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First edn. Field Guide for Supervisors: Oxford PGMDE Apr 2013

Field Guide for Supervisors of Medical and Dental trainees working in the Oxford Postgraduate Medical & Dental Education (PGMDE) programmes (excluding training in General Practice)

Jane Siddall, Associate Dean for Educator and Faculty Development

John Derry, Director CDU and Associate Dean

Tony Jefferis, Deputy Dean

Simon Street, GP Associate Dean

Greg Simons, GP Associate Dean

Chris Morris, Associate Dean for Quality

Amit Gupta, Associate Dean for International Medical Graduates

First Edition April 2013

This edition is valid until September 2013. New editions will be online at the Oxford PGMDE website.

Health Education Thames Valley

49087 Ox PGMDE Handbook v4.indd 1 16/04/2013 09:57


This handbook has been produced using material from the Gold Guide, (4th edition, 2010)

GMC guidance (The Trainee Doctor, July 2011 and Tomorrow’s Doctors, Oct 2011)

NACT guidance (Managing the Trainee in Difficulty, 2008),

The Oxford PGMDE workshops for both Clinical and EducationalSupervisors

‘Best practice’ from Employment Tribunal experience, (August 2011).

The UK Foundation Programme Reference Guide, (July 2012).

Oxford PGMDE Policies (2012)

NHS Medical Careers website (2012)

The British Dyslexia Association (2012)

The Equality Act (2010)

This first edition will be updated with feedback from users, and whenever there is a national change of significance. The most up to date iteration will be found on the deanery’s website in the Education section.

If you have any comments about material, which you believe should be in this handbook, but is not, please email me [email protected]

Jane SiddallAssociate Dean for Educator Faculty Development


mailto:[email protected]

First edn. Field Guide for Supervisors: Oxford PGMDE Apr 2013 3

Contents

Introduction and Background ..................................................................... 4

Chapter 1: Definitions and Differences ...................................................... 6

Chapter 2: What are the ‘essential’ responsibilities of Clinical Supervisors? ..................................................................................... 8

Chapter 3: Feedback on performance ...................................................... 11

Chapter 4: The International Medical Graduate trainee ......................... 14

Chapter 5: ‘Something isn’t right’ ............................................................. 16

AppendicesA: ARCP outcomesB: Generation Y: what they expectC: The Oxford PGMDE Descriptors of BehaviourD: Adult checklist for DyslexiaE: Role of educational supervisor in the revalidation of trainees

Oxford PGMDE polices are accessible from the home page of the deanery’s website at www.oxforddeanery.nhs.uk

Policies that may be especially useful include

• Policy for approving and recognising medical and dental trainers

(covers training requirements, time, duties etc, found in the Educator

Development section)

• Equality and Diversity

• Bullying and Harassment

• IMG policy

• Less than fulltime training

• Trainee in difficulty / Supporting the Trainee

And can be found in the ‘About Oxford Deanery section’ of the website


http://www.oxforddeanery.nhs.uk


IntroductionForward by Postgraduate Dean:“The expectations on those who undertake roles in medical and dental education have increased significantly in the last few years. There is now a requirement for us to properly induct, plan, assess, deliver specific curriculum objectives and vitally, record many aspects of doctors/dentists’ performance during their training. There is abundant evidence that well-trained and supported clinicians work safely; those who are not supported in this manner are more likely to be involved in adverse events which may damage their professional standing, the reputation of the department, Trust or training programme as well as result in harm to patients.

I am delighted that our team of Associate Deans have produced this field guide for trainers in medical and dental practice across our patch. It is intended to be a ‘Quick Look Book’ to help busy clinical and educational supervisors navigate through an increasingly complex training landscape. It is not, however, a replacement for training in effective supervision.”

Dr Michael BannonPostgraduate Dean

Background

There are comprehensive national frameworks for Foundation, General Practice and Specialty Trainees, and local PGMDE policies, which can be accessed on the internet. Most, if not all, can be seen by visiting the deanery’s website at www.oxforddeanery.nhs.uk and clicking on the relevant school tab. The new Foundation handbook can be downloaded from the Foundation Programme NHS website at http://www.foundationprogramme.nhs.uk

Why is training (and support) for trainers important?

During 2012 the GMC opened a consultation on the recognition and approval of non-GP trainers. The outcome of the consultation was published in August 2012 as the GMC ‘Approving and Recognising Trainers: the Implementation Plan’. Trainers must have training, and have been updated as required under the PGMDE’s policy for Approving and Recognising Medical and Dental trainers.

The GMC plan relates to:

• Named educational supervisors in postgraduate training

• Named clinical supervisors in postgraduate training

• Lead co-ordinators of undergraduate training at each local education provider

• Doctors responsible for overseeing students’ educational progress for each medical school.



http://www.foundationprogramme.nhs.uk


Other doctors whose practice contributes to the teaching, training or supervision of students or trainee doctors, on a more sessional or occasional basis, such as senior trainees and most specialty doctors who observe practice are not included in the GMC plan, but the PGMDE has commissioned training in supervision for such staff.

The GMC trainer standards

The GMC already has existing standards for postgraduate training set outin The Trainee Doctor (in section 6 of the 2011 publication) and forundergraduate education in Tomorrow’s Doctors. These address

• The differing levels of supervision trainees require during the entire postgraduate training programme, (6.29 to 6.31)

• The expectation that the Postgraduate Medical education team will support the trainer and that job plans will factor time for the trainer to facilitate trainee development (6.32-6.36)

• The expectation that trainers understand the structure and purpose of the training programme, and their role in training (6/38- 6.39)

• And for GP training, section 6.37 stipulates that GP trainers must be trained and selected in accordance with the Medical Act 1983.


http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors_2009.asp

http://www.gmc-uk.org/Trainee_Doctor.pdf_39274940.pdf


Chapter 1

Definitions and Differences

Definitions

The GMC has defined the roles of both clinical and educationalsupervisors, which are:

Named clinical supervisor: a trainer who is responsible for overseeing a specified trainee’s clinical work for a placement in a clinical environment and is appropriately trained to do so. He or she will provide constructive feedback during that placement, and inform the decision about whether the trainee should progress to the next stage of their training at the end of that placement and/or series of placements.

Named educational supervisor: a trainer who is selected and appropriately trained to be responsible for the overall supervision and management of a trainee’s trajectory of learning and educational progress during a placement and/or series of placements. Every trainee must have a named educational supervisor. The educational supervisor’s role is to help the trainee to plan their training and achieve agreed learning outcomes. He or she is responsible for the educational agreement and for bringing together all relevant evidence to form a summative judgement at the end of the placement and/or series of placements.

It is expected that educational supervisors should have all the attributesexpected of trained clinical supervisors. Being an educational supervisordoes not necessarily preclude a trainer from having any other educationalrole, and is it desirable for senior educators to be active educationalsupervisors.

PGMDE definitions of other key supervisors are:Academic supervisors are responsible to help the trainee to plan their research activity and achieve agreed outcomes. Even if he or she has a clinical contract, they should not normally be the trainee’s educational or clinical supervisor. He or she is required to provide an annual report on a trainee for the ARCP panel.

A sessional supervisor is a clinician who supervises a trainee for individual sessions, and who may be required to provide formal assessment and feedback on the trainee to their clinical, or educational, supervisor.



The table below, adapted from the Oxford PGMDE Clinical Supervisortraining workshop and RCPsych Handbook for Trainers, summarises thedifferences between clinical and educational supervisors:

The table below, adapted from the Oxford PGMDE Clinical Supervisor training workshop and RCPsych Handbook for Trainers, summarises the differences between clinical and educational supervisors:

Clinical supervisor Attribute Educational supervisor

Operational Vision Strategic

Clinical Experience Depth and breadth

Work place based assessments

(Including feedback on performance)

Assessment Educational/ behavioural (e.g.

multisource feedback)

Clinical competence Curriculum All competencies (i.e.clinical and professional behaviours)

Trainer and apprentice

(To include equal opportunity and diversity

awareness and awareness of ‘trainee in

difficulty’)

Relationship with trainee

Mentor or coach

(To include equal opportunity and diversity

awareness and awareness of ‘trainee in

difficulty’)

Skills, knowledge andexperience

Evidence Portfolio of training progress

Specified and defined(may include advice on suitable courses/ study

leave)

Guidance Broad and generic (may include advice on suitable

courses/ study leave)

First edn. Field Guide for Supervisors: Oxford Deanery Jan 2013 7



Chapter 2

What are the ‘essential’ responsibilities of Clinical Supervisors?

