"Educational Tools for Dealing with Trainees with Difficulties"

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I Interesting Do I find this subject interesting? If not how can I help make it more interesting? How will I make sure I do it if I am avoiding it?

E Economic Is it economic to do (remember economies need Time & Money)

S Success Success needs acknowledging, achievements along the way documented and records kept. This is all part of the evidence that you may need for revalidation . You may not get to the end of every area but will have travelled along the road towards this. Remember Maths exams, some of the marks are for the answer at the end, but a lot of them are for the calculations along the way!!


Any communication where the goals of 2 or more parties were seen to be in opposition and that change was wanted or required.”


Successful negotiation depends on meticulous pre-negotiation preparation and the essentials for this are.

  • Define what OUTCOME you wish.

  • Have clear REASONS as to why you think there is a problem. The reasons should be limited to ones where you have a strong belief in them or they strongly back your proposal.

  • Have EVIDENCE in place to justify your argument.

  • INFORMATION GATHER, so that you know as much as possible about the views, personality, background and culture of the PERSON you are negotiating with.

  • INFORMATION GATHER, as to the OUTSIDE INFLUENCES that may have an impact on the negotiation. E.g. resources/money/outside life.

  • Check if there is ANY POINT IN CONTINUING?

  • If this means yes then look at the OUTCOME in detail and decide what is your bargaining BEST outcome and what the WORST (Your fall back position.) acceptable would be. Think about the outcome in the SHORT/MEDIUM AND LONG TERM.

  • Think of a range of bargaining OPTIONS that might be used.

  • Ensure that the meeting is at the RIGHT TIME and in the RIGHT PLACE. I.e. to ensure there is plenty of time and that you feel comfortable in the environment. (Agenda, ground rules, uninterrupted time to present material, time specific and if limited time to identify how much ground to be covered at 1st meeting.)

  • The actual negotiation is mainly about using SKILLS to achieve your outcome and a list of skills is made out separately. It is also about making sure you are the right person to do the negotiation and not a middle person caught between differing factions.

  • Initially you will need to DISCOVER the desired outcome of the other person and what THEIR BEST OFFER is likely to be. (And to acknowledge this and understand the differences.)

  • Can you identify the INTENT of the other person? What is motivating their position

  • The COMMON GROUND of negotiation is that between their best offer and your worst acceptable scenario.

Some of the useful phrases when exploring the common ground are,


  • If you STEP INTO MY SHOES for a minute.

  • When I STEP INTO YOUR SHOES I can see your point of view but…


  • My FEELINGS are that. (Knowing your own and understanding others feelings important.)

  • I believe we are trying to ACHIEVE THE SAME THING.

In general you need to be REALISTIC and try and identify a COLLABORATIVE approach that will try and reach a WIN/WIN result. (Mutual gain)

CONFLICT and then COMPROMISE will lead to a likely WIN/LOSE situation with everybody aware of what they have lost and not positive about the gains.

Collaboration is more likely to occur with negotiation in the “common ground” and conflict if negotiators stick rigidly to their best offer only.


  • Good COMMUNICATION SKILLS. The usual suspects of building rapport, picking up cues, non-verbal communication and also being able to clarify and summarise regularly. Etc….

  • Being FLEXIBLE.(Have some options thought about before but also try and think creatively.)

  • CHUNK UP. This is just a term suggesting if negotiation is stuck in the specifics you could try to be a bit more general to see if other options occur.

  • CHUNK DOWN. This makes things more specific and might be used to move negotiation on.

  • Being able to stress the POSITIVE CONSEQUENCES of your proposal being accepted. (For example if we concentrate on this the evidence is that the majority of trainees pass the CSA component of the exam.)

  • Let the other person know the NEGATIVE CONSEQUENCES of your proposal being rejected. (For example that certain competencies will not be signed off for WPBA.)

  • Be aware that the block on a lot of negotiation is based on conflict of BELIEFS AND VALUES so you have to acknowledge what yours are and try and explore what is important to the other person.

  • Try to identify whether the other person’s perspectives are locked in the PAST (We have always done things this way) the PRESENT (At this moment in time we have to consolidate things) or the FUTURE. (The only way is to make changes and move ahead.)

  • Recognise when TIME OUT is needed either to consider options or for some housekeeping.

Things won’t always resolve and sometimes we need mediation.

Negotiation and your preferred style

What is it good for? Challenging how we deal with conflict and analyzing how we can do so more effectively, flexibly and with less anxiety

How to use it? As GP’s we should have most of the skills for successful negotiation embedded in how we communicate and consult. However many of us find managing conflict difficult. This model explores the ways individuals prefer to deal with conflict

References This model is based on the work of Thomas and Kilmann www.kilmann.com and also see other sections in the workbook on Communication skills, NVC and Effectiveness for more general information on negotiation

In the 1970s Kenneth Thomas and Ralph Kilmann identified five main styles of dealing with conflict that vary in their degrees of cooperativeness and assertiveness. They argued that people typically have a preferred conflict resolution style. However they also noted that different styles were most useful in different situations. They developed the Thomas-Kilmann Conflict Mode Instrument (TKI) which helps you to identify which style you tend towards when conflict arises.





















