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Doctors In Difficulty Saunton Sands 30. 3. 12
What is a DID A doctor in training who, for whatever reason, is struggling to complete satisfactorily what is required of them to become an independent general medical practitioner.
Established or emerging? Have they been taken on by the trainer as a DID who isn’t succeeding elsewhere and the deanery want to re-place in a different setting, or. . . Are you the 1 st trainer to suspect they have developmental problems of some sort
Some experience already in the room. . . Break into 3 groups, each has at least 1 trainer with DIDs experience. . . Discuss what the difficulty was (for the trainer, the trainee, the practice) How was it approached What help was available How did it turn out
‘Difficulty’ can be of various types. . . Lack of knowledge Inability to apply knowledge in clinical GP Poor skills, especially communication Attitudinal issues Health issues Probity issues
Main training issues: Defining level of knowledge & skill Identifying areas most lacking Initial education programme based on these learning needs but flexible. . . most immediate needs can change with time Coping with complex medical problems and complex patients Living with uncertainty
Main issues (cont): Ensuring pt safety Documentation – achievements & progression as well as anything not up to standard Individualising training to maximise potential Reaching conclusion re registrar’s competence. . . fit for independent practice?
Starting off in the practice. . . Gather info from previous trainers & deanery, how has difficulty manifested itself Make registrar feel welcome & part of team (baggage of seeming to be failing) Induction programme – sit in with all doctors, whole practice needs to be engaged with their training Setting the scene – shared understanding of expectations & responsibilities of trainers & registrar – operate in open honest environment V. clear ‘rules’ re feedback – make registrar aware trainer will be giving constant feedback on their performance, both good & not so good
Getting down to training. . . Main trainer has additional time (offsets more funding) Initially all cases discussed before pt leaves – trainer’s timetable reflects this – more slots blocked
‘the devil’s in the detail’. . . pt discussion takes place at a different level – probing Qs to test knowledge & understanding at a deep level – seemingly superficial answers are challenged & drilled down to ensure trainer is happy with level of ability Detailed checking of knowledge/understanding re medical conditions, drugs, Rx protocols, guidelines (NICE, SIGN, BHS, BTS etc) Inadequacies revealed incorporated into flexible learning plan
Spot problems early & develop culture of talking about them & using them as trigger for learning needs Ask registrar to keep PUNS & DENS which is shared Weekly joint surgeries & frequent viewing of video consultations – how is registrar applying knowledge & communicating
Feedback – on a daily basis Make sure good work is praised as well as noting where improvement is required Substandard work or excuses for it not accepted; likewise behaviour Other trainers involved in training schedule – so educational supervisor has colleagues with whom to discuss registrar’s progress
Documentation – be aware of & record comments & informal feedback from staff & patients Training documentation – weekly log but also day to day recording of good and less good feedback eg Doctors in Difficulty. doc
Assessing & reaching conclusion re competence: Big responsibility – for safety of patients & future of registrar Detailed documentation of training process & progress – using in-house methods & e-portfolio Triangulation – gathering feedback from multiple sources – other trainers (own & other practices), other staff, pts, OOH clinical supervisors, deanery – small group leader & AD
Conclusion: DID training more of a challenge but for some experienced trainers this is welcomed Practice needs to be a learning environment Additional time for supervision to enable reliable assessment & complete thorough documentation Support from deanery
So. . If all these factors are in place it is often possible to nurture a registrar who is struggling and turn them into one who gets there in the end.