It is important to make early contact with the trainees allocated to you, ideally face to face, but if not, by email to arrange a meeting. A suggested algorithm is at the end of this chapter.

It is important that CSs inform a trainee’s Educational Supervisor of anything which is noteworthy, but should include involvement in Serious Incidents, complaints from patients and health / probity issues (see Chapter 4) as these events are noted at ARCP and inform the revalidation process.

Your knowledge of the curriculum

As a clinical supervisor (CS), one is not expected to produce the annual assessment report for the ARCP, but a CS should know what skills the trainee should develop, or acquire, during the phase of training with you. This should be available on your Royal College website.

CSs do not personally have to sign off every workplace-based assessment, but it is good practice for a proportion to be completed by a consultant. Some colleges require the final one confirming independent competence for a procedure to be signed by a consultant.

Whilst a clinical supervisor will not be suggesting the likely outcome of the ARCP to a trainee (this is the responsibility of the Educational Supervisor), it is worth being aware of the possible outcomes and what the trainee needs to achieve (See Appendix A for detail on forms and ARCP outcomes).

The e-portfolio

All foundation trainees use an electronic portfolio, and increasingly, trainees in all specialties are being registered through the Royal Colleges. Each specialty has a slightly different set of sections to be completed by trainees and their assessors, which is outside the scope of this handbook. However, your local College / Specialty Tutor should have a good understanding of your eportfolio system, or there may be a member of your School Board who has been charged with ensuring consultants know how to navigate the system. Your specialty Head of School may organise formal training on eportfolio from time to time.



Work place based assessments (WPBAs)All trainees are required to demonstrate their acquisition of relevant clinical skills and behaviours in a structured manner, as described in the relevant specialty curriculum. A clinical supervisor is expected to facilitate this process by aiding learning using WPBA tools formatively, to give constructive feedback on performance and advice on how to improve further, and summatively, when a trainee is observed carrying out the procedure or consultation independently.

There are three steps in the assessment process:

• Evidence by observation of trainee, e.g. ‘I see evidence of your findings’

• Relevance by explanation, e.g. ‘if you don’t record your findings, no-one else will know what you did’

• Competence by evaluation, e.g. ‘these notes do not contain enough information’

And finally, giving feedback to trainee.

What sorts of work place based assessments are there and how can they be fitted into my job plan?

Fundamentally, there are three types of activity that trainees undertake where a more senior clinician should observe practice, and feedback to the trainee, using forms delivered by the Foundation Programme or relevant medical Royal College. The forms can be found in the relevant specialty eportfolio and / or college website.

These are:

• One where the trainee carries out a practical procedure, such as a cannulation, insertion of a chest drain or a hysterectomy (DOPs, OSATS or other acronyms, dependent upon specialty).

• Mini clinical examinations, where the trainee is observed for part of a consultation with a patient. The focus for assessment may be one of: the presentation of the patient’s history, the taking of a history, the examination, proposed management and explanation of investigations.

• Case-based discussions, where the trainee may discuss a real case, or a condition which is rare, but of which the specialty curriculum demands evidence of at least some supervised discussion (such as a pregnant woman with cystic fibrosis).

The first two activities can usually be easily accommodated ‘on the job’ in theatres, on ward rounds, and occasionally in clinic consultations. Casebased discussions will need some time setting aside, but it is possible to pool resources and invite other trainees and run an interactive and discursive tutorial session. These could time tabled for a number of afternoons a year within the teaching timetable, with one or two supervisors leading each session.


A suggested flow chart for clinical supervisors supporting all trainees is shown below:

At the start of the post • Invite trainee to have a conversation about their clinical training to date.

The meeting should take place within the first two weeks of the trainee taking up the post. Invite them to show you their log of work place based assessments.

• Ideally undertake WPBAs electronically uploading to the trainee’s eportfolio in real-time. If this is not possible, keep a copy of the paper documents in a secure filing cabinet just in case the trainee loses their copy.

• Identify clinical skills training goals.

• Ensure that the trainee knows what material should be collated for the period of training you are supervising.

• Invite the trainee to make regular, informal contact with you.

Regularly • Share good and positive feedback from colleagues, as well as any issues of

concern.

• If there are specific issues or targets to be addressed, write to educational supervisor and other colleagues as necessary. Copy the trainee in to this letter. This applies to good trainees just as much as those with emerging issues.

Pre ARCP assessment (month 10) • Advise trainee to collate all evidence six to eight weeks before ARCP

scheduled.

• Ensure that you have provided written evidence of any outstanding practice, or concerns, to the ES. This might include written material from patients, complaints, cases reviewed through clinical governance (good or bad care / outcomes).

• Ideally, trainee will have all necessary material for summative assessment to be made (sufficient WPBA, mini Cex, CbDs, TO1s) and ‘annual assessment review’ to be written by educational supervisor. Trainee should submit papers or eportfolio of evidence to programme manager at least two weeks before ARCP.

It is best practice to (i) Keep copies of invitations sent to trainee by using

‘read receipts’ on email (ii) Sign all entries made by yourself into any trainee’s

eportfolio

10 First edn. Field Guide for Supervisors: Oxford Deanery Jan 2013First edn. Field Guide for Supervisors: Oxford PGMDE Apr 201310

A suggested flow chart for clinical supervisors supporting alltrainees is shown below:

It is best practice to(i) Keep copies of invitations sent to trainee by using ‘read

receipts’ on email(ii) Sign all entries made by yourself into any trainee’s eportfolio


A suggested flow chart for clinical supervisors supporting all trainees is shown below:

At the start of the post • Invite trainee to have a conversation about their clinical training to date.

The meeting should take place within the first two weeks of the trainee taking up the post. Invite them to show you their log of work place based assessments.

• Ideally undertake WPBAs electronically uploading to the trainee’s eportfolio in real-time. If this is not possible, keep a copy of the paper documents in a secure filing cabinet just in case the trainee loses their copy.

• Identify clinical skills training goals.

• Ensure that the trainee knows what material should be collated for the period of training you are supervising.

• Invite the trainee to make regular, informal contact with you.

Regularly • Share good and positive feedback from colleagues, as well as any issues of

concern.

• If there are specific issues or targets to be addressed, write to educational supervisor and other colleagues as necessary. Copy the trainee in to this letter. This applies to good trainees just as much as those with emerging issues.

Pre ARCP assessment (month 10) • Advise trainee to collate all evidence six to eight weeks before ARCP

scheduled.

• Ensure that you have provided written evidence of any outstanding practice, or concerns, to the ES. This might include written material from patients, complaints, cases reviewed through clinical governance (good or bad care / outcomes).

• Ideally, trainee will have all necessary material for summative assessment to be made (sufficient WPBA, mini Cex, CbDs, TO1s) and ‘annual assessment review’ to be written by educational supervisor. Trainee should submit papers or eportfolio of evidence to programme manager at least two weeks before ARCP.

It is best practice to (i) Keep copies of invitations sent to trainee by using

‘read receipts’ on email (ii) Sign all entries made by yourself into any trainee’s

eportfolio

10 First edn. Field Guide for Supervisors: Oxford Deanery Jan 2013First edn. Field Guide for Supervisors: Oxford PGMDE Apr 2013 11

Chapter 3Feedback on performance

What is effective feedback?

‘Information about a performance or behaviour which leads to action to affirm, or develop, that performance or behaviour’.

Ideally, feedback should be given close in time to the event, and should be in a private setting (particularly if behaviour modification is mooted). It should also be clear; avoid sandwiching the bit which needs improvement between two nuggets of praise as the trainee will miss hearing the awful bit.

Feedback should increase the trainee’s insight and motivate them to either continue (or modify if necessary) their practice or behaviours. It is helpful to have a benchmark the level expected of the trainee. However, if the goal is perceived to be unrealistic, trainee motivation will drop off. Thus, feedback needs to be offered using the Norcini and Burch (2007) headings:

S specific N non-judgemental B balanced P promotes reflection T timely

For example, you have just observed a consultation between a patient with recurrent episodes of cramping abdominal pain and a trainee, where the patient mentioned a fear that the pain may be a symptom of cancer, and alluded to a relative having been diagnosed with colon cancer a few years earlier. The trainee did not pick up on this thread of concern, simply suggesting that a colonoscopy would be a useful investigation. As a clinical supervisor, you might open the feedback conversation with, ‘What do you think was the patient’s greatest concern today?’

