Trainees in Difficulty

Jim BoddingtonHackney Trainers’ Workshop Sept 2012

1.45 Intro to session

2.00 Trainees in difficulty: strengths as weaknesses; case studies; diagnosis and resolution.

3.00 Tea

3.15 Issues affecting international medical graduates

4.15 Practicalities: when and how to act

Deanery definitionThe nationally accepted term ‘trainee in difficulty’ describes a doctor in training, who needs extra help and support - beyond that which is normally required - to deal with problem(s) that threaten to delay their completion of a postgraduate training programme.  The purpose of identifying a trainee as being ‘in difficulty’ is not to label them; it is to aid the addressing of relevant issues so that they may complete their training successfully.

In pairs

Think of a time when you have had difficulty with your own learning or training.

5

How strengths become weaknesses(Hogan and Hogan, 1997)

Strength Dysfunctional behaviour

Enthusiastic Volatile

Shrewd Mistrustful

Independent Detached

Focussed Passive-Aggressive

Confident Arrogant

Charming Manipulative

Vivacious Dramatic

Imaginative Eccentric

Diligent Perfectionist

Dutiful Dependent

Case studies• Individually, think of a trainee you have

supervised and considered to be in difficulty• In groups of 3, share your stories (preserving

confidentiality)• Choose one case to consider in detail, with a view

to an educational diagnosis• You may need to speculate about underlying

causes• Don’t engage in problem solving at this stage• Invest time in problem definition

ASSESSMENT DOMAINS

Health and home

Personality and behaviour

Organisational issues

Clinical capability

8

A model for “diagnosis”

Capacity

Learning

Arousal (Motivation)

Distraction

Alienation

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What kind of problem is it?

Type of

problem What is it?

CapacityA fundamental limitation that is unlikely to change

Learning A deficit of knowledge, skills or experience

Arousal/

Motivation

Boredom ; stress; burn-out; low morale

DistractionA problem elsewhere causing a problem here

(or illness/health problems)

AlienationDeep rooted anger/mistrust, leading to sabotage

10

Matching resolution to diagnosis

Factor What is it? Resolution

CapacityA fundamental limitation

that is unlikely to change

Change job or role

LearningA deficit of knowledge,

skills or experience

Training (adapted to learning

style); feedback (e.g 360°)

Arousal/

Motivation

Boredom ; stress; burn-

out; low morale

Coaching,

counselling,mentoring; new

project or role

DistractionA problem elsewhere

causing a problem here

Set limits; discuss referral to

appropriate source of help

Alienation

Deep rooted

anger/mistrust leading to

sabotage

Move OUT! Or ring-fence

OR “negotiated settlement”

Case studies (part 2)• Back in the same groups of 3, try applying this

scheme to your case• Clarify the educational diagnosis• What strategies might help resolve the

difficulties?• Role play: trainee, supervisor, observer

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What predicts the likelihood of change?

Do they have the “key” personality traits to help them change?

• Are they stable enough?

• Can they persevere?

Do they have insight?

• Are they psychologically minded?

• Can they reflect on their behaviour and learn from their experience?

Do they want/intend to change?

• Have they a history of successful change attempts?

• What will motivate them to change?

What kind of environment will they be working in?

• What support is available?

• What are the contextual factors that may influence their behaviour?

RECOMMENDED APPROACH

• Act early

• No surprises – involve learner

• If it isn’t written down it hasn’t happened

• Objective – fact not opinion

IMPORTANCE OF EFFECTIVE FEEDBACK

• Ask trainee’s point of view and encourage reflection

• Phrase feedback in descriptive, non-evaluative language

• Be specific not general

• Address decisions and actions rather than assumed intentions and interpretations

• Be constructive – acknowledge appropriate behaviour as well as areas for improvement