Competitive: People who tend towards a competitive style take a firm stand, and know what they want. They usually operate from a position of power, drawn from things like position, rank, expertise, or persuasive ability. This style can be useful when there is an emergency and a decision needs to be make fast; when the decision is unpopular; or when defending against someone who is trying to exploit the situation selfishly. However it can leave people feeling bruised, unsatisfied and resentful when used in less urgent situations.

Collaborative: People tending towards a collaborative style try to meet the needs of all people involved. These people can be highly assertive but unlike the competitor, they cooperate effectively and acknowledge that everyone is important. This style is useful when you need to bring together a variety of viewpoints to get the best solution; when there have been previous conflicts in the group; or when the situation is too important for a simple trade-off.

Compromising: People who prefer a compromising style try to find a solution that will at least partially satisfy everyone. Everyone is expected to give up something, and the compromiser him- or herself also expects to relinquish something. Compromise is useful when the cost of conflict is higher than the cost of losing ground, when equal strength opponents are at a standstill and when there is a deadline looming.

Accommodating: This style indicates a willingness to meet the needs of others at the expense of the person's own needs. The accommodator often knows when to give in to others, but can be persuaded to surrender a position even when it is not warranted. This person is not assertive but is highly cooperative. Accommodation is appropriate when the issues matter more to the other party, when peace is more valuable than winning, or when you want to be in a position to collect on this "favor" you gave. However people may not return favors, and overall this approach is unlikely to give the best outcomes.

Avoiding: People tending towards this style seek to evade the conflict entirely. This style is typified by delegating controversial decisions, accepting default decisions, and not wanting to hurt anyone's feelings. It can be appropriate when victory is impossible, when the controversy is trivial, or when someone else is in a better position to solve the problem. However in many situations this is a weak and ineffective approach to take.

Once you understand the different styles, you can use them to think about the most appropriate approach (or mixture of approaches) for the situation you're in. You can also think about your own instinctive approach, and learn how you need to change this if necessary.

Ideally you can adopt an approach that meets the situation, resolves the problem, respects people's legitimate interests, and mends damaged working relationships.



I cheat a bit by using the term certainty when what we really have to help with is a learner’s UNCERTAINTY.

A lot of uncertainty is linked to the ability to make DECISIONS. With decreasing hours for hospital doctors, less continuity of care, increasing use of protocol led decision making and senior doctors making most decisions many trainees come to general practice with very little experience of decision making.

One way they try to deal with this is by trying to increase their knowledge. But as Bertrand Russell noted “What people really want is not knowledge but certainty.” And what we want is to help them through experiential learning to develop the skills to cope with not knowing and be comfortable with and able to manage uncertainty.

At the same time we are assessing using a competency based model.

One definition of COMPETENCE is that individuals “know” or “can do” in terms of knowledge skills and attitudes.

But in the increasingly COMPLEX world of GP what trainees need to show is CAPABILITY which has been described by Greenhaugh (20) as

CAPABILITY – can adapt to change, can generate new knowledge and can continue to improve on their performance

And this is what we are really trying to assess in WPBA. This also includes our capability to assess someone’s performance as they show that they can actually DO.

And if we don’t get it right things can descend into CHAOS!

I suggest that COMPLEXITY THEORY can help us discuss with our trainees the issues that create uncertainty and how we become capable at dealing with complex situations.

AND the suggestion uses my as simple as possible version of complexity theory!

In this version, the degree of agreement about what to do between practitioners in circumstance x is plotted on a graph against the degree of certainty in order to determine where on the competence - complexity - chaos spectrum the matter lies:






It is easy to measure competence in area A.

Everybody agrees what should be done and there is a high level of agreement for the trainee to follow. Commonly this high level of agreement is based on protocols which in themselves should be underpinned by good evidence. If a trainee has a protocol to follow they become more confident and certain that they are doing the right thing.

In discussion with trainees it is clear that the majority think their trainers are good GPs because they know lots and are usually very certain what to do. I.e. they work with a very large Area A.

But trainers know that most of the work we do is in Area B. Many of the things we deal with do not have a good evidence base to support clear agreement. But we have the capability of managing complex situations by developing shared agreement with patients and of knowing how to develop some certainty by discovery and discussion. We usually become comfortable about it being ok for an individual patient to be managed outside the usual norms. And we know that sometimes chaos is the lot of certain patients.

In practical terms we know that many things influence how we manage individual patients and most protocols don’t allow for this.

In complexity theory these influences are thought of as agents (Something that takes part in an interaction & is subsequently changed)

So I think of these as the things that affect how I manage the individual situation. And that each individual will be affected by different influences.

