Helping the underperforming trainee

As a supervisor, faced with a number of complaints about a trainee’s attitude and communication with colleagues and patients, you may begin to fear you have an underperforming trainee. Add to this a potentially serious clinical error, increasing concerns about missed meetings, a reluctance to work after-hours rosters and poor clinical record-keeping and the conclusion seems clear. But thinking about this as a diagnostic challenge may help to avoid misjudging the issue.

AS Avant’s senior medical officer and a GP supervisor with many years’ experience in assessment and remediation of underperforming trainees, I see a number of familiar elements in the scenario above.

At Avant, we have been examining disputes arising between trainee doctors and their colleges for some time, partly in response to concerns raised by several specialist medical colleges about an apparent increase in such disputes.

Our data show that numbers of training disputes have increased over recent years, although overall numbers are relatively low. The numbers, however, do not reflect the impact disputes may have on those involved. In our experience, medical defence organisation involvement gives much-needed support to doctors during stressful interactions with their colleges, and in many instances, ensures procedural fairness.

Figure 1: Claims relating to training disputes 2006–2016 involving mature members or doctors in training. Source: Avant national claims data.

Avant sought to better understand the problem and, in 2016, held a workshop with industry representatives to explore the problems and encourage trainees, supervisors, college representatives and hospital administrators to develop a common understanding, share ideas and seek solutions.

For me, the workshop exercise of working through a fictitious scenario from multiple perspectives reinforced the need for caution before diagnosing “underperformance”.

As with many complex problems confronting clinicians, performance issues are often multifactorial. A trainee’s personal circumstances, home environment and physical or mental health problems may impact their performance. We need to give adequate consideration to the entire bio-psycho-social context in which they work and live. Becoming familiar with the early warning signs and symptoms is also key.

One clear message from the workshop was that trainees have changed significantly over the last generation. They tend to be older, more culturally diverse and have more family and financial commitments.

While training programs have evolved to meet the demands of increasing numbers of trainees and greater expectations of accountability, they have not generally become more flexible to meet the changing lives of trainees. College-based training programs have moved from a loose, apprentice-style of training with a final exam, to more structured, rule-based programs with defined curricula, multiple assessments and increasing numbers of policies.

Comments from the workshop suggested that the relationship between the colleges and the employers is complex and often remote, with fractured communication and unclear boundaries of responsibilities for a trainee who is not progressing.

However, the relationship between trainee and supervisor remains pivotal. If this relationship is working well, it incorporates trust, graded skills development, regular honest and open feedback and career mentoring.

Problems arise when a trainee does not meet the supervisor’s expectations, or there are performance problems. These may be observed, reported by staff or patients and may include workplace rather than purely clinical issues; for example, absenteeism or conduct at work. The incidents can be single events, recurrent or pervasive.

In my experience, ongoing performance problems are unusual in trainees, as most are diligent and motivated to perform well, complete their training and become quality specialists in their field. Therefore, it is important to rule out other possibilities before concluding that there is an underperformance problem.

As an attendee at Avant’s workshop commented, “‘lack of insight’ may really mean ‘you don’t agree with me’”.

As supervisors, we need to be willing to test our own assumptions, and it is important that we clarify expectations and get to know trainees early in their rotation. Supervisors also need to assure themselves of the assumed skills of the trainee, gain some understanding of the trainee’s life situation and explore their anxieties and goals.

Developing trust and understanding between trainee and supervisor also requires giving prompt and specific feedback when problems arise. The supervisors’ reluctance to deal with performance issues promptly and openly was raised at the workshop as a factor in training disputes. Where concerns can be raised promptly, many trainees will self-correct following a single incident.

However, some performance problems will need more management. While this is always challenging, we may draw on many aspects of good clinical practice: following agreed protocols, communicating clearly and documenting interactions thoroughly are key. Seeking support and expert advice when we feel we are beyond our skill level, and involving support people for particularly difficult discussions are also invaluable strategies.

Managing the supervision relationship is at times difficult and requires education, support and practice. A willingness to acknowledge the complexity and to look beyond our own assumptions to identify the underlying problems may be an important first step to effectively diagnose and manage performance concerns.

Avant produced a report that covered the key problems raised at the workshop and will shortly release a discussion paper on training disputes.

Dr Penny Browne is Senior Medical Officer with Avant.

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