1. Saunton Sands 30.3.12

2. 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.

3. 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

4. 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) Discuss what the difficulty was (for the trainer, the trainee, the practice) How was it approached How was it approached What help was available What help was available How did it turn out How did it turn out

5. Difficulty’ can be of various types... ‘Difficulty’ can be of various types... Lack of knowledge Lack of knowledge Inability to apply knowledge in clinical GP Inability to apply knowledge in clinical GP Poor skills, especially communication Poor skills, especially communication Attitudinal issues Attitudinal issues Health issues Health issues Probity issues Probity issues

6. Main training issues: Defining level of knowledge & skill Defining level of knowledge & skill Identifying areas most lacking Identifying areas most lacking Initial education programme based on these learning needs but flexible...most immediate needs can change with time 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 Coping with complex medical problems and complex patients Living with uncertainty Living with uncertainty

7. Main issues (cont): Ensuring pt safety Ensuring pt safety Documentation – achievements & progression as well as anything not up to standard Documentation – achievements & progression as well as anything not up to standard Individualising training to maximise potential Individualising training to maximise potential Reaching conclusion re registrar’s competence...fit for independent practice? Reaching conclusion re registrar’s competence...fit for independent practice?

8. Starting off in the practice... Gather info from previous trainers & deanery, how has difficulty manifested itself Gather info from previous trainers & deanery, how has difficulty manifested itself Make registrar feel welcome & part of team (baggage of seeming to be failing) 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 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 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 V.clear ‘rules’ re feedback – make registrar aware trainer will be giving constant feedback on their performance, both good & not so good

9. Getting down to training... Main trainer has additional time (offsets more funding) Main trainer has additional time (offsets more funding) Initially all cases discussed before pt leaves – trainer’s timetable reflects this – more slots blocked Initially all cases discussed before pt leaves – trainer’s timetable reflects this – more slots blocked

10. ‘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 ‘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) Detailed checking of knowledge/understanding re medical conditions, drugs, Rx protocols, guidelines (NICE, SIGN, BHS, BTS etc) Inadequacies revealed incorporated into flexible learning plan Inadequacies revealed incorporated into flexible learning plan

11. Spot problems early & develop culture of talking about them & using them as trigger for learning needs 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 Ask registrar to keep PUNS & DENS which is shared Weekly joint surgeries & frequent viewing of video consultations – how is registrar applying knowledge & communicating Weekly joint surgeries & frequent viewing of video consultations – how is registrar applying knowledge & communicating

12. Feedback – on a daily basis Feedback – on a daily basis Make sure good work is praised as well as noting where improvement is required Make sure good work is praised as well as noting where improvement is required Substandard work or excuses for it not accepted; likewise behaviour 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 Other trainers involved in training schedule – so educational supervisor has colleagues with whom to discuss registrar’s progress

13. Documentation – be aware of & record comments & informal feedback from staff & patients 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 Training documentation – weekly log but also day to day recording of good and less good feedback eg Doctors in Difficulty.doc

14. Assessing & reaching conclusion re competence: Big responsibility – for safety of patients & future of registrar Big responsibility – for safety of patients & future of registrar Detailed documentation of training process & progress – using in-house methods & e-portfolio 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 Triangulation – gathering feedback from multiple sources – other trainers (own & other practices), other staff, pts, OOH clinical supervisors, deanery – small group leader & AD

15. Conclusion: DID training more of a challenge but for some experienced trainers this is welcomed DID training more of a challenge but for some experienced trainers this is welcomed Practice needs to be a learning environment Practice needs to be a learning environment Additional time for supervision to enable reliable assessment & complete thorough documentation Additional time for supervision to enable reliable assessment & complete thorough documentation Support from deanery Support from deanery

16. 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.