors were underperforming. I had the misfortune to tolerate 1 very painful supervisor. It was made sure that no stone was left unturned to give mental torture to me. Trainee in difficulty pathway was initiated. But the college never took any reasonable steps. Every time I would receive a different new adverse feedback from the supervisor. New bad qualities were discovered in me on every meeting. As per the trainee in difficulty pathway the supervisors are to help and improve the performance of their trainees. But I only received cruel criticism and nothing more. Before this unfortunate year with this supervisor I had received good reviews and reports for many years. Suddenly this supervisor discovered the most incompetent and evil person hidden in me which hitherto was not noticed. The college never suspected anything wrong of the supervisor and never bothered to ask the supervisor what steps were taken to improve the trainee. The next year when I moved to another hospital I started getting good reports once again.
There is no good system in RACP to address these issues. When I considered making a complaint I was told by the colleague of the ‘underperforming’ supervisor to refrain from this as the colleagues of the supervisors would not side with a trainee who was to leave after a few months whilst the supervisors they had to live with. So all I could do was to document the meetings with the supervisor and send them to the RACP and the supervisor. Perhaps no one reads it in RACP.
Anyway here I am as a successful specialist. The lessons learnt are to never give up and keep going, care and respect your trainees when the time comes and find something out of hospital to get support from such as family, friends and hobbies. If one in four supervisors was underperforming then three were good too!
It is not easy to improve the system of training and supervising. One easy step is to have an acknowledgement by the colleges that some supervisors are problematic. This possibility should be considered in cases where a trainee in difficulty pathway has been commenced.
Thank you Ruth for a thoughtful article. I agree with many of your points – particularly the need for recognition of the pressures that both trainee and supervisor may be facing, and for recognition and support for the challenges of the training process.
I know that for myself, I am a much better supervisor when I am working with an engaged trainee, so that the learning process can be a challenging partnership. But this takes skill, time and support and an openness to feedback on both our parts.
I also agree that we need greater care for each other. In my additional role at Avant, I hear the concerns you describe from both doctors in training and from supervisors. I am concerned that while we are locked into an ‘us’ and ‘them’ mentality around the training program issue, we will struggle to provide that care for each other.
It is good to see the discussion on this issue. If anyone would like to comment further, in my Avant role I am seeking feedback on our discussion paper on training disputes ( http://www.avant.org.au/news/preventing-and-resolving-training-disputes/ ). We intend to report back to the colleges on our paper, and would value your responses.
Interesting discussion – I’m sure all of us can see good points in all the different points of view.
It’s certainly true that hospital senior staff are primarily appointed for patient care – that is the core role of hospitals. Those who behave so badly as to set a poor practice example to trainees should be managed through the employer’s policies and processes. For the rest of the mainstream, though, skills and strengths vary – some of us are better problem-solvers than others, some more risk-averse than others, some are better technicians than others, some are better educators than others.
Just like Iam Hargreaves notes – we can’t all be equally good teachers – even trained teachers aren’t all equally competent. What we do need, however, are standarised systems that collect relevant information about trainees in a reproducible way, and that reflect the important aspects of work performance and aptitude for the relevant specialty practice.
Feedback forms must be well-designed. The learning domains assessment must reflect those that are important for patient care, first and foremost, with collaboration and communication skills taking an important place, but not surplanting clinical skills.
Ian Hargreaves’ comments about individual initiative by learners are still relevant, but the social and cultural context is different. Every generation thinks that their parents are old-fashioned and backward, but their children lazy and self-indulgent. That’s how humanity works. There are still, as there have always been, people who will sit back to be “spoon-fed”, and others who take their own initiative. I saw both types during my own training, and I see them now, among both new graduates, specialty trainees and IMGs.
None of this means that we shouldn’t continually improve. We have better and safer cars than ever before, better communications technology, better engineering, better medical technology, and everyone wants the latest model of mobile phone, so why wouldn’t we continually review supervision systems?
Every hospital department needs a training supervisor with knowledge and aptitide for that job. Between the group, roles can be allocated to individuals with the best skills – for teaching, supervision, mentoring, reporting etc.
Finally, trainees must not perpetuate this “if I speak up I won’t get a good reference” assumption by creating systems of their own. Groups of trainees can form site groups or College groups, join committees and unions, and advocate as a group. No no-one need be singled out.
I appreciate Ian’s Douglas Adams references but regret that I can’t share his enthusians for emoticons.
My comments regarding the self-directed learning were somewhat tongue in cheek, in reply to the anonymous poster #4 who was frustrated by struggling to educate while exhausted, then being criticised for ‘underperforming’, as Ruth referred to in her final paragraph. Perhaps any internet post which starts with a Douglas Adams reference should be regarded as satirical insight rather than academic literature [insert whimsical emoticon here].
