"Educational Tools for Dealing with Trainees with Difficulties"

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Identification and Recognition (Breaking things into the 6 CLMDHA areas to help focus on the right solutions) (21)

All possible steps should be taken to identify and act on early signs and symptoms of difficulty. This helps to prevent problems escalating to a more serious situation that may pose greater risks to the doctor to colleagues, to patients and/or to the organisation in which the doctor works.

Symptoms and Signs

Is the trainee demonstrating any of the following behaviour?

Anger, rigidity, emotionality, absenteeism, failure to answer bleeps, poor time keeping or poor personal organisation, poor record-keeping, change of physical appearance, lack of insight, lack of judgement, clinical mistakes, failing exams, discussing a career change, communication problems with patients, relatives, colleagues or staff?

Have there been complaints from patients or staff about any of the following?

Bullying, arrogance, rudeness, lack of team working (e.g. isolation; unwilling to cover for colleagues; undermining other colleagues (e.g. criticising or arguing in public/in front of patients), defensive reactions to feedback, verbal or physical aggression, erratic or volatile behaviour.

Underlying reasons/explanations

The different causes are likely to have different management approaches and it is therefore important to consider whether the problem is due to any of the following factors within the individual?

Capacity – a fundamental limitation that will prevent them from being able to do their job (e.g. mental or physical impairment). If so, then a change of role or job may need to be considered.

Learning – a skills deficit through lack of training or education. In these cases, skills-based education is likely to be appropriate, provided it is tailored as closely as possible to the individual learning style of the doctor and is realistic within exiting resources.

Motivation – a drop in motivation through being stressed, bored, bullied or overloaded – or conversely being over-motivated, unable to say no, anxious to please, etc. In these cases some form of mentoring, counselling or other form of support may be appropriate and/or addressing organisational issues like workload, team dysfunction or other environmental difficulties that may be affecting motivation.

Distraction – something happening outside work to distract the doctor; or a distraction within the work environment (noise or disruption; team dysfunction). The doctor may need to be encouraged to seek outside professional help if the problem is outside work.

Health – an acute or chronic health problem including drug and alcohol issues which may in turn affect capacity, learning or motivation. Occupational health may have a role here; or the doctor may need to be encouraged to visit his or her GP.

Alienation – a complete loss of any motivation, interest of commitment to medicine or the organisation, leading to passive or active hostility, “sabotage” etc. This cannot generally be rectified and damage can be caused to others (patients and colleagues) and to the organisation if allowed to continue for too long. The doctor should be moved out of the organisation, with whatever support or disciplinary measures may be deemed appropriate.

1 Cecil Helman was a Medical Anthropologist, with constantly enlightening insights

into the cultural factors in health and illness. He suggested that a patient with a

problem comes to a doctor seeking answers to six questions:

2 In the mid-1970’s the humanist psychologist John Heron developed a simple but comprehensive model of the array of interventions a doctor, counsellor or therapist could use with a patient

3 Described by Eric Berne in his book “Games People Play” www.ericberne.com

4 The Honey and Mumford Learning Styles Questionnaire that was first published in 1982. www.peterhoney.com

5 The original VAK concepts were first developed by psychologists and teaching (of children) specialists such as Fernald, Keller, Orton, Gillingham, Stillman and Montessori, starting in the 1920's.

6 Grow, Gerald. (1991). "Teaching Learners to be Self-Directed." Adult Education Quarterly, 41, 125-149.

7 John Fisher developed the transition curve during his work on constructivist theory in relation to service provision organisations at Leicester University (1999) (Description of detail on www.businessballs.com )

8) Developed by Joseph Luft and Harry Ingham in the 1950s

9 Culture, Religion and Patient care in a Multi-ethnic Society by Alix Henley & Judith Schott, Age Concern Book

10 From a course devised by Kiddy and Company (Bristol) on “Advanced Interviewing and Assessment”.

11 www.geert-hofstede.com

12 Edward De Bono Six Thinking Hats - Penguin Books

13 Adapted by Scaling the Heights from the original work of anthropologist Gregory Bateson who developed the original model on logical levels, which was later adopted and developed by Robert Dilts a pioneer in Neuro-linguistic Programming (NLP)

14 Key paper on rolemodelling BMJ 2008;336;718-721 Cruess et al

15 The place to go for Bandura’s theory is Social Foundations of Thought and Action (1986).  But its heavy going so you might want to try his earlier Social Learning Theory(1977)

16 1984, Experiential Learning: Experience as the Source of Learning -D Kolb

17 l983, The reflective practitioner. How professionals think in action – D Schön

18 PUNs and DENs: discovering learning needs in general practice

 By Richard Eve Radcliffe Publishing

19 Identifying and addressing registrars' concerns using a discomfort log. Authors: Dodd M, Rutt G, Suchdev M.S. Education for Primary Care, Volume 13, Number 4, 1 October 2002.

20 Greenhaugh (BMJ 2001; 323: 799-803 Coping with Complexity: educating for Capability)

21 From the Yorkshire and Humber Postgraduate Deanery document on GP training performance concerns

I’ve tried to acknowledge sources for this booklet. If you note something that should have been acknowledged please let me know.

I note that there many useful resources on the following websites.





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