If you are checking a set of notes where the trainee has failed to record important negative findings during an examination, for example there being no weakness in the limbs of an elderly patient admitted following a collapse at home, the feedback should not be ’these notes are useless’, but something along the lines of ‘it is really valuable to state that she did not have any weakness on admission, so that the team on duty overnight will be aware of a deterioration if this develops’.

It can also be tricky to give feedback to a trainee who is doing well, but finding something to gently challenge them is educational in a way that the report ’well you obviously can do that OK’ is not. In these circumstances, open questions such as ‘is there anything you would do differently next time?’ or ‘have you considered…’ , or ‘what would you like to do to make this even better?’ might open a conversation up.



Other phrases, which could be helpful in a debriefing episode, might include:

What was going well?What ELSE was going well?Was there anything you found difficult/ what were the difficulties?Are there any skills you think need more development?What were you thinking whilst this was all going on? (Might be useful afterdealing with an emergency situation)What were you feeling?What would be the best role for you in that situation?What would you do next time?What else needs to happen?

The Johari Window (Joe Luft and Harry Ingram, 1955)

This tool was initially developed for self help groups, but is commonlyused for examining personal effectiveness. The factors are: selfdisclosure,openness to feedback and perceptiveness.

And with a shared dialogue the windowpanes change size

It may be worth remembering that even experienced supervisors can find it challenging to give positive feedback to learners. Frequently, there is a mismatch between teachers’ and learners’ perceptions of the adequacy and effectiveness of feedback.(Ramani S and Krakov SK, Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher, 2012;34: 787-791)

Other phrases, which could be helpful in a debriefing episode, might include:

What was going well?What ELSE was going well?Was there anything you found difficult/ what were the difficulties?Are there any skills you think need more development?What were you thinking whilst this was all going on? (Might be useful after dealing with an emergency situation)What were you feeling?What would be the best role for you in that situation?What would you do next time?What else needs to happen?

The Johari Window (Joe Luft and Harry Ingram, 1955)

This tool was initially developed for self help groups, but is commonly used for examining personal effectiveness. The factors are: self-disclosure, openness to feedback and perceptiveness.

And with a shared dialogue the windowpanes change size

It may be worth remembering that even experienced supervisors can find it challenging to give positive feedback to learners. Frequently, there is a mismatch between teachers’ and learners’ perceptions of the adequacy and effectiveness of feedback. (Ramani S and Krakov SK, Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher, 2012;34: 787-791)

12 First edn. Field Guide for Supervisors: Oxford Deanery Jan 2013



Effective or ineffective feedback?Effective or ineffective feedback?

Effective Ineffective

Good performance

Celebratory Baffled or puzzled

Performance improvement needed

A hand up Dejected




Chapter 4

The International Medical Graduate trainee

International medical graduates constitute 32% of the medical workforce with more than one-in-three hospital doctors and one-in-five general practitioners having qualified overseas.

Studies have shown that this group of doctors perceive discrimination, which may be subtle, or overt. This can be due to a limited opportunity to train in a certain part of the UK, entering the specialty at a more junior level than they had worked at before arriving in the UK, and lack of familiarity with assessment and career progression in the NHS. (Chen P, Nunez-smith M, Bernheim SM, Berg D et al, Professional experiences of International Medical Graduates Practising primary care in the United States, 2010; J Gen Intern Med 25 (9): 947-953 )

In addition, many of these doctors have become voluntarily separated from family and friends in order to gain UK training experience, and may not have a geographically local network of contacts from their country of origin.

Induction programme

IMGs should attend the Trust run Induction Programme, normally on the first day or two days at the start of the new appointments (in the first week of August or February). Attendance at this is compulsory, as it will provide all the vital local information about working in any particular Trust.

Support

The BMA have published a very useful document entitled: “Working and Training in the United Kingdom National Health Service - a guide for International Medical Graduates (IMGs)”, available through its website.

The PGMDE Associate Dean for Overseas Doctors (IMGs), Dr Amit Gupta, has responsibility for matters specific to doctors who have qualified outside the UK, whether in the EEA countries or elsewhere, or whose nationality does not allow automatic right of permanent residence in the UK. These include:

• Guidance regarding visa status • Career guidance in relation to overseas status • Advice in connection with training and non-training posts • Assistance with the Medical Training Initiative Scheme • Provision of induction for IMGs • Advice to doctors enquiring from overseas about postgraduate training • Support for refugee and asylum-seeking doctors in the Oxford area



Both IMGs and their supervisors can contact Dr. Amit Gupta, the AssociateDean for IMGs through the PGMDE for specific advice [email protected]

The CDU can also help with mentoring and confidential coaching fordoctors who for whatever reason finds they are in personal or careerdifficulty. The CDU can be contacted on [email protected].





Chapter 5

‘Something isn’t right’

Concerns over performance during training

Concerns about a doctor’s performance during training arise more commonly than one might expect, and educators are often not sure what to do. Some doctors will have periods where their performance ‘slips’ from a previous high standard, and some doctors exhibit challenging behaviours from the beginning of a training placement. Factors both inside and outside work may be at play. These factors can include:

The symptoms may manifest as:

• Absenteeism: o Arriving late o Leaving early o Not answering bleep • Presenteeism o Arriving very early o Staying behind to finish work regularly o Volunteering for every task and project but not completing them

Chapter 5

‘Something isn’t right’ Concerns over performance during training Concerns about a doctor’s performance during training arise more commonly than one might expect, and educators are often not sure what to do. Some doctors will have periods where their performance ‘slips’ from a previous high standard, and some doctors exhibit challenging behaviours from the beginning of a training placement. Factors both inside and outside work may be at play. These factors can include:

Situations The ‘8 Bs’ mnemonic Relationships These could be new ones, or

failing ones, could include weddings, or professional problems (bullying /harassment)

‘Birds and blokes’ ‘Bosses’

Family pressures Parental expectation Fertility issues New parenthood

‘Babies’

Financial pressures May be doing locum shifts ‘Broke’ Loss or separation Lack of a local supportive

network Lack of cultural reference points Death of a family member or other close friend

Being bi-lingual’ ' ‘Bereavement’

Exam pressures May impede training progress

‘Books’

Substance dependency Prescription drugs, especially analgesics, non prescription drugs and alcohol

‘Booze’

The symptoms may manifest as:

• Absenteeism: o Arriving late o Leaving early o Not answering bleep

• Presenteeism o Arriving very early o Staying behind to finish work regularly o Volunteering for every task and project but not completing

them


• Lack of rapport with peerso Nurseso Colleagues at same levelo Junior or student colleagues

• Higher incidence of name appearing in grumbles, formal complaints or case reviews than peers

• Poor attention to paperworko Reviewing patient’s results and following them upo Uneven accrual of WPBAso Failure to register with NHS e-portfolio

Behaviours

It is helpful to characterise behaviours using the seven domains of Good Medical Practice:

Good clinical care, Maintaining good medical practice, Relationship with patients, Working with colleagues, Teaching and training, Probity, and Health.

A detailed appendix describing incompetence, competence and performance descriptors (appendix C) is included at the end of this handbook, and should be referred to regularly.

Personality as a factor

Human beings do not all perform in the same way, nor do we perceive things similarly. At times of stress, previous strengths may become over-exaggerated and metamorphose into weaknesses, or ‘difficult’ behaviours.

Enthusiastic Volatile

Shrewd Mistrustful

Careful Cautious

Independent Detached

Confident Arrogant

Focused Passive-aggressive

Charming Manipulative

Vivacious Dramatic

Imaginative Eccentric

Diligent Perfectionist

Dutiful Dependent




• Lack of rapport with peers o Nurses o Colleagues at same level o Junior or student colleagues • Higher incidence of name appearing in grumbles, formal complaints or

case reviews than peers • Poor attention to paperwork o Reviewing patient’s results and following them up o Uneven accrual of WPBAs o Failure to register with NHS e-portfolio

Behaviours


• Good clinical care, • Maintaining good medical practice, • Relationship with patients, • Working with colleagues, • Teaching and training, • Probity, and • Health.



