The under-performingtrainee – concerns andchallenges for medicaleducatorsDavid Black and Jan Welch, Postgraduate Deanery for Kent, Surrey and Sussex,London, UK

Akey component of anyorganised medical trainingprogramme should be

systems and processes to identifydoctors in difficulty, and a clearunderstanding of the issues andresources for interventions tomitigate later problems. Althoughdifficulties can occur at any stageof a doctor’s career, they oftenappear early: for example, unpro-fessional behaviour in medicalschool predicts disciplinary actionlater in a doctor’s career.1

EARLY IDENTIFICATIONAND INTERVENTION

In the UK, it is recognised thatthe first year following qualifica-

tion is often especially stressful,despite a highly supportive andsupervised environment.2 In2005, the first two years ofpostgraduate medical educationwere re-organised into a coherentprogramme, to form a new cur-riculum. The objectives were totrain doctors who would uniformlyprovide safe emergency care,would have experienced a numberof specialties (usually six), wouldhave succeeded in competencyassessment and would have pro-ven generic professional skills. Forthe first time there was a definednational curriculum based oncompetencies, not just on timeserved in specialty.3 The resultant‘foundation programme’ was to be

delivered with workplace-basedtraining within a managed ‘foun-dation school’ (FS), including amedical director and managers,training programme directors(each responsible for 20–40trainees), and individual namededucational supervisors (ESs) forevery doctor each year.4

Anyone interested in medicaltraining appreciates that signifi-cant problems remain in identify-ing the trainee in difficulty earlyon, and in intervening effectively.The signs of a doctor in difficultyare well documented, and includepoor clinical performance, unex-plained absences, irritability andoutbursts, and sometimes serious

Althoughdifficulties canoccur at anystage of adoctor’s career,they oftenappear early

Postgraduateeducation

� Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 79–82 79

problems of probity.5 The riskfactors are complex, including notonly environmental factors, suchas medical education and healthcare infrastructures, but also fac-tors relating to the individualtrainee, such as learning style,personality, mental health andresponse to stress.6 Whereas con-siderable work has been under-taken to identify risk factors,there is little information on theirrelationship to outcomes, espe-cially patient outcomes.6

A further challenge for organ-isations managing training pro-grammes is that the employmentof trainees and any disciplinaryaction are matters for the hospi-tal, as the employer, whereas thepostgraduate deanery and itsassociated FS remain responsiblefor planning educational inter-ventions and remediation.7 Ten-sions regularly arise over complexissues requiring not only educa-tional remediation, but also fur-ther investigation and sometimesdisciplinary action.

The aim of this paper is todescribe the following topics.

• Organisational processes inplace to support and manage

trainee doctors identified asbeing in difficulty.

• The caseloads, over one aca-demic year, of trainees expe-riencing difficulties, who werereferred to their FS.

• The issues involved.

• The eventual outcome fortrainees.

TRAINEES IN DIFFICULTYIN SOUTH THAMES

The settingThe Kent, Surrey and Sussex(KSS) Postgraduate Deanery wasresponsible for managing two FSsduring 2006 ⁄ 2007. Each schoolhad a director and a manager: intotal, there were 711 foundationyear 1 (FY1) trainees and 771FY2 trainees, based in 39hospitals, predominately situatedacross South London, and thecounties of Kent, Surrey andSussex. Overall, there wereapproximately 60 programmedirectors, with between 20 and40 trainees each to manage,usually based within a singlehospital. Each trainee had theirown ES, usually responsible foran entire year of training,comprising three or four different

clinical placements, each withone or more clinical supervisors.In each hospital, a multi-profes-sional foundation faculty group(FFG) had been developed to planthe local delivery of both taughtand workplace curricula.4 EachFFG included the foundationtraining programme directors,relevant ESs, a medical educationmanager, one or more traineerepresentatives, and oftenexternal support from medicaleducators and FS staff. It wouldmeet at least three times yearly,and be expected to discuss allfoundation trainees in the localprogramme, ensuring thatworkplace-based assessments(including 360� feedback for alltrainees, twice yearly) were beingcompleted, and that ESs werehappy with the progress. FFGswould discuss in detail trainees forwhom concerns were being raised,and were responsible for planninginterventions as necessary.

Faculty groups were expectedto contact the FS whenever theyhad concerns about a trainee,especially when remedial trainingmight be required, as this couldhave funding implications. Allsignificant matters were thenbrought to a joint ‘trainee indifficulty’ meeting: a multi-pro-fessional group chaired by thepostgraduate dean, and includingassociate postgraduate deans,foundation school heads andmanagers, senior educationalacademics, the head of humanresources and the dean of generalpractice training. All cases werediscussed and tracked monthlyuntil resolved.

RESULTS

Data from all trainees identifiedduring a full academic year wereanalysed. A total of 20 traineeswho only had a health problem(such as a broken leg) only werediscussed, as additional oradapted training may have beenrequired, but have not beenconsidered further here. Sixty

Significantproblemsremain in

identifying thetrainee in

difficulty earlyon, and in

interveningeffectively

80 � Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 79–82

doctors were identified as havingperformance issues.

