The Trainee In Difficulty

SOURCES OF HELP – FOR TRAINEES

  • Please contact one or more of your Clinical Supervisor, Trainer, Educational Supervisor and TPD.   You will find at least one (if not all) of them understanding and sympathetic.
  • Yorkshire & Humber Deanery’s coaching service: www.yorksandhumberdeanery.nhs.uk/coaching
  • Please make an appointment with your own GP.  If you’re not registered with one, now is the time to do it.  
  • You can ask to see the doctor at the local Occupational Health Department  (usually based at the local hospital you’ve been working in).  FOR BRADFORD: Joanne Hoban, Employee Health & Wellbeing Manager, Lynfield Mount Hospital, Daisy Hill House, Heights Lane, Bradford, BD9 6DP, Tel:01274228570, Mobile 07432721813.  Click here for a Occupational Health Referral letter template.
  • Take Time Project – confidential counselling based at Leeds University for trainees in psychological issues.   www.leeds.ac.uk/studentcounselling   Tel: 0113 343 4642   Email: taketime@leeds.ac.uk
  • Doctors’ Support Line: 0844 395 3010       www.dsn.org.uk       info@dsn.org.uk     DSN provides ongoing confidential advice and support to doctors with mental health problems. All calls are dealt with by doctors.
  • GP Safe Housewww.gpsafehouse-avon.co.uk   GP Safe House (GPSH) is a virtual safe house providing a refuge and support for practitioners experiencing professional challenges.
  • Use the BMA Counselling Service.  Click here for the BMA Counselling Service.  They also have Industrial Relations Officers available to provide free advice about contractual and employment issues.
  • Do not forget about your defence organisation as a source of advice too.
  • Forced Marriage – the government have set up a help and information page for those being forced into a marriage who clearly don’t want to be.   There is help available to you.   Most police departments have a specialised Forced Marriage Unit who can protect you and tell you what your options are – please ring your local police department for more information.    To go the Government’s help page click on https://www.gov.uk/forced-marriage.   This page also provides an advice link for professionals and front line workers.  Many of you will find this document helpful : forced marriage – guidance for professionals.
  • Specific Support OrganisationsClick here for a full list of support organisations – including addiction, gambling, bereavement, financial, housing, mental health, stress, disabilities and lots of others.

This page provides guidance for BOTH trainers and trainees who are experiencing difficulty either with each other, in their personal lives or with their progression of training.

Dear Trainees…

Please be discuss things EARLY with either your GP Trainer, Consultant, Educational Supervisor or Training Programme Director.   If the issue involves one of these people – try someone else in the list.  The important thing is to aire your problems early to stop them from escalating to exponential levels.  We understand that this requires a level of openness, honesty and trust.   Please take a moment now to review the content of the second rounded box above.

Please thing about going for Coaching.  Click here to read more about coaching.

Dear Trainers…

PLEASE talk to someone EARLY to help implement early remediation and stop things from deteriorating drastically. Remember that there are many sources of support for you too.

  1. Start by talking to the trainee – keep them involved right from the beginning. Do not act in haste. Stop and gather more information first. Try and understand the situation.
  2. Following on from that, perhaps talk to other members of the practice or perhaps a fellow trainer?   Consider doing an RDMp assessment to determine what the problem is and help identify causal and maintaining factors (see resources above).
  3. Then there is your local Training Programme Director. In Bradford, we have specific Training Programme Directors nominated to be the ‘TPD advisors’ for specific trainees. You can find the latest list here.
  4. For contractual or employment issues, don’t forget about the BMA – they have Industrial Relations Officers available to provide free advice.   Involve the Deanery too (speak to Deputy Director).
  5. There are the Defence organisations who might be able to help especially if a trainee is involved in a Serious Untoward Incident (SUI).  Again, involve the Deanery too (speak to Deputy Director).
  6. If there are serious performance or health concerns
    • Ask the trainee to see their own GP if there are health concerns.  If there are patient safety concerns, stop the trainee from working (get them to take sick leave) and review the patients they have seen so far to ensure no harm has been incurred.
    • If the trainee could benefit from counselling, please think about referring them to the Take Time Project – a confidential counselling based at Leeds University for trainees with psychological issues. www.leeds.ac.uk/studentcounselling 
    • Ask the TPDs whether they need to involve the Deanery . They usually need to if there are performance/health/patient safety concerns. Deputy Directors are available to help GP training schemes and its individual members. Deputy Directors: Kirsty Baldwin for WYLO, David Rose for NENL, and Ben Jackson for SYLO. They can sometimes remove the load of making difficult decisions from your shoulders if you would find this helpful. At all times they must be provided with documented information to facilitate their decision making. Other people to contact at the same time at the Deanery is the Doctors in Difficulty Tutor & School Lead (currently Dr. Jayashree Mangapudi & Dr. Mike Tompson) and the Performance Tutor (who is currently Nick Whelan).   Do not short-circuit the ladder however, the natural place for Trainers to initially voice any concerns is with their Programme Director(s).
    • Do a referral to Occupational Health at the local hospital for an assessment (use the template letter above).  But before you do this, PLEASE LIAISE WITH LOCAL YOUR TRAINING PROGRAMME DIRECTOR – write the report in a collaborative way.
    • Inform the Responsible Officer for NHS Englandwww.england.nhs.uk contact-us or (0300 311 22 33 and ask for the Responsible Officer for GP Trainees).
    • And of course, involve the GMC.