Human beings do not all perform in the same way, nor do we perceive things similarly. At times of stress, previous strengths may become overexaggerated and metamorphose into weaknesses, or ‘difficult’ behaviours.

• Lack of rapport with peerso Nurseso Colleagues at same levelo Junior or student colleagues

• Higher incidence of name appearing in grumbles, formal complaints or case reviews than peers

• Poor attention to paperworko Reviewing patient’s results and following them upo Uneven accrual of WPBAso Failure to register with NHS e-portfolio

Behaviours


Good clinical care, Maintaining good medical practice, Relationship with patients, Working with colleagues, Teaching and training, Probity, and Health.



Human beings do not all perform in the same way, nor do we perceive things similarly. At times of stress, previous strengths may become over-exaggerated and metamorphose into weaknesses, or ‘difficult’ behaviours.

Enthusiastic Volatile

Shrewd Mistrustful

Careful Cautious

Independent Detached

Confident Arrogant

Focused Passive-aggressive

Charming Manipulative

Vivacious Dramatic

Imaginative Eccentric

Diligent Perfectionist

Dutiful Dependent




The Oxford PGMDE policy for supporting trainees about whom there are concerns over performance during training can be seen on the deanery’s website.

Although the term “Trainee in Difficulty” has been used commonly as shorthand, the deanery recognises that such labelling of individual trainees is often unhelpful. The Gold Guide refers to “managing concerns over performance during training” (see paragraphs 8.19-8.35, Gold Guide Fourth Edition, 2010), and the deanery’s policy has been revised to set out how trainees should be supported where there are such concerns.

NACT (UK) (the National Association of Clinical Tutors) has published a useful guide, updated in July 2012, ‘Managing Trainees in Difficulty: Practical Advice for Educational and Clinical Supervisors’, which outlines the relationships between employers, Deaneries and the GMC in such circumstances. It can be downloaded from the NACT website athttp://www.nact.org.uk/documents.

Training workshops are hosted by the deanery and are delivered in each Trust on an annual basis. Please see the website for details of dates and venues. Any supervisor can attend a session at other Trusts; subject to local study leave procedures.

It should be evident that where there are concerns about atrainee’s performance in training, or achievement ofcompetencies, there should be more frequent reviews of progressthan the ‘minimum’ set out by the medical royal colleges.

Clinical or educational supervisors may need assistance from College Tutors, Training Programme Directors or School Board officers. If in any doubt it is prudent to seek early confidential advice. The PGMDE Career Development Unit (CDU) can provide educators with advice about the appropriate steps to take in managing concerns about trainee performance, as well as personal coaching and mentoring support for individual trainees. Further information is available from the CDU website at www.oxforddeanerycdu.org.uk/index.html.

Issues that are related to patient safety should be discussed with the Director of Medical Education and / or the Medical Director of your own Trust.

Equality and diversity

It is important for clinical supervisors, educational supervisors, College Tutors, Training Programme Directors and School Board officers to treat all trainees equally and without discrimination. This is of particular importance when the trainee’s problems begin to impact on their performance, as less than equal treatment might be alleged through either PGMDE appeals panels or even Employment Tribunals. The same standards of communication and support to all trainees should be applied from the outset. An electronic file is recommended for every trainee with whom you have any dealings, password protected of


http://www.nact.org.uk/documents

http://www.oxforddeanerycdu.org.uk/index.html


course, and any paper material should be kept securely under lock and key.

The Oxford PGMDE policy can be viewed on the website.

Harassment

Harassment can take various forms and may be directed against males or females, ethnic minorities or subgroups, towards people because of their age, sexual orientation, physical or mental disability, or some other characteristic.

It may involve action, behaviour, comment or physical contact which is found to be objectionable by the recipient or which causes offence and can result in the recipient feeling threatened, humiliated, patronised or isolated. It can also create an intimidating work environment. Individual perceptions about certain types of behaviour will vary, so what is acceptable for one person, may be inappropriate or unacceptable behaviour to another.

Harassment may be persistent or occur on a single occasion. It may be intentional or unintentional on the part of the perpetrator, but it is the impact of the behaviour on the recipient, and the deed itself, which constitutes harassment.

As before, this policy can be viewed on the deanery’s website.

Concerns about health

If there are any concerns about an individual’s health affecting training, the doctor should be encouraged to see their own GP. If there is a possibility that a doctor’s health may be affecting their work, then the employer may ask for an occupational health assessment. Further information and guidance is available from the CDU website and from NCAS at http://www.ncas.nhs.uk/resources/handling-healthconcerns/

Dyslexia in relation to Postgraduate Medical and Dental Education and Training

Dyslexia is one of a group of conditions called Specific Learning Difficulties in Adults, which also includes Dyspraxia or Development Co-ordination Disorder, Dyscalculia, and Attention Deficit Disorder. Further information about these is available on the British Dyslexia Association website – see http://www.bdadyslexia.org.uk/about-dyslexia. Hereafter in these notes the term “dyslexia” will be used to refer to all the Specific Learning Difficulties in Adults.

Specific information about dealing with dyslexia in postgraduate medical and dental education and training is hard to find. There is useful information on the BMA website produced by the BMA Medical Students Committee – see http://bma.org.uk/developing-your-career/studyingmedicine/common-challenges-while-studying/studying-with-dyslexiabut this does not refer to what happens after qualification.



The GMC website includes references to dyslexia under its Gatewaysguidance – see http://www.gmcuk.org/education/undergraduate/gateways_guidance.asp for general information about this guidance. In summary:

• GMC Gateways guidance • This advisory guidance is aimed primarily at medical schools. It will also

interest organisations involved in postgraduate medical training and many individuals, including disabled doctors, students and potential students.

• It provides practical suggestions to help schools ensure that disabled students do not face unnecessary barriers to successful medical careers.

• The advisory guidance originally resulted from a partnership led by the GMC and financially supported by 11 medical schools. Matched funding was provided through Gateways to the Professions, set up by the Department for Education and Skills (England), as it then was. The guidance has been revised to take account of developments including the 2009 edition of Tomorrow’s Doctors and the Equality Act 2010.

• The guidance does not lay down new requirements, quality assurance standards or ‘policies’ from the GMC or any of the other organisations involved.

• Section 4.2 of the guidance covers the legal definition of ‘a disabled person’ (copied from GMC guidance – the emphasis is added):

The Equality Act 2010 defines a disabled person as:

‘A person (P) has a disability if P has a physical or mental impairment which has a: • Long-term and • Substantial adverse effect on P’s ability to carry out normal day-today

activities.’

As this is a legal definition, it is ultimately for a court or tribunal to determine to whom it applies. Where there is doubt about whether an individual will be covered, it is best practice to assume that they will be and focus on identifying reasonable adjustments that will assist them.

The effect of an impairment is long-term if: • It has lasted for at least 12 months • It is likely to last for at least 12 months or • It is likely to last for the rest of the life of the person affected. • A ‘substantial’ adverse effect is defined in the Act as one that is

‘more than minor or trivial’.


http://www.gmcuk.org/education/undergraduate/gateways_


• Medical schools, postgraduate deaneries and employers should use this definition when considering how to assess and support disabled applicants, students and employees. They should also encourage a greater understanding of who is protected by the Act, and seek to protect the rights of disabled people in their use of all the services at university and medical school.

• People with a range of impairments and long-term health conditions are included in this definition, such as people who are hard of hearing or have mental health issues, multiple sclerosis, cancer or HIV. Importantly, others who would not usually describe themselves as disabled people, such as those with dyslexia, may be protected by the Act if the effects of the impairment are ‘long term’ ‘adverse’ and ‘substantial’ on normal day-today activities. People with hidden disabilities such as epilepsy are also covered.

• It is not clear from the above to what extent The Equality Act 2010 places any obligation on postgraduate deaneries in relation to doctors and dentists in training that have diagnosed or suspected dyslexia. There are certainly obligations under the Act for the employers of doctors and dentists in training.

• There is most useful and comprehensive guidance for employers on the British Dyslexia Association website (see http://www.bdadyslexia.org.uk/about-dyslexia/adults-andbusiness. html). For example, there is:

• An Adult Dyslexia Checklist which can be used as a screening tool for adult dyslexia – see http://www.bdadyslexia.org.uk/files/Adult%20Checklist.pdf This test is said to be 90% accurate in predicting dyslexia.

