Dilemma: Borderline trainee
You are the trainer for a GP trainee whose work is borderline passable. He is the first GP trainee you have been responsible for.
You believe you should not pass him for the placement he has spent with you, but you have never had to fail a trainee before. You know this is a sensitive matter and anecdotally, you have heard that it can be very ‘messy’ for all parties.
What should you do?
Make sure the trainee is offered support in terms of clearly identifying the areas they need to work on
These decisions are always difficult and the educational supervisor (ES) may even find he is on the receiving end of anger or an emotional response from the trainee. The trainee may contest the decision taken which puts further pressure on the educational supervisor.
Nevertheless, taking the correct decision is vitally important: the ES has a responsibility to both the trainee and the public whom that doctor will serve. It is important that the decision is backed up with clear evidence and that the evidence is fully documented within the ePortfolio (ePF).
The ePF provides several different areas from a number of assessors, all of which should be used and quoted as the evidence to underpin the decision the ES makes. It is really useful to discuss the case with a colleague and preferably the trainers’ workshop. The Associate Director must be involved to both help reinforce the outcome and make sure that all appropriate avenues of support have been properly explored.
The trainee must be given the decision with sensitivity. Doctors are high performers and mostly not familiar with negative assessments. The ES should try and get a feel for the trainee’s understanding and insight as this will direct the rest of the conversation. It is not enough just to give the decision: make sure the trainee is offered support in terms of clearly identifying the areas they need to work on and how they might go about achieving this with a successful eventual outcome.
Dr Nigel de Kare-Silver is associate director for assessment and recruitment at the London Deanery and a GP in Brent.
I would hope and expect that if a trainer does not think my performance is up to scratch they would tell me - and tell me early
Being told you are not good enough is not something that as doctors we like to hear and as a trainee I am no different. I can readily bring to mind times this has happened to me and they are not pleasant memories. On reflection they have been some of the most useful experiences I have had - even though it certainly did not seem that way at the time.
As a trainee I would hope and expect that if a trainer does not think my performance is up to scratch they would tell me - and tell me early. A trainee might be justifiably upset if their assessments throughout a placement have been ‘passed’ only to find that they are ‘failed’ at the end of placement review. I think we would much rather know about our areas of weakness so that we have opportunity to work on them. I think we recognise our trainer’s duty to act if our practice is not adequate - especially in the light of recent events like at Mid-Staffs.
I think it would be reasonable for a trainee to expect their trainer to be familiar with the deanery policy on trainees on difficulty, to be in a position to discuss the action that can be taken to improve performance and to know where appropriate support can be accessed. Conversations about these things may need to take at other meetings depending on the trainee’s reaction to the initial news.
The scenario assumes that the trainee will cause a fuss about a negative outcome. It may be the opportunity the trainee needs to disclose their own concerns about their performance such as a loss of confidence, problems at home or health problems.
Dr Michael Kilshaw is an ST2, living and working in Cheltenham. He is also a ‘GP to be’ blogger on Pulse.
Put to one side any concerns you might have about the potential for the situation to become ’messy’ or personally uncomfortable
Whilst this is undoubtedly a very uncomfortable position for anyone to find themselves in, the professional responsibilities of a registered medical practitioner in such circumstances are clear. The GMC states in Good Medical Practice (2006) that: ‘18. You must be honest and objective when appraising or assessing the performance of colleagues, including locums and students. Patients will be put at risk if you describe as competent someone who has not reached or maintained a satisfactory standard of practice.’
Accordingly, you must put to one side any concerns you might have about the potential for the situation to become ’messy’ or personally uncomfortable. Remember, that if appropriate action is not taken now it may have potentially serious repercussions in the future, and is not fair to patients, colleagues, or the trainee.
As this is the first trainee you have been responsible for, you should take the opportunity to thoroughly review the situation before coming to a decision. This should include a review of the procedures you have in place, the support available to the trainee, and the documentation that has been kept. You should review the GMC’s more detailed advice at paragraphs 63 - 65 of Leadership and management for all doctors (2012) which gives further details about those involved in managing teaching and training within their organisation (including GP trainers).
You should also consider seeking advice from colleagues involved in training, and from the deanery to help inform your decision. It might also be helpful to review the material available on the RCGP website. Above all, be honest and objective in your decision-making and carefully record not only the decision itself, but the reasoning behind it. This will stand you in good stead if you are challenged at a later date.
Dr Nick Clements is head of medical services at the Medical Protection Society (MPS).