Remember – if you are ever worried about a trainee seeing patients, the precautionary principle in relation to patient safety should be applied – i.e. put measures in place to stop them seeing patients until further assessments (e.g. occ. health, own GP etc), clear supervision and safeguards have been applied. And get in touch with the TPDs ASAP – who will advise you further.

Dear Training Programme Directors…

  1. Start by talking to the trainee, the trainer and the Educational Supervisor and keep them involved right from the beginning.  Do not act in haste.  Stop and gather more information first.  Try and understand the situation. Consider doing an RDMp assessment to determine what the problem is and help identify causal and maintaining factors (see Downloads above).
  2. You may need to do a referral to Occupational Health at the local hospital for an assessment (use the template letter above).  But the best person to do this is the person who knows the trainee the best – and this may be the GP trainer or the Hospital Consultant – and you may simply need to work with them to help them write the report in a collaborative way.   In some circumstances, the report may be better coming from you (and being informed by others).
  3. Then follow point 4 onwards under the ‘Dear Trainers…’ section above.

The Occupational Health (OH) Referral

Some Key Points

  1. The more detailed the OH referral letter and details the more likely it is to get a useful answer
  2. Informing the OH department of nature of the trainee’s rotation and expected work helps ( hence the draft OH letter on this website above under the Downloads box)

Who Should Do the Referral?

  • At present most referrals are either done by the employer ( e.g. GP practice or employing trust) or by the schemes; the choice seems to be really around who knows the trainee best , and who has greatest need … often the scheme because the concerns are likely to go beyond the current post (and some of the information may need passing on).
  • So, in summary, it is best done by the person who knows the trainee the best.   This may be the trainer, the hospital consultant or the TPD.  However, whoever writes the report needs to collaborate with others who need to input into the report.

Sharing of OH reports

  • The report is done for the referrer and shared by OH with the referrer and the trainee. Trainees are encouraged to put the OH report on their ePortfolio.  However, as it is confidential material it is appropriate not to demand/ expect full release to this open access forum.  As it contains personal/confidential information about a trainee’s illness, it is appropriate to allow some editing.
  • When making the referral ensure that all other relevant people are informed of the referral and told how to access the report ( e.g. HR dept of future employers, scheme if ref done by GP practice, or GP practice if ref done by scheme, DiD team/ locality office ).  HOWEVER, please remember issues around consent to share the report here – which the GP trainee needs to give first.  DiD = Doctors in Difficulty.
  • The DiD tutor has a role in checking that OH has been used when appropriate and that relevant OH reports are not lost but are seen, followed up and acted on.  The current DID Tutor is Dr. Jayashree Mangapudi.
  • Schemes do have a co-ordinating role in knowing that OH has been referred to and sharing the information which they have ( provided there is consent to share the details… if no consent then sharing awareness that a report has been done).

To Summarise…

The important rule is to involve others early.  Don’t fret too much over whether you think you are making too much of a fuss or not – it’s better to be safe than sorry!   When concerns are past on late, there is very little space for effective suggestions and alternatives.  The hierarchy for involving others would go something like this:

  1. Talk to trainee
  2. Talk to other members of the practice
  3. Do an RDMp assessment – to isolate the problem
  4. Talk to TPDs
  5. Inform Deanery – Deputy Director, Doctor in Difficulty (DID) Tutor, Performance Tutor
  6. If there are health or serious performance concerns (a) refer trainee to own GP, (b) refer for counselling (e.g. Take Time in Leeds), (c)  refer for Occupationhal Health assessment, (d) Inform NHS England, (e) Inform GMC
  7. Matters relating to contract and employment – think of the BMA (Industrial Relations Officer)
  8. Significant Untoward Incident – involve Deanery and Defence organisation.