Some relevant text copied from the BDA guidance follows:

o There is no legal requirement to disclose a disability. However once the employer has been informed of an employee’s dyslexia or been given a copy of an assessment report, they are on notice that they have a duty under the Equality Act.

o Disciplinary proceedings around performance issues are frequently dyslexia related. Many are off sick with stress as a result. In many circumstances they could seek redress under the Equality Act in an Employment Tribunal.

o Assessment. Where an employee has not been previously assessed for dyslexic difficulties (post 16 years), the first step would be for the employer to arrange for the employee to have a full diagnostic assessment:


http://www.bdadyslexia.org.uk/about-dyslexia/adults-andbusiness

http://www.bdadyslexia.org.uk/files/Adult%20Checklist.pdf


• This should by carried out by a Chartered Psychologist specialising in adult dyslexia. The cost could be around £500 or more.

• However in the case of a job not involving significant paperwork, a screening test such as the one linked to our website may be sufficient. This test is 90% accurate in predicting dyslexia.

• Most large employers and those in the public sector would be expected to fund a dyslexia assessment for an employee as part of their duty under the Equality Act. A small employer may help with the cost. For recommendations of appropriate psychologists for a diagnostic assessment, contact your nearest Local Dyslexia Association.

Workplace Need Assessment for doctors with dyslexia

Following the diagnostic assessment, (or where an employee is able to show an existing adult assessment report), a workplace needs assessment should be arranged with a dyslexia specialist. This will detail the most appropriate accommodations and support, (reasonable adjustments) which would be successful in mitigating any weak areas and reduce stress. This is not something that either the individual or the employer would be able to work out for himself or herself.

Workplace needs assessments can normally be obtained from Access toWork, part of the Jobcentre organisation.

• The application to Access to Work should be made by the employee. For information on this process see Dyslexia Support in the Workplace.

• Independent dyslexia workplace consultants can also be appointed to do an assessment. Their report can still be submitted to Access to Work for the grant to the individual for items and training recommended.

Implementing Reasonable Adjustments.

Reasonable Adjustments should be put in place as soon as possible.Failure to implement Reasonable Adjustments would be a breach of theEquality Act. Reasonable Adjustments are not a quick overnight remedy.Depending on the individual circumstances, it may take 2 or 3 months formeasures to become embedded and for any associated training andlearning to become effective.



External sources of support for trainees

There are a number of well-regarded external sources of support, and it isstrongly recommended that supervisors direct trainees to them and do nottry to act as, for example, marriage guidance counsellors, or ‘doctors’ totheir trainees.

The agencies which may be suitable include:

Medic Support Funded by the Oxford PGMDE to provide a free and confidential counselling service for doctors and dentists in training. See http://www.oxforddeanerycdu.org.uk/health/help_for_trainees/medic_support.html

The CDU See the CDU website for more information

‘Doctors for Doctors’ A BMA service for medical students and qualified doctors. Contact on 08459 200169


http://www.oxforddeanerycdu.org.uk/health/help_for_


Appendix A: Forms usually collated by the Educational Supervisor and ARCP outcomes

These are described in detail in ‘The Gold Guide’. Increasingly these forms are lodged in the specialty eportfolio. Both trainee and Educational Supervisor normally have access to the same site: other assessors may be invited by the trainee sending an ‘e ticket’ to login.

The Educational Agreement (EA)

Both the trainee and their Educational Supervisor at the start of each year of training should sign it. The form looks like this:

The Trainee’s Personal Development Plan (PDP)

This should be written by the trainee at the start of the training year, andreviewed after each assessment, as a minimum (due at 4, 8 and 11+ months)

The Annual Assessment Review Form (AARF)

This document forms the summative assessment of a trainee’s progress during the preceding year and is an integral part of the evidence required for the ARCP panel review. It will include the domains laid out by theGMC:

Good clinical careDeveloping and maintaining good medical practice


Working with colleaguesTeaching and trainingProbityHealth

and attributes / targets required by the specialty curriculum, including an overview of progress and all the work place based assessments. Confirmation that an audit has been completed, evidence of reflective learning and, from 2013, reporting of the trainee’s involvement in complaints or critical incidents are usually required fields on these forms.

An example of such a form is shown below (note TO2 is the abbreviation for multisource feedback used by the example specialty)




Action Plans / Improvement Plans These are formulated to address any concerns about the trainee’s performance, should be agreed and documented between the educational supervisor and trainee. This is effectively what we call a Professional Improvement Plan (PIP) in the PGMDE ‘Supporting the Trainee Protocol’. ARCP outcomes Outcome 1 The trainee has achieved all the required technical and

educational targets set for the period of training under review

Outcome 2 The trainee has almost achieved the targets set, and does not need to have the CCT date delayed. This may be a small shortfall in WPBA numbers. Exam failure may be such a target, unless the trainee is at a point in training where continued progress demands exam success.

Outcome 3 This trainee has not achieved the training targets set for the period of training and will need more time in programme to achieve these targets.

Outcome 4 This trainee is leaving the programme, either with the required targets having been achieved, or without. Some trainees choose to leave the specialty because it was the ‘wrong’ choice for them, others leave because their training time has already been prolonged by the maximum of two additional years, but has still not achieved the educational targets required to progress further.

Outcome 5 This trainee has not submitted the required evidence of training to the ARCP panel and a decision on their progress cannot be made. This trainee is expected to produce the necessary evidence within two weeks of the date of the ARCP.

Outcome 6 This trainee has completed the entire specialty training programme and can apply for the CCT

Outcome 7 This prefix is used for trainees in LAT or FTSTA posts. The suffix is .1, .2, .3 as above.

Outcome 8 This trainee is currently ‘out of programme’. This may be for research, specific clinical experience elsewhere, or as a career break.


Appendix B: Expectations of generation Y

This has been taken from the Medical Careers pages of the NHS Medical Careers website.

People born between 1946 and 1964 are often described as ‘baby boomers’, those between 1965 and 1981 as ‘generation X’ and those after 1981 as ‘generation Y’. Whilst these terms are American, the expectationsand experiences of the groups are transferable to the UK. The demographic groups have different expectations and values when compared to each other.

There have been several recent studies that have looked into the differences in attitude between generations and how this relates to the working environment. These studies do not relate strictly to medicine; however they are relevant as they are valid in any working environment. This article focuses on the attitudes of Generation Y as today the majority of medical trainees fall into this category.

One recent study is the ‘Gen Up’ report, published in September 2008, which is a joint survey report commissioned by the CIPD and Penna. This study surveyed over 5,500 employees across 6 Western European countries.The ‘Gen Up’ report compares attitudes between the above four generations under the following headings:

• Retention and loyaltyAccording the report ‘Gen X and Y may ‘demand’ more flexible hours and are less likely to take a long term career view with the organisation’. However, ‘nearly half of Gen Y intend to be with their current employer in five years time and one in four expects to change jobs every two to three years.... So the commonly held belief that Gen Y is easy to recruit, hard to retain may not be strictly true.’

• Driving Customer Service‘Gen Y is more positive about service being recognised than other generations’, although ‘16% of Gen Y are not at all interested in customer service being part of their role.’

• Performance Management‘Gen Y is much less tolerant of under-performance. Nearly one in five Gen Ys believe that the best solution for under-performance is for someone to be fired’.

• Mobile and Flexible Working‘As a generation, Gen Y are the first to truly adopt technology to manage their life/work balance as the boundaries of office and personal life become blurred.’




Action Plans / Improvement Plans

These are formulated to address any concerns about the trainee’s performance, should be agreed and documented between the educational supervisor and trainee. This is effectively what we call a Professional Improvement Plan (PIP) in the Deanery ‘Supporting the Trainee Protocol’.

ARCP outcomes

Outcome 1 The trainee has achieved all the required technical and educational targets set for the period of training under review

Outcome 2 The trainee has almost achieved the targets set, and does not need to have the CCT date delayed. This may be a small shortfall in WPBA numbers. Exam failure may be such a target, unless the trainee is at a point in training where continued progress demands exam success.

Outcome 3 This trainee has not achieved the training targets set for the period of training and will need more time in programme to achieve these targets.

Outcome 4 This trainee is leaving the programme, either with the required targets having been achieved, or without. Some trainees choose to leave the specialty because it was the ‘wrong’ choice for them, others leave because their training time has already been prolonged by the maximum of two additional years, but has still not achieved the educational targets required to progress further.

