Doctor training: in praise of difficult conversations

I AM heartened at the thoughtful, careful and respectful conversations I am seeing in media and social media about training program issues and doctors in distress. This is a conversation I have been having for some time now in my role as an Avant medical adviser. I’m not sure that I have the answers to the challenges being discussed, but I know it is complicated and that there are significant problems and legitimate concerns for all involved in any training program dispute.

Training disputes, as defined in our recent discussion paper on training disputes, are defined as “any matter in which a doctor in a vocational training program (trainee) is in dispute with a training provider who is approved or recognised by a medical college, or with the hospital where a trainee is completing rotations, or where a supervisor, assessor or reviewer of a trainee is involved in a trainee’s dispute with their training provider”.

In reviewing the question of training disputes for the discussion paper, Avant proposed some principles to inform responses to such disputes. I explore some of these principles here.

Trainees should be supported to become competent doctors equipped with the necessary skills for independent practice

One thing that struck me at a workshop convened in 2016, with representatives from a number of colleges and associations, training providers and local health districts, was the collective will from all in the room to encourage and support trainees. Attendees commented that they were reassured and inspired by the shared commitment to addressing the challenges of training program disputes. I would say, too, that support in this case also means support for the supervision relationship. 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 openness to feedback on the trainee’s and supervisor’s part.

All practitioners are entitled to work in a safe, respectful and supportive workplace

There is a growing awareness that behaviours such as bullying, harassment and discrimination are problematic not only for the devastating impact they can have on the health and wellbeing of the individuals experiencing them, but also because they can impact on performance and may put patient safety at risk.

Equally, it is important that supervisors and trainees are clear about the distinction between appropriate performance management or feedback and inappropriate bullying so that performance issues can be addressed.

Performance concerns should be raised and managed early in the training program

A common concern I hear is that:

“… trainees are surprised by failure at a late stage in their training, when they have made significant investments in their careers. This ‘failure to fail’ can compound the impact of negative feedback on a trainee, and risk exacerbating disputes as trainees at this point may feel they have no options but to fight a decision through all possible avenues.”

Supervisors are in the inherently difficult position of acting as both coach and assessor and those roles may conflict. In addition, supervisors and trainees may never have had training in effective performance management and giving and receiving feedback, skills that generally need to be learned. All people in supervisory relationships, including trainees, need support to develop the necessary skills to manage these relationships.

A key element in addressing any dispute is to ensure the health, safety and wellbeing of all parties involved

We, as doctors, need to recognise the pressures that both trainees and supervisors may be facing, and to support all those involved in navigating the challenges of the training process within the current health environment.

Having policies in place to deal with concerns, resolve conflicts and provide support is an important first step. But while most workplaces have policies in place, there is often a considerable gap between these and how they are applied in practice. Being able to find and access these policies without fear of repercussion is often problematic. Often, we at Avant see that doctors caught up in disputes within their training program have become quite isolated. Being able to access support and assistance to define the problems and understand their options is critical.

Disputes should be addressed early and resolved between the parties informally where possible

It is important to recognise that some level of conflict is often inevitable. Training will be challenging, testing and difficult at times. Training relationships are complex, involving a range of mutual obligations and overlapping roles between employee and employer, trainee and training provider and accreditation body. What we see is that disputes often involve multiple different perspectives. An adversarial dispute resolution process may mean that views quickly become entrenched, and the dispute becomes more difficult to resolve.

Equally, the supervisors responsible for deciding on trainee progression should also have some flexibility in applying policies so that inflexible adherence does not in itself become disproportionate and unreasonable. Disagreements over eligibility to sit exams, recognition of training experience, delays in certifying training, administrative errors and oversights should not have to escalate into formal disputes.

We, as doctors, need greater care for each other. I realise what an extraordinary perspective I have gained as an Avant medical advisor, hearing the concerns described from both doctors in training and from supervisors. I am concerned that while we are locked into an “us” and “them” mentality around training program issues, we will struggle to provide that care for each other.

If anyone would like to comment further, in my Avant role I am seeking feedback on our discussion paper on training disputes. The issues I have outlined here and others are explored further in the paper. We intend to report back to the colleges on our paper, and would value your responses.

Dr Penny Browne is Senior Medical Officer with Avant.

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