IF YOU ARE REFERRED TO THE DEANERY'S PERFORMANCE TEAM....(click to open me)

If you are referred to the Deanery’s performance team, please don’t be scared about meeting them.   Remember: their job is to try and help you (a doctor in difficulty) in order to help increase your chances of successfully completing the scheme.  But before they can do that, you need to be open and honest with them.

Who is a DiD? ( Doctor in Difficulty)

The definition is broadly that a DiD is a trainee who has an adverse ARCP (outcome 2 or 3 or 4), involvement with a SUI or involvement with a GMC investigation or identified Conduct issues.  For the obsessional DiDs are classified by Deanery into 6 groups : DiD1= Conduct , Did 2 3 or 4 relate to ARCP outcomes 2 3 or 4, 5 = GMC and 6=SUI.  All DIDs are followed up by the Deputy Directors (Kirsty Baldwin, Ben Jackson and David Rose) through a discussion with the Deputy Deans.  This discussion is important because the Deanery wants to make sure they help these Doctors In Difficulty in the best way they can.  The school of GP also follows up those where there are School concerns. School Concern: Trainee who has failed their AKT or CSA examinations, there are scheme concerns or sickness concerns (14 days or more).  The reason that the school of General Practice intensively follows up trainees is to a) help them as best as they can, b) help institute remediation as early as possible to ensure a better chance of success and c) budget planning – in case extensions are necessary.

What does a DiD tutor or the Performance team Do?

The aim broadly of the performance team is to help trainees who appear to be struggling to complete their training successfully. This may include looking at the ePortfolio to advise on elements of WPBA / log diaries etc which if not addressed will raise the possibility of failure at ARCP.  The team would also look at the overall picture of a trainee who e.g. fails the AKT early on to see if there are other concerns in ePortfolio etc (= a holistic approach). Where there are none and (for instance) AKT was simply taken too early,  little other direct input might be offered.  Where there appear to be more concerns it is more likely that a 1 to 1 meeting with Nick Whelan (performance Tutor) would be suggested.  The team is working to develop a coherent package of inputs and supports for those trainees who struggle , both preventively and in response to identification of failure.

So are all AKT fails DiDs?

Simple answer = no

Complex answer : the team should look to see if there are other concerns and should look from a distance at those who have failed exams to check progress continues to be OK e.g. by looking at e-P every 2 months to check on progression between ARCP or ES reviews.

HAVE YOU ANY TENETS FOR MANAGING DIFFICULT SITUATIONS?

You must share your concerns with the trainee at the earliest possible time. Document all concerns that you have (in the trainee’s ePortfolio, under Educators’ Notes). You must involve the TPD at an early stage and they may involve the Deanery.


If you believe it will be difficult for you to make the decision relating to signing off the Clinical Supervisor’s Report or the Educational Supervisor’s Report then you should share this concern with your TPDs at an early stage. DO NOT FALL INTO THE TRAP OF SIGNING THE ESR/CSR IN THE HOPE AND BELIEF THAT THE DOCTOR INVOLVED IS CERTAIN TO IMPROVE IN FUTURE POSTS.

SIX SPECIFIC SITUATIONS

Let’s look at the following 6 problems…

  1. A personality clash
  2. Health problems
  3. Criminal activity
  4. Failing academically
  5. Unexplained Absence from Work
  6. Abscence from Half Day Release

HOW TO DEAL WITH THESE SITUATIONS?

1. Personality Clashes

These situations should be faced sooner rather than later. Share your concerns with the involved trainee. Try and seek advice from your TPD and perhaps fellow GP Trainers (if at a Trainers’ Workshop – try and maintain confidentiality). A TPD should involve themselves at this stage with the aim of clarifying issues and arbitrating if this is feasible. Every effort should be made to solve this problem quickly at a Scheme level. If the problem seems complicated Deputy Directors are available to advise and guide you and your TPD. It is vital that trainers document their concerns and also share these concerns with the involved trainee – the place to do this is in their ePortfolio (under Educators’ Notes). Do NOT keep hidden external records. The outcome of external arbitration may be to move the trainee to another practice. It is important that neither of the involved people see this as failure. The scheme will have a responsibility to keep in contact with those involved over the following few months to deal with any developments.

What not to do : Do not keep these situations to yourself. Do not think that the answer is to “sack” the trainee. Do not think the Deanery will sort this out `sometime’.

2. Health Problems

The important principle again is that you share your concern about your trainee’s health both with the trainee and your Scheme’s TPDs. You should encourage your trainee to have a personal GP who is not based within the training practice. You should document any concerns in the trainee’s ePortfolio (Educators’ Notes). Occupational health services are available for trainees and you should refer them via your scheme for an assessment if you are concerned. It may be necessary for the trainee to take sick leave from work to allow this process to happen. Where trainees lose a period of training due to illness there are now easy mechanisms for ensuring extended training is provided.