Outcome 5 This trainee has not submitted the required evidence of training to the ARCP panel and a decision on their progress cannot be made. This trainee is expected to produce the necessary evidence within two weeks of the date of the ARCP.

Outcome 6 This trainee has completed the entire specialty training programme and can apply for the CCT

Outcome 7 This prefix is used for trainees in LAT or FTSTA posts. The suffix is .1, .2, .3 as above.

Outcome 8 This trainee is currently ‘out of programme’. This may be for research, specific clinical experience elsewhere, or as a career break.


Appendix B: Expectations of generation Y

This has been taken from the Medical Careers pages of the NHS Medical Careers website.

People born between 1946 and 1964 are often described as ‘baby boomers’, those between 1965 and 1981 as ‘generation X’ and those after 1981 as ‘generation Y’. Whilst these terms are American, the expectationsand experiences of the groups are transferable to the UK. The demographic groups have different expectations and values when compared to each other.

There have been several recent studies that have looked into the differences in attitude between generations and how this relates to the working environment. These studies do not relate strictly to medicine; however they are relevant as they are valid in any working environment. This article focuses on the attitudes of Generation Y as today the majority of medical trainees fall into this category.

One recent study is the ‘Gen Up’ report, published in September 2008, which is a joint survey report commissioned by the CIPD and Penna. This study surveyed over 5,500 employees across 6 Western European countries.The ‘Gen Up’ report compares attitudes between the above four generations under the following headings:

• Retention and loyaltyAccording the report ‘Gen X and Y may ‘demand’ more flexible hours and are less likely to take a long term career view with the organisation’. However, ‘nearly half of Gen Y intend to be with their current employer in five years time and one in four expects to change jobs every two to three years.... So the commonly held belief that Gen Y is easy to recruit, hard to retain may not be strictly true.’

• Driving Customer Service‘Gen Y is more positive about service being recognised than other generations’, although ‘16% of Gen Y are not at all interested in customer service being part of their role.’

• Performance Management‘Gen Y is much less tolerant of under-performance. Nearly one in five Gen Ys believe that the best solution for under-performance is for someone to be fired’.

• Mobile and Flexible Working‘As a generation, Gen Y are the first to truly adopt technology to manage their life/work balance as the boundaries of office and personal life become blurred.’




• Internal communication‘Gen Y is actually the most positive generation about communication. They may be expected to be more demanding of internal communication given the fact that they are used to ‘information at their fingertips’.

• Leadership and Management‘Gen Y may find that older generations demonstrate less trust for senior management. Gen Y are also more likely to rate senior mangers well including the fact that they make work priorities clear.’ The report also finds that ‘Gen Y is the most trusting of the organisation as they have not been exposed to significant downsizing or economic uncertainty.’ This characteristic may now be subject to change, however, with the effects of the current recession.

• Career development‘Gen Y may find some generational conflict in terms of career development’.

’Gen Y may find development conversations with other Gen Y much easier to manage – conversations are likely to stretch beyond the current organisation’. The Baby Boomer may be surprised at the ‘self- sufficiency’ of Gen Y as they expect to manage their own career development’.


Appendix C: Good Medical Practice: Indicators for assessors

1 Good Clinical Care

IncompetentHistory TakingIncomplete, inaccurate and confusing history taking from, and communication with, patients (carers). Fails to take into account the patients (carers) concerns, expectation or understanding. May repeatedly upset patients (carers). Examination Regularly fails to elicit physical signs of common clinical problems. Poor technique Frequently takes inappropriate short cuts when examining. Routinely fails to adequately explain procedures for intimate examinations. Cannot get patient co-operation for examination.

Investigations

Regularly fails to order appropriate basic investigations Orders inappropriate, random unnecessary investigations, no thought given. Often fails to perform investigations requested Fails to recognise normal and abnormal results of common investigations. Fails to ask for help or take appropriate action thereon.

CompetentHistory TakingClear history taking and communication with patients (carers). Uses open & closed questions appropriately Knowledge of ‘alarm’ symptoms Appreciates the importance of clinical, psychological and social factors. Attempts to incorporate the patients (carers) concerns, expectations and understanding. Ability to take specialised histories: mental health, sexual health, from children / parents.

Examination Explains the examination procedure and minimises patient discomfort. Uses chaperones appropriately Can elicit individual clinical signs but may lack co-ordinated approach and sometimes fails to target detailed examination as suggested from the patient’s symptoms. Able to use instruments appropriately.

Investigations

Requests common investigations appropriately for patients’ needs. Ensures investigations requested by team are completed. Discusses risks, possible outcomes and later results with patients (carers) appropriate to level of expertise. Recognises normal and abnormal results. Prioritises importance of results and asks for help appropriately. Understands local systems and asks for help appropriately from the relevant individuals.

PerformanceHistory TakingAccomplished, concise and focused (targeted) history taking and communication, including difficult circumstances (when English not the patients first language; confused patients or other psychiatric / psychological problem or special educational needs; deaf patients; child abuse / neglect.

Examination Elicits signs appropriately and with attention to patient dignity. Skilled examination technique Teaches examination techniques. Able to examine children of all ages

Investigations

Arranges, completes & acts on investigations intelligently, economically & diligently. Teaches F1 trainees about requests for, interpretation of and action on normal and abnormal results, for common investigations.




1 Good Clinical Care (2)

IncompetentMaking a diagnosis / management planDecisions frequently questionable. Unable to make decisions or even make a working diagnosis Seeks help all the time. Fails to involve patients in decision making.

TherapeuticsPrescribing regularly shows lack of clarity. Repeatedly fails to take account of drug history. Frequently fails to prescribe according to standard BNF recommendations, including potentially harmful interactions.

Record KeepingKeeps inaccurate or illegible notes with key information missing. Fails to sign entries.

Clinical Risk ManagementLacks knowledge or understanding of common complications/side effects of treatments / procedures. Fails to identify signs that might indicate acute illness. Does not seek help appropriately. Consistently fails to hand over.

CompetentMaking a diagnosis / management planDecisions generally satisfactory, though occasional inadequacies when under work pressure. Can make a sound diagnosis & produce safe, appropriate management plans. Involves patients (& other professionals where appropriate – aware of own skill & competency) TherapeuticsTakes an accurate drug history. Uses the BNF and other sources to access information. Prescribes drugs (including oxygen, fluids and blood products) clearly and unambiguously. Understands the implications of religious beliefs. Describes common drug interactions and allergic reactions. Record KeepingRoutinely records accurate, logical legible history which is timed, dated and clearly attributable. Medico – legally sound. Routinely records patients’ progress including management plans and discussion with relatives and other health care professionals. Utilises information systems effectively. Adapts style to multidisciplinary case record where appropriate. Clinical Risk ManagementDescribes common complications and side effects of treatments/procedures. Identifies and responds appropriately to patients with abnormal signs. Recognises personal limitations and seeks help at an early stage. Communicates effectively to ensure continuity of care.

PerformanceMaking a diagnosis / management planDecision making satisfactory even when under pressure. Shows intelligent interpretation of available data to form an effective hypothesis, understands the importance of probability in diagnosis.

Teaches F1 trainees on taking drug history, obtaining prescribing information and unambiguous prescribing. Describes the implications of pregnancy for safe use of commonly used drugs.

Therapeutics Teaches on common drug interactions and management of allergic reactions. Ability to manage adverse drug reactions

Record KeepingTeaches record keeping and intra/internet access skills to F1 trainees. Timely sending out of letters, discharge summaries. Structures letters to communicate findings and outcome of episodes clearly.

Clinical Risk ManagementAppropriately discusses potential advantages and disadvantages of treatments/procedures with patients (carers). Teaches F1 trainees the appropriate response to patients with abnormal signs. Sets example by calling for help from appropriate health care professionals in timely fashion. Demonstrates good handover to ensure continuity of care. Involvement in critical incident analysis.