Table 1 summarises the routesof problem identification orreferral. The national Health CareAssessment and Training (HcAT)computerised system, for report-ing the comparative results ofassessments, alerted the school toconcerns recorded in 360�assessments (using the mini-PeerAssessment Tool, mini-PAT),sometimes before the trust no-ticed that they had a problem.

Table 2 sets out the initialpresenting features leading tosubsequent action.

Table 3 summarises the maincategories of problem followinginitial exploration: some casesinvolved multiple problems. Thesecategories (Table 4) are based onthe KSS Postgraduate Deanery’sTrainee in Difficulty guidelines.8

Table 5 summaries the maininterventions used: occupationalhealth (OH) services were activelyused in managing 18 per cent ofthe trainees.

Overall 53 (3.5%) traineesreceived interventions and con-tinued to progress, although 15(1%) needed additional time,varying from one month to

repeating a full foundation year.Four trainees (0.03%) left medi-cine, and two were dismissed bytheir employers and left the FS.One had unresolved police andGeneral Medical Council (GMC)issues.

DISCUSSION

Managing the underperformingtrainee is time consuming andcomplex. Medical educators seekto identify problems early, andto resolve them with educationalintervention. Health and per-sonal issues regularly add to thecomplexity, however, seriousprofessional misconduct is notusually amenable to educationalintervention. Our experience isthat infrastructure is vital at theTrust level, with FFGs and pro-fessionalised (both trained andfunded) training programmedirectors actively looking forconcerns. In addition, multiplesources of input – for example,FFG minutes and electronicflags – can enable the FS toidentify problems early. Thispaper describes a committeestructure that has the appropri-ate expertise to facilitate, debateand resolve the most complexproblems. Our objective is todevelop a system in which prob-lems are proactively identified,rather than only becomingapparent following a crisis.

Workplace-based assessmentsintroduced into the foundationprogramme have been a source ofdebate and challenge. Our expe-rience is that using mini-PAT (anapproved multi-source feedbacktool), together with a centralisedelectronic analysis and reportingsystem, can be a powerful tool foridentifying struggling or under-performing doctors. In this groupof new doctors, at a very earlystage in their careers, we pickedup a significant proportionexperiencing difficulties usingmini-PAT alone, and it will beinteresting to see if this isrepeated when multi-source

Medicaleducators seekto identifyproblems early,and to resolvethem witheducationalintervention

Table 1. Routes of indentification or referral

RouteNumber oftrainees

Educational supervision 34

Medical education or staffing manager 8

Mini-PAT* flags 10

Faculty minutes 6

Transfer of information 2

*Mini-PAT: mini-Peer Assessment Tool.

Table 2. Presenting features at point of referral

DifficultyPercentageof trainees

Clinical issues ⁄ mistakes ⁄ poor insight 60%

Time-keeping ⁄ organisation 22%

Absenteeism 15%

Not performing clinical assessments 18%

Team integration problems 8%

Other behavioural issues 23%

Table 3. Problem categorisation

ProblemPercentageof trainees

Environment 2%

Personal (including stress) 33%

Craft development 45%

Generic professional 20%

Serious professional issue 12%

� Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 79–82 81

feedback becomes standardised inpost-foundation training.

Making access to specialisedOH services easy for doctors withproblems, as has been high-lighted by the National ClinicalAssessment Service,8 is crucial.Early postgraduate medical train-ing is a stressful time, anddepression and related illnesseshave been found in a significantnumber of trainees identified asbeing in difficulty.2 Although18 per cent did use OH services,there was a continual challengefor the deanery and the FS toensure that doctors were referredearly to OH, and took OH advicebefore returning to work.

Some of the biggest chal-lenges remain in cases wherethere are allegations not just ofpoor performance, but of profes-sional misconduct, particularlywhen these are serious. A proac-tive and integrated response aimsto minimise the recognised prob-lem of disciplinary proceduresbeing dropped, or never started,because the trainee was due toleave soon.10 It should also be amechanism for ensuring that onlyappropriate cases are referred tothe GMC. The processes describedensured that trusts fulfilled theirobligations, as employers, toproperly investigate conductissues in line with nationalguidance.7

The South Thames FoundationSchool is currently the largest inthe UK, and therefore is likely toidentify many trainees in diffi-culty. As a result, our staff aregaining significant experience intrying to manage these difficultproblems.

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A proactiveand integratedresponse aims

to minimisethe recognised

problem ofdisciplinaryprocedures

being dropped

Table 4. Assessment outcomes

Training environmentMismatches between trainee and trainer, excessive workload, harassment,bullying, wrong level of expertise expected of the junior doctor.

Personal issuesHealth, emotional difficulties (partner ⁄ spouse relationship, critical familyillness), wrong career path.

Craft developmentSpecialty-specific skills and knowledge. Problems with procedures, manualdexterity, depth of understanding and clinical decision-making.

Generic professional developmentRapport with patients, staff and families, respect for people holdingdifferent views, cultural acclimatisation, and acting effectively within theteam. Motivation, maturity, a lack of insight. Time management and basicorganisation skills.

Professional behavioursIntegrity and probity, reliability, substance abuse.

Table 5. Types of intervention

InterventionPercentageof trainees

Occupational health services 18%

Directed supervision 69%

More time 29%

Change of post 4%

Counselling ⁄ mentoring 12%

82 � Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 79–82