But the original article referred to the problem of “I hear of supervisors not met until the last week of term”. I had precisely that situation in 1983, when I attended an RACS review of my training position. The reviewers mentioned that of course my official Supervisor of Surgical Training had been absent for my entire term (due to fulminant hepatitis B, prior to the vaccine’s availability.) No problem, I replied, as I had my logbook with me for them to examine, and had sourced written references from all of my other consultants. I was one of two in my year to have sat and passed my primary exam, with my printed results in hand to show them. I passed the review with flying colours.
In 1986, during the orthopaedic surgeons’ dispute in New South Wales, I again faced an RACS review, a quinquennial inspection of training posts by two surgeons from Melbourne, one of whom was the formidable RACS chief examiner. The interview started as they asked how my training was going, given that all my supervisors had informed them they had just resigned. Knowing the precarious situation of orthopaedic training in this environment, I had been in communication with my supervisors about this, so it was not a surprise.
I was able to tell the examiners that I had already liaised with the chairman of the Sydney board of studies, and had local board approval as well as agreement from the other surgeons at my hospital, to change supervisors. The Orthopaedic Association changed the job description, deleting my existing post and reinstating me in a different one at the same hospital, with no loss of training time. Not really much effort on the first-year accredited trainee’s part, but an awful lot of fear in that process, dealing with all the heavies of my specialty!
In these days of emails and instant communication, all of the anonymous trainees whom Ruth refers to who were under-supervised, should be able to present an email/SMS trail of all the correspondence they have initiated with their supervisor, and again, source testimonials from the other department members with whom they have had contact. That way, the supervisor’s supervisor can see clearly where the fault lies. If a trainee simply says: “I waited all term for my supervisor to contact me”, I would mark them down for lack of initiative. Been there, done that–it’s not rocket surgery.
I have a son who is a doctor in training, 2 daughters who are public schoolteachers, and 1 daughter still at University. Believe it or not, what I hear is no different from my own experience a generation ago, that there are doctors, teachers, lecturers and tutors who underperform, as assessed by their juniors. Even [insert shocked-faced emoticon here] professors and principals are known to underperform! The fact that trainees in all fields encounter underperforming supervisors, even where those supervisors are professionally trained educators, makes me believe that the problem is part of the human condition, rather than specific to medical practice.
I ticked the ‘strongly agree’ box to the question of whether I had had a supervisor who underperformed, but would also tick strongly agree if I was asked about a schoolteacher, professor of medicine, or hospital administrator.
I strongly believe in the Hippocratic paradigm of apprenticeship and amateurism in teaching, because it has worked for thousands of years, and I am not convinced that any more professional system works better. I wrote at length in the RACS EAG regarding this, as I fear that the colleges are abandoning the Hippocratic principle of treating trainees as if they were your own children, and swinging towards a corporatised model of regarding them as your external customers, cash cows to be milked. No doubt this has arisen as colleges have acquired executives from other professions, who have no experience of this tradition.
Two of my daughters are also professional musicians, and the concept of ‘regular unforgiving assessments and extensive repercussions for a single complaint’ is not foreign to them. Ask Meatloaf what one bad performance can do to your career. Musicians are able to source their own supervisors/teachers, but the corollary of that is that they have to pay them, with the cheapest ones starting at $100/hour + GST. And again, neither Meatloaf nor his critics named/blamed his singing tutor for his off-key performance at the AFL. Other professionals take personal responsibility for their own actions, including self-directed learning. There is no other profession as well organised as medicine, providing (overall) high-quality training for free.
In the medical profession we have much less scrutiny than the average restaurateur or hotelier, and certainly less immediate posting on our performance than an Uber driver. My daughter who is at University works part-time in a shoe shop, and every shift is monitored, showing her sales performance compared to every other worker in that shop, and every other worker state wide, in real time. Performance figures are used to allocate shifts. ‘Trust and collegiality’ is rare in the nonmedical world.
The technology exists for every trainee to rate every interaction with every supervisor, and every patient to rate every interaction with every doctor. That would certainly identify the underperformers, like fake Dr Acharya. Will a rigorous system of weeding out underperfomers make us any better, or more caring? I suspect not – the banks have always done that. Should we simply accept there will be bad supervisors, just like there will be politicians like Donald Trump or Milton Orkopoulos? Sadly, I think that’s the reality – public scrutiny does not guarantee good performance. Will hospitals employ bad teachers who are good clinicians or researchers? Indubitably, they know what are the most valued contributions to the hospitals’ reputation. Will the government do anything? Watch season 3 of Utopia which starts next week. Or any rerun of Yes Minister (obviously, the one with the best performing hospital is the benchmark).