In a small number of cases the health problem will be such that it raises doubt about the safety of the doctor to practice. If you have these concerns you should share then urgently with your Scheme and also with your patch’s Deputy Director at the Deanery. The Deanery has clear mechanisms for referral to the General Medical Council. It is vitally important that you have documented your concerns in these situations (again, the place to do this is in the ePortfolio, under Educators’ Notes) as you will eventually have to provide a written report for the General Medical Council.

What not to do : Do not take on the role of becoming the trainee’s personal GP and taking over all responsibility for their health. Refer them back to their own GP.

3. The Registrar who may have committed a criminal act

As an employer you must follow employment law. All training practices should ensure that the contract that they provide for GP trainees contains sections relating to discipline and is in line with current employment law. Advice about contracts is available from the BMA. In any situation where you have concerns you should share your concerns at the earliest possible moment with your TPDs and with the Deanery. You may have to suspend the GP trainee on full pay whilst investigation is taking place.

4. The Registrar who is failing academically

The key words again come into play.

  • SHARE
  • INVOLVE
  • DOCUMENT

You must share your concerns with the trainee at the earliest possible time. Document all concerns that you have (in the trainee’s ePortfolio, under Educators’ Notes). You must involve the TPD at an early stage; they may have to involve the Deanery. If you believe it will be difficult for you to make the decision relating to signing off the Clinical Supervisor’s Report or the Educational Supervisor’s Report then you should share this concern with your TPDs at an early stage too. DO NOT FALL INTO THE TRAP OF SIGNING THE ESR/CSR IN THE HOPE AND BELIEF THAT THE DOCTOR INVOLVED IS CERTAIN TO IMPROVE IN FUTURE POSTS.

5. Unexplained absence from work

Any unexplained absence from work should trigger an attempt to contact the involved GP trainee. “Case Law” usually suggests that there is an underlying problem that has overwhelmed the involved doctor. Be supportive. If you are unable to contact the doctor or unable to undercover a significant problem communicate with your local TPDs who may involve the Deanery. Do not “sack” a GP trainee without discussing this with your TPDs first.

6. Absence from Half-Day Release (HDR)

GP Trainees vary in their attendance at half-day release. It may well be that they have identified a more effective personal method for education. They should however have discussed this with you and got your and the TPDs’ agreement. What is not acceptable is absence because they don’t feel like attending. If they are not spending the time, when they are not at half-day release, working in the surgery they are in fact acting fraudulently and action will have to be taken. They are paid to attend HDR.

I'M NOT SURE MY GP TRAINEE IS SUITED TO GENERAL PRACTICE

The Sci59 link in the ‘Resources’ section above is an online assessment tool for doctors or medical students. Once your student or trainee has answered all 130 questions, he/she will be provided with a report which states which out of fifty-nine specialties or sub-specialties he or she will be most suited to. In addition it will provide a list of the specialties the student/trainee is least suited to. The assessment report also provides a list of 12 career-related dimensions.  There is a cost implication for using the tool, however Sci59 is freely available to members of the BMA.  Otherwise some medical schools, NHS Trusts and deaneries may have paid for additional licences so it is worth finding this out.

WHERE DO I RECORD MY CONCERNS ABOUT MY GP TRAINEE?

Rule 1: DO NOT KEEP SEPARATE RECORDS DETAILING THE CONCERNS YOU HAVE ABOUT A TRAINEE.   It’s against the Data Protection Act and you will be fined!   A trainee has a right to see everything that is written about them – including emails!

Rule 2: KEEP THE TRAINEE IN THE LOOP AT ALL TIMES.  This means sharing all your concerns with them, and perhaps even documenting them together so that both of you are on the same wavelength or that subsequent dialogue can ensue.

Rule 3: DO NOT BE HOSTILE.  There’s no need for hostility.  Aim for and adult-to-adult type conversation with your trainee.   If your trainee is being defensive, it’s often because they are scared (wouldn’t you be?).   Be open and honest.  Show them that you want to do what’s right for them and get them back on track.

Rule 4: RECORDING MEETINGS AND EVENTS SHOULD GO IN THE ePORTFOLIO.  Write things in the Educators’ Notes section.   This section is open for all who have access to the trainee’s ePortfolio to see (including the trainee).  If you’re going to put something potentially emotionally upsetting in the ePortfolio – please consider writing it up in the presence of the trainee (of course, after signposting it).  There’s nothing worse than a trainee logging in and finding an unexpected comment which they also find hurtful.