Management of Acutely Ill patients (1)

(i) Promptly assesses airway, breathing, circulation in the collapsed patient

IncompetentFails to respond promptly to calls for help Slow, incomplete or unstructured initial assessment

CompetentCompletes initial assessment within 2-3 minutes Supports and clears airway Observes respiratory pattern and rate, identifies inadequate ventilation Assesses pulse rate, rhythm, volume Measures blood pressure using automated methods or sphygmomanometer

PerformanceAs preceding, plus… Makes a clinical assessment of adequacy of cardiac output & oxygen delivery Capable of leading multi-disciplinary team Helps others stay calm

(ii) Identifies & responds to acutely abnormal physiology

IncompetentFails to focus on correcting abnormal physiology as a priority Lacks understanding of clinical relevance of abnormal vital signs Uses oxygen or intravenous fluids in a potentially unsafe manner Fails to monitor effect of interventions

CompetentAdministers oxygen safely, monitors efficacy Identifies and attempts to correct hypotension appropriately Identifies oliguria, checks for common causes, intervenes appropriately

PerformanceInterprets abnormal vital signs correctly in context Anticipates and prevents deterioration in vital signs Recognises patients at risk Investigates causes for abnormal vital signs

(iii) Where appropriate, delivers a fluid challenge safely to an acutely ill patient

IncompetentRegularly fails to identify need for a fluid challenge Unable to distinguish between different fluids

CompetentSelects an appropriate fluid for intravenous resuscitation Sets up fluid administration giving set correctly Administers fluid bolus(es), observes response, ensures continued administration with monitoring of effect to desired endpoints Identifies hypokalaemia and chooses a safe & effective method of potassium supplementation

PerformanceReviews impact of fluid administration on organ system function Considers additional electrolyte replacement requirements




1 Good Clinical Care (2)

IncompetentMaking a diagnosis / management planDecisions frequently questionable. Unable to make decisions or even make a working diagnosis Seeks help all the time. Fails to involve patients in decision making.

TherapeuticsPrescribing regularly shows lack of clarity. Repeatedly fails to take account of drug history. Frequently fails to prescribe according to standard BNF recommendations, including potentially harmful interactions.

Record KeepingKeeps inaccurate or illegible notes with key information missing. Fails to sign entries.

Clinical Risk ManagementLacks knowledge or understanding of common complications/side effects of treatments / procedures. Fails to identify signs that might indicate acute illness. Does not seek help appropriately. Consistently fails to hand over.

CompetentMaking a diagnosis / management planDecisions generally satisfactory, though occasional inadequacies when under work pressure. Can make a sound diagnosis & produce safe, appropriate management plans. Involves patients (& other professionals where appropriate – aware of own skill & competency) TherapeuticsTakes an accurate drug history. Uses the BNF and other sources to access information. Prescribes drugs (including oxygen, fluids and blood products) clearly and unambiguously. Understands the implications of religious beliefs. Describes common drug interactions and allergic reactions. Record KeepingRoutinely records accurate, logical legible history which is timed, dated and clearly attributable. Medico – legally sound. Routinely records patients’ progress including management plans and discussion with relatives and other health care professionals. Utilises information systems effectively. Adapts style to multidisciplinary case record where appropriate. Clinical Risk ManagementDescribes common complications and side effects of treatments/procedures. Identifies and responds appropriately to patients with abnormal signs. Recognises personal limitations and seeks help at an early stage. Communicates effectively to ensure continuity of care.

PerformanceMaking a diagnosis / management planDecision making satisfactory even when under pressure. Shows intelligent interpretation of available data to form an effective hypothesis, understands the importance of probability in diagnosis.

Teaches F1 trainees on taking drug history, obtaining prescribing information and unambiguous prescribing. Describes the implications of pregnancy for safe use of commonly used drugs.

Therapeutics Teaches on common drug interactions and management of allergic reactions. Ability to manage adverse drug reactions

Record KeepingTeaches record keeping and intra/internet access skills to F1 trainees. Timely sending out of letters, discharge summaries. Structures letters to communicate findings and outcome of episodes clearly.

Clinical Risk ManagementAppropriately discusses potential advantages and disadvantages of treatments/procedures with patients (carers). Teaches F1 trainees the appropriate response to patients with abnormal signs. Sets example by calling for help from appropriate health care professionals in timely fashion. Demonstrates good handover to ensure continuity of care. Involvement in critical incident analysis.



(i) Promptly assesses airway, breathing, circulation in the collapsed patient

IncompetentFails to respond promptly to calls for help Slow, incomplete or unstructured initial assessment

CompetentCompletes initial assessment within 2-3 minutes Supports and clears airway Observes respiratory pattern and rate, identifies inadequate ventilation Assesses pulse rate, rhythm, volume Measures blood pressure using automated methods or sphygmomanometer

PerformanceAs preceding, plus… Makes a clinical assessment of adequacy of cardiac output & oxygen delivery Capable of leading multi-disciplinary team Helps others stay calm

(ii) Identifies & responds to acutely abnormal physiology

IncompetentFails to focus on correcting abnormal physiology as a priority Lacks understanding of clinical relevance of abnormal vital signs Uses oxygen or intravenous fluids in a potentially unsafe manner Fails to monitor effect of interventions

CompetentAdministers oxygen safely, monitors efficacy Identifies and attempts to correct hypotension appropriately Identifies oliguria, checks for common causes, intervenes appropriately

PerformanceInterprets abnormal vital signs correctly in context Anticipates and prevents deterioration in vital signs Recognises patients at risk Investigates causes for abnormal vital signs

(iii) Where appropriate, delivers a fluid challenge safely to an acutely ill patient

IncompetentRegularly fails to identify need for a fluid challenge Unable to distinguish between different fluids

CompetentSelects an appropriate fluid for intravenous resuscitation Sets up fluid administration giving set correctly Administers fluid bolus(es), observes response, ensures continued administration with monitoring of effect to desired endpoints Identifies hypokalaemia and chooses a safe & effective method of potassium supplementation

PerformanceReviews impact of fluid administration on organ system function Considers additional electrolyte replacement requirements





(iv) Reassesses acutely ill patients promptly following initiation of treatment

IncompetentIs unreliable in performing regular review of acutely ill or unstable patients Does not pass on information to other members of the health care team to ensure continued review

CompetentImplements a system of regular checking of unstable patients Calls for help if patient does not respond to initial measures Makes patient safety a priority

PerformanceProvides clear guidance to colleagues about monitoring Supports nursing staff in designing and implementing monitoring or calling criteria

(v) Requests senior or more experienced help when appropriate

IncompetentPermits problems to remain unresolved without seeking help Does not make decisions Seeks help all the time Over-confident No insight into own limitations

CompetentAnalyses clinical problems, considers possible causes & solutions. Calls for help or advice appropriately

PerformancePrioritises problems Puts the patient first Seniors are confident in his/her judgement

(vi) Undertakes a secondary survey to establish a differential diagnosis

IncompetentFails to consider underlying cause for deterioration Inaccurate examination technique, mistakes or overlooks important clinical signs

CompetentRecognises the importance of iterative review Competent history taking and clinical examination Arranges basic laboratory tests

PerformanceFocused further history taking in difficult circumstances and/or when patient unable to co-operate (see 1.A) Rapidly identifies clinical signs, links them to the history to form a differential diagnosis Plans appropriate investigations to confirm or refute a diagnosis



(vii) Obtains an arterial blood gas sample safely, interprets results correctly

IncompetentFails to understand the need for arterial blood gas sampling and often omits or delays taking the sample Does not know the main indications and contraindications for sampling Fails to attend to patient comfort during the procedure

CompetentTakes an arterial sample safely using a heparinised syringe Describes common causes of abnormal values. Interprets results in context Documents results clearly in the case record

PerformanceCommunicates significance of acid base disturbances to others in the team Directs corrective measures

(viii) Manages patients with impaired consciousness including fits

IncompetentOmits major supportive measures Unaware of complications of anticonvulsant therapy Fails to provide a safe environment for the patient, including seeking senior assistance

CompetentAppreciates urgency Administers oxygen, protects airway in unconscious patient Places unconscious patient in recovery position Calls for help if fitting does not respond to immediate measures Follows local protocols

PerformanceSeeks and corrects abnormalities of physiological signs, particularly hypoxaemia, hypotension, hypoglycaemia and electrolyte disturbances Questions and discusses scientific content of protocols in use Capable of leading multidisciplinary team

(ix) Safely uses common analgesic drugs

IncompetentDoes not routinely seek information about patient comfort Fails to review patient’s comfort in a timely manner Lacks knowledge of side effects of commonly used analgesic drugs Prescribes analgesics unsafely Fails to consider interactions between patient’s condition and side effects of commonly used analgesics