Can trainees do anything? Certainly, because ultimately, your education is your responsibility. Not the hospital’s, the government’s, the college’s, or even the supervisor’s. Learn from the good ones, don’t be tainted by the bad ones, and resolve to be a better one when your time comes. Stand on the shoulders of giants, or at the very least, on the headstones of pygmies.[just enough space for a wanly optimistic emoticon]
#6 probably has a few valid points. It is true that the colleges rely on amateurs. However, what many consultants seem to forget is that by accepting a job in a public hospital, being involved in the education of junior doctors is part of the role. Instead of taking one hour lunches and regular coffee breaks, perhaps working on a presentation for the jr docs would be more helpful. (I’ve also seen consultants leave the hospital to jr staff while they go and work privately) A component of the breakdown of the training culture falls with employers (which often understaff departments to the point that education is next to impossible) but significant blame is deserved by the colleges themselves.
The colleges charge relatively high fees for exams, training and other fees but what they give in return is limited at best. There needs to be more transparency and possible outside review of these colleges. Sure they can call themselves non profit organisations, but what are the salaries and perks? Should the registrars be paying for the college staff to fly first class and stay in 5 star accommodation? Shouldn’t there be a national inquiry when over 50% of GP trainees fail their exit exams? Why is this culturally acceptable? Either trainees are more stupid these days, the training programs are inadequate or someone is simply profiting off of the exam process.
#6 also mentions self directed learning. That only goes so far. You can’t teach yourself a specialty. PBL started at McMaster but they have shifted away from it as a main teaching method which says something. Self directed learning is a way to provide less education, while charging more. This goes for both the universities and the specialty colleges. To suggest that the current generation of training doctors are spoiled or lazy is ridiculous and adds to the toxic culture that currently exists. I would have gladly worked longer hours for less pay if it had meant better training.
Thank you for an important article. The role and skills required for supervision, assessment, mentorship and teaaching are all different, and also vary with both the stage of training and the practice setting.
Much has been done to standardise feedback for hospital JMOs, with assessments now occurring mid-term as well as at the end of term – to ensure that the end of the term is not the first opportunity for formalised feeback. Forms and terminology have been re-designed, and systems for communication and feedback improved.
The same processes need to be refined for specialty trainees with the Colleges. Although standardisation is more difficult, an attempt should be made to use evidence-based formats and language, and to explore all the relevant domains of adult learning. It should also be mandatory to incorporate feedback from the entire clinical team and perhaps other specialty units with which the trainee has to collaborate.
Great points as always Ruth. Distressing (although not particularly surprising) to see how many trainees have strongly agreed with the statement that they have had an underperforming supervisor. Like you I have been really fortunate regarding my supervisors so far, which just serves to highlight more starkly those few who have not been up to par.
Trite generalisations about demanding Gen Y attitudes and “back in my day” comments are not particularly helpful in my view. It’s not back in the day anymore. The system is changing and usually to benefit administrators and politicians rather than clinicians (dare I even mention patients?). We’re all in this together and today’s juniors are tomorrow’s seniors, so we need to figure out how to do it better.
I think we need to acknowledge the difference between a supervisor and an educator. Not all senior doctors are supervisors, and even fewer are true educators. Supervisors have a responsibility to teach and train, but we can’t expect them all to be great at it. So long as people behave appropriately and participate in unit level teaching activities (including assessments of junior staff) I think they are meeting their responsibility. The problem arises when people are put in a position to be an educator with no real training (or perhaps aptitude) for it. The onus is then on those people to perform or learn how to perform, or get out of the way to make room for someone else who will. Courses like those offered by RACS are a great start, but people have to want to take it on.
I’m grateful to all my supervisors past and present – even the ones who taught me by modelling what not to do.
Any reader of Douglas Adams knows that the question is as important as the answer. If the hospital or training body is asking questions about time management, then those answers are clearly relevant to them: The trainee who regularly takes 10% longer than average to do their paperwork, and bills overtime for it, is costing the health system significantly more.
But whether time management is an important factor is a different question. As a patient, I don’t care if my operation takes 10% longer, if it gives me a 10% better survival probability.
As a current supervisor of IMGs, the questions asked by AHPRA are woefully inappropriate for overseas trained plastic or orthopaedic surgeons undergoing further training in hand surgery in a tertiary referral unit. Judging from their questions, it is clear that they are predominantly considering the training of remote area GPs. I answer the stupid questions, with care and diligence, to help my trainees.
But what is not acknowledged is the underlying fact that most supervisors are not professional educators, but are actually amateurs (in the true sense of the word) who are training their future competition for no payment, other than the satisfaction of fulfilling one’s Hippocratic duty to train the next generation without reward. The Colleges have somewhat sullied this relationship by charging exorbitant fees for ‘training’ provided by these unpaid volunteers, while at the same time, offering multiple expensive courses for supervisors to increase their skills. There is no collegiality coming from the Colleges – at least the compulsory AHPRA supervisors’ course and online exam was free.