So for example a trainee might be certain that sending a patient to hospital is the only right thing because the protocol they used in A/E stated this clearly.

And then they learn the patient is also a carer for their wife, refuse to go into hospital, note that their next of kin is on holiday abroad and they are looking after their cat, won’t accept any tablets until their own “proper” doctor visits because you just don’t know what you are doing and it’s all an unnecessary fuss.

(As trainers you know this and many other variations and have learnt how to handle the situation in some form or other and deal with the “agents” that are involved – and you know the difficulties trainees have in doing this. We in our way become an agent and move things back to certainty. For example we use our skills to discuss risk and choices, can advise about emergency social support, arrange to speak to a relative on the phone etc)

And the final term I’ll mention from Complexity theory is Complex Adaptive Systems. (A non linear system with the potential for self-organisation in an environment which at times is far from equilibrium. Evolution is based on its history. E.g. the immune system, stock markets, the human nervous system)

This potential for self organization is important and if we think linear we think teaching that is based on structure and knowledge.

If we think non linear we think of less structure and something based on;

  • Experiential learning.

  • Situational learning (shadowing, apprenticeship, rotational attachments)

  • Small group learning (case based, role play, problem solving peer support)

  • Problem based learning (how to find out, teamwork)

  • Self Directed (reflective practice, using patients learning log, networking informally)

And think of how we challenge trainees to become not just competent but capable and excellent. Look at the descriptors in the 12 competencies and see how often uncertainty and complexity are mentioned!

With thanks to Shake Seigel for introduction to complexity theory and his summary is on http://www.napce.net/products.php?catId=143 and also to the Scottish Scaling the Heights Group – Edradour for helping develop the ideas. In particular David Bee for linking all the “Cs”.


SID identifies 3 key things that are a must in problem solving

Share- Share your concerns with others. Don’t get stuck with trying to solve things by yourself. Some issues will just benefit with discussion with colleagues, others with professional bodies for advice but some concerns need referred as per your deanery or organisation’s policy.

Involve- Involve the learner in those concerns and discussions. Even though it might be difficult it is important to speak to the learner because there may be 2 sides to a story or something that is at the ROOT of the difficulty.

Document- Keep detailed specific documentation of the facts of what has happened and any other relevant issues. What you record should be Accurate, Factual, Objective, Justifiable and Relevant and use specific, descriptive and non-judgmental language.

Remember the Data Protection Act governs how personal information is collected and stored. Any data on a learner’s performance will be classed as personal data and subject to the act. So you may have to justify what you have recorded and what evidence you have to back it up.

And remember that there will be document(s) a trainee has signed up to (their educational contract) or that they wish signed off (WPBA) or which provide guidance (From the GMC or College) that details what they should be doing or achieving to become a doctor who is fit and safe enough to work in General Practice in the future.

At some stage a difficulty becomes apparent through the effect of the difficulty on others or in work performance for example. Try to understand the root of the problem by using the Venn diagram and consider what evidence you have that there is a difficulty. (These used on NHS Education Scotland SCOTS courses)

Questions for the trainer

Am I dealing with competence and performance or conduct issues

Is there an underlying health issue

What overlap is there between these

Is the working environment causing difficulties

Are there issues outside work influencing things

Managing the difficulty


What is the REAL difficulty?

Why has it happened?

Why has it happened now?

Who is it causing difficulty for?

What is the effect of the difficulty?

Does the learner accept there is a difficulty?

Yes / no

Am I prepared to put up with the difficulty?


What might happen if I do nothing about it?

What is the best outcome that could be achieved?

What options are there for reaching this outcome?

Which is the best option?

Does this option create other knock-on difficulties?

Who else should deal with the difficulty?

Is the learner happy with the outcome?

Yes / no




Summary of what has been agreed, how it will be monitored and the consequences of failure to meet agreements.


Information Gathering

When a question is raised over the conduct or performance of a trainee, there are a wide variety of circumstances within which this may occur. On the one hand there may be overwhelming evidence from varied, reliable and attributable sources whereas on the other hand the information may be much less substantial. Educational supervisors and other senior staff have a duty to the trainee, to patients and to other staff when difficulties like this arise. There is also a need to observe strict ethical standards, particularly confidentiality as far as this is possible.

Must differentiate genuine concerns from tittle-tattle, personality clashes, discrimination etc

There is a need to determine if concerns are significant and relevant to clinical practice. Remember it is only reasonable to pursue an issue with a medical trainee if rota is legal, hours are new-deal compliant, supervision is adequate and there are no health problems

Minor questions are raised and answered about performance issues every day in the workplace.

But if there is any suggestion of an investigation the trainee has significant rights from the beginning.

So be wary of making an informal investigation and consider how complaints are logged and documented before using them.

Confidentiality is difficult to maintain but appropriate standards should be followed for this.

What is the right of trainee to be fully informed?

    • natural justice

    • employment law

    • terms and conditions

    • human rights

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