CompetentEvaluates the patient in pain Prescribes opioid and non-opioid analgesic drugs safely Re-evaluates the efficacy of analgesia in a timely manner Monitors patients for common side effects of analgesic drugs Safely uses anti-emetic drugs to treat or prevent nausea & vomiting

PerformanceConsiders the effect of hepatic and renal dysfunction on analgesic pharmacology Makes patient comfort a priority





(x) Explains the principles of managing a patient following self-harm

IncompetentFails to consider possibility of self harm as cause for patient’s presentation Omits appropriate investigations in patients who present after self-poisoning Does not identify main monitoring goals

CompetentFocussed history taking, including psychosocial causes requiring social services or police intervention Can access Toxbase Recognises need for involvement of Mental Health or more experienced personnel Demonstrates tolerance & understanding

PerformanceProtects and supports colleagues faced with an abusive patient Anticipates necessary steps to minimise risks to patient Can perform a mental state assessment

(xi) Describes the management of a patient with an acute psychosis

IncompetentFails to recognize features of psychosis Unaware of provisions of Mental Health Act

CompetentRecognizes diagnostic features of psychosis Summons experienced help promptly Can discuss safe administration of anti-psychotic drugs Can discuss provisions of Mental Health Act

PerformanceProtects patient and colleagues from harm Can safely administer anti-psychotic drugs Can initiate requirements of the Mental Health Act Considers underlying causes of psychosis

(xii) Resuscitation training

IncompetentNo certification or indication of not reaching the required standard

CompetentTrained to Intermediate Life Support (ILS) standard

PerformanceTrained to Advanced Life Support (ALS) standard

(xiii) Discusses Do Not Attempt Resuscitation (DNAR) orders/advance directives appropriately.

IncompetentDoes not understand the importance of timely DNAR decisions and their discussion with patients, relations and/or colleagues. Ignores advance directives. May cause unnecessary upset

CompetentUnderstands the criteria for issuing orders and level of experience required to issue them Can discuss with colleagues including nurses and also relatives. Facilitates the regular review of DNAR decisions and understands actions required if decision challenged

PerformanceDiscusses the DNAR criteria and their legal framework with colleagues including nurses and also relatives Encourages regular review of this order and takes appropriate action if challenged


Practical procedures

IncompetentHigh failure rate for simple procedures Hurts patients Ignores patients feeling and wishes Unsafe, prepares badly Unclear and worrying consent Muddled records

CompetentFor each procedure consider the following:

1. Knowledge of indications & contraindications

2. Explanation to the patient 3. Skill in gaining informed consent 4. Preparation of equipment 5. Preparation of the skin where

appropriate 6. Positioning of the patient 7. Trainees hygiene where appropriate 8. Sharing of information and aftercare

arrangements 9. Monitoring of the patient 10. Disposal of equipment 11. Documentation of procedure 12. Recording complications

PerformanceA model performer, seen as the example to follow. Contributes to the improvement of this aspect of the service

Procedures

• Venepuncture, cannulation and venesection • Central venous access • Blood cultures from peripheral and central sites • Intravenous infusions including the prescription of fluids, blood and blood products • Performing an ECG • Arterial blood sampling • Injection- subcutaneous, intradermal, intramuscular, intravenous • Urethral catheterisation, male and female • Airway care, oxygen, nebulisers • Respiratory function tests – spirometry, peak flow rate • Nasogastric tube insertion • Urinalysis • Proctoscopy • Pleural aspiration • Lumbar puncture diagnostic and therapeutic • Skin suturing




2 Maintaining good medical practice

Incompetent

LearningLazy Never turns up to timetabled teaching sessions Never voluntarily addresses gaps in their knowledge. When assessed for a second time on core knowledge has made no progress. Does not learn from mistakes No use of IT No personal learning plan No engagement with the e portfolio Inadequate number of SLEs/WPBAs Clustering of SLEs, over reliance on other trainees and allied health professionals Evidence / audit / guidelinesFails to show any knowledge or understanding of the evidence base in medical care. Avoids discussions with colleagues and patients (carers) in this area. Ignores or unaware of local guidelines/protocols Has no knowledge of the audit cycle, or any recognition of its relevance to the assessment and improvement of clinical standards

Competent

LearningHard working Regular and active contribution at organised teaching sessions. (>50% attendance) Uses sensible methods to build up their knowledge and skills. When assessed for a second time on core knowledge has a well-formulated answer. Awareness of & can access electronic learning resources, databases, library Personal learning plan (reflective learner) Contemporaneous engagement with the e portfolio Prescribed number of SLEs/WPBAs Regular SLEs, mainly by consultants

Evidence / audit / guidelinesDemonstrates a clear ability to critically appraise evidence base of medical care Willing to discuss with colleagues and seeks to inform patients (carers) appropriately Applies local guidelines/protocols. Understands the audit cycle and recognises how it relates to the improvement of clinical standards

Performance

LearningExemplary Sets standards (>75% attendance at teaching sessions) Always has a well researched and organised approach to medical practice Reports own errors unhesitatingly & shows ability to learn from the experience Actively evolving personal learning plan (reflective self-directed learner) E portfolio exemplary organisation More than enough SLEs: with evidence that the curriculum is being systematically covered Evidence / audit / guidelinesImplements the available evidence base in most areas of clinical care Seeks out opportunities to discuss with colleagues. Supports patients (carers) in making sense of the evidence base in terms of their personal circumstances Seeks to refine local guidelines/protocols Has been actively involved in undertaking a clinical audit, and recognises how it relates to the improvement of clinical standards and addresses the clinical governance agenda


3a Relationship with Patients

IncompetentA: patient centrednessDiscourteous, inconsiderate of patients’ views, preferences, cultural norms, dignity & privacy Discusses one patient in front of another Unable to reassure, subject of repeated complaints. Discriminates against patients with disabilities Exploits relationships with patients to own advantage Has inappropriate financial or personal relationships with patients

B: Communication SkillsConsistently ignores, interrupts or contradicts patients

CompetentA: patient centrednessRespects the autonomy, dignity, confidentiality & privacy of the patient. Knowledge of limits to confidentiality Elicits the patients hopes, fears & expectations Relates to patients as equal partners, encourages questions Knowledge of children’s rights

B: Communication SkillsCourteous, polite, communicates well with patients Demonstrates active listening & an ability to establish trust & rapport Able to break bad news to patients sensitively, & avoid conveying unrealistic optimism & undue pessimism Able to handle difficult patient interactions – reassurance of the ‘worried well’, self discharge, complaints, do not resuscitate decisions Avoids jargon Telephone skills

PerformanceA: patient centrednessAble to anticipate patients emotional & physical needs & plans to meet them Recognises & responds to their health beliefs

B: Communication skillsExplains clearly & checks understanding Able to apply models of the consultation appropriately Able to use language (and interpreters) appropriately; including communicating with patients with a disability e.g. deafness, visual impairment Respond to a patients understanding when breaking bad news or in discussion of life threatening or terminal illness Able to handle difficult patient interactions –advance directives / living wills, organ donation, reporting patients to DVLA, compulsory detention under a section of the Mental Health Act




3b Relationship with Patients

Incompetent

C: PatientInvolvement:Ignores the patients best interests when deciding about treatment or referral Fails to obtain patients consent to treatment

Competent

C: Patient Involvement:Explain the concept of risk to a patient Knowledge of legal framework of consent Apply the rules of consent – gain consent for a variety of procedures Able to provide patients with understandable information Appropriate use of leaflets & written information

D: Patient in ContextUnderstanding of the impact of the patient as a person in a family

E: Relationship with patients relatives / carersCan gain consent for a post-mortem Able to break bad news to relatives sensitively Able to share decision making with relatives

F: Health PromotionGive simple health promotion advice

Performance

C: Patient Involvement:Respond to a patients understanding & attitude towards riskEnsure patients are able to make informed choices in health care decisions Respects the rights of patients to refuse treatments or tests Share an understanding of printed or internet information to enhance the patients concordance with management plans & prescriptions

D: Patient in ContextGain understanding of physical, psychological, social & cultural dimensions of problems presented

E: Relationship with patients relatives / carersAble to deal with patients who cannot give informed consent

F: Health PromotionAssess an individual’s risk factors & tailor make health promotion advice


4 Working with Colleagues – Team working

Incompetenta. Communication