It seems churlish to criticise amateurs for not being professional, and I can guarantee that if “accreditation standards” are introduced, that will simply impose another burden on volunteer supervisors, and finding someone to actually bother to supervise will be harder than filling the Christmas and New Year roster. The other point to consider about the unsatisfactory supervisor, is that learning what not to do is even more important than learning what to do. From the worst of bosses, one learns how not to do things.
In relation to post 4 above, the current generation of medical students has largely been selected and trained by the universities for the ability to pursue self-directed, problem-solving learning, rather than the old-fashioned concept of the baby bird being nourished by having everything regurgitated by a caring elder. Despite this, there seem to be more Bernard Tomics and Nick Kyrgioses in trainees who feel the world owes them a living, so it’s someone else’s responsibility to keep them from boredom or stress in the workplace…Maybe those wickedly inadequate unpaid volunteer supervisors will have to be sacked, and trainees can hire and fire their own professional coaches…and be as happy and successful as Bernard and Nick. Based on Medicare and AMA rates, trainees should be able to get supervisors in the $100-500/hr range (+GST)…and have the fun of setting KPIs for their supervisor, so underperformance will not be an issue…
I Have been actively and viciously bullied by a number of alleged senior paediatricians.
It was only when i trained overseas for five years that I really found my feet and now head a large clinical and academic site. The more mature Paediatricians were magnificent it seemed to be a subset of their junior consultants.
Somehow I resent the question. I was an RMO way back in the 70s and 80s; and had NO expectation that my supervisors should have been guiding me!..I just thought it was up to ME to make something of the polyglot spectrum of ability and collection of human foibles that were my seniors! So, I never regarded a senior with personality problems, or personal issues as “underperforming”..rather just another human being caught up in the incessant and at times cruel demands of a medical life, and I’d take whatever pearls fell from the table (surprisingly valuable pearls often from the most unlikeable of supervisors!). This question just feeds into the exaggerated sense of self-importance of today’s graduates who feel that it’s up to “the system”, or “the older members of the profession” to make life easier for them!
Having said that, I would have liked some feedback about my performance….it was a shock to me at final interview to learn that I was HIGHLY regarded by most senior members of the hospital…..If I’d known that, I might have pursued a career in adult medicine instead of Paediatrics….(!)
But I still don’t see anything but harm coming from feeding a sense of being let down by various seniors….especially remembering the experience of having been on call for a large country district for stretches up to 168hours straight, with at times no sense of whether you’d slept well, as the phone had interrupted you severally through the night, with no opportunity to cancel rooms full of patients; and then turning up to rounds of judgmental Gen Y RMOs and students, (with NO understanding of how to deal with an under slept senior and indeed a ready ability to judge it harshly as an evil life-style choice!) ready to write reports criticising any politically incorrect statement because I was an undeniably older white male!!
This problem is widespread in several training programs. This issue represents a significant cause of stress and psychological issues. The standard of training can be quite poor but the expectations of the registrar quite high. The colleges themselves apply this double standard and do little to ensure that training standards are met even when there are multiple complaints from the trainees. Simply put, a registrar has little or no voice on his/her own and often will not be heard unless it is the entire group of trainees voicing a concern. There is often zero to minimal help given to trainees in difficulty. This is not the system that the majority of the old clinicians trained in and they have no idea how toxic it is to be training in such an environment.
Well done, good article.
The medical profession is decades behind the private corporate sector in this regard.
Most high-performing organisations have instituted “360 degree feedback” which is a silly name for a common sense idea: that feedback should be given not just down the hierarchy but up the hierarchy as well.
So just as senior doctors provide feedback on junior doctors, the junior doctors should do the same for their supervisors.
Most importantly, the feedback from junior doctors regarding their supervisors should form part of the overall performance review of the supervisor.
A senior doctor may be very good at clinical medicine, but if he is incompetent at supervising and training the doctors in his charge, then he is failing in his role. And it is about time that the performance review system in our public hospitals encourages doctors to become good supervisors and trainers as they move up the hierarchy — instead of largely ignoring that crucial responsibility, as we have done up to now.
Great article Ruth, and a long neglected one.
The issue has many causes and will require multiple solutions.
Like anything though, it is a very difficult problem to address without efforts to measure – how else are we to understand the impact of potential solutions?
Making teaching and training a core key performance indicator of the supervisor will begin to address the issue. It will become incumbent on the supervisor to demonstrate their performance, and their efforts to improve.
Vehicles to capture activity and feedback of (and for) supervisors exist (http://osler.community) and if widely adopted, allow individuals and their employers alike to identify how they can improve supervision in practice.
As you note, few supervisors are formally trained in providing supervision, training and assessment. The clinical environment is challenging to perform these tasks, so one important step is to provide clinical supervisors with user-friendly, cloud-based tools to structure the process. This represents the low-hanging fruit of the solution, and could result in very rapid improvements.