2204059683_09eb09601b_zSarita Sochart is a consultant in Geriatric and Stroke medicine and Foundation Programme Director Health Education North West. Paul Baker is a geriatrician in Bolton and Deputy Postgraduate Dean, running the largest Foundation School in the country.

In this blog, based on their presentation at the BGS Spring Conference in Nottingham, they look at quality management in training, and trainees in difficulty.

Our presentation at the BGS conference this spring focused on the Trainee in Difficulty (TID). Evidence suggests that nationally 2-6% of all doctors may experience difficulties, sufficient to raise concern about their performance (Donaldson, 1994; NCAS, 2006).

For the purposes of the study the Northwestern Deanery has identified a TID as-

Any trainee who has caused concern to his/her educational supervisor(s) about the ability to carry out their duties, which has required unusual measures”

This would mean anything outside the normal trainer-trainee processes where the Training Programme Director has been called upon to take or recommend action.”

(NW Deanery, 2013)

Trainees consistently experience high intensity of work, conflicting time demands and a progressive increase in professional responsibility. They are not supernumerary to service requirements and are aware of increasing expectations from the public and threat of litigation. However, with compulsory appraisals, assessments based around work and a culture of reflection, it is hoped that any TID will receive adequate and appropriate support.

Most trainees will require help at the local Trust level. Many problems can be resolved with extra supervision and support. But some trainees cause enough concern to escalate to senior educators and the employer. Some, depending on the level of difficulty, will need involvement of external parties such as the local deanery, National Clinical Assessment Service (NCAS) and General Medical Council (GMC).

One of the key challenges is to be able to identify the “Early Warning Signs” (EWS) which flag up the trainee followed by the involved supervisor’s concerted efforts and preparedness to respond to these early signs. The signs aid in categorising the difficulties into performance related, personal/professional conduct, health problems, environmental issues and or an overlap between all of the interconnected factors. They are outlined in Box 1.

Box 1: Early Warning Signs (EWS) of TID (Paice 2006) 

  • The disappearing act: not answering bleeps; disappearing between clinic and ward; lateness; excessive sick leave.
  • Low work rate: slowness at procedures, clerking, dictating letters, making decisions; coming in early and staying late and still not getting a reasonable workload done.
  • Ward rage: bursts of temper when decisions are questioned; shouting matches with colleagues or patients; real or imagined slights.
  • Rigidity: poor tolerance of ambiguity; inability to compromise; difficulty prioritising; inappropriate ‘‘whistle-blowing’’.
  • Bypass syndrome: junior colleagues or nurses finding ways to avoid seeking their opinion or help.
  • Career problems: difficulty with exams; uncertainty about career choice; disillusionment with medicine.
  • Insight failure: rejection of constructive criticism; defensiveness; counter-challenge.

Developing effective and reliable strategies for when TID have been identified has not been easy. The simultaneous engagement of the TID and the supervisor in the diagnostic process is far more important than seeking a quick fix solution to the problems.

There is changing trend of clinical services in the NHS from being reactive to proactive. The same should hold good for education and training. Some excellent work has been done in this area by National Association of Clinical Tutors (NACT) UK, summarised in a document “Managing Trainees in Difficulty (version 3, October 2013) Practical Advice for Educational and Clinical Supervisors” .

The document introduces various systems and processes required to manage a TID along with practical advice on how to analyse and deal with the problems as they are presented to supervisors. We believe that individual supervisors and organisations on the whole need to become familiar with pathways for responding to TID.

Understanding the category of difficulty will allow one to manage the concerns appropriately. Ensuring consistency in effective communication will entail tackling difficult questions. The set up of a perfect scene for a negative outcome would be when a TID has a relative lack of insight of his/her problem and the supervisor has no documentation. There are no shortcuts for clear documentation and maintaining confidentiality.

Without good facts one is unlikely to make good ethical decisions. In particular, health issues must be identified early on and managed appropriately. One must not confuse health issues with disciplinary procedures.Performance issues can have a direct profoundly serious effect on patient care and safety in addition to collateral damage to the team that the trainee is attached with.

Therefore it is imperative to have a deliberate coordinated and systematic approach. Focus should be on the assessment, followed by tailored supervision and remedial measures. These may well be complex and multi-dimensional but importantly they need to be malleable.

Within the constraints of this blog, it is impossible to describe in detail the various complex underlying factors that cause a trainee to get into difficulty. Discerning whether the trainee is in difficulty or a “difficult” trainee is paramount. As educators it is our responsibility to support trainees throughout their training programme along with balancing patient safety and the trainee’s educational needs. We hope the readers find the key points in Box 2 useful.

Box 2: Key points

  • Define the nature of the problem early.
  • Document formal and informal discussions with the trainee.
  • Clarify roles and responsibilities
  • Keep the trainee involved and maintain confidentiality.
  • Provision of pastoral support
  • Seek help/advice early either within organisation or appropriate external agencies
  • Appropriate transfer of information when required
  • Referral to occupational health department where appropriate
  • Tailored remedial measures with regular reviews


Paice E. The role of education and training. In: Cox J, King J, Hutchinson A, et al, eds. Understanding doctors’ performance. Oxford: Radcliffe, 2006:78–90.

NACT UK 2013

Donaldson 2004

Image credit: bottled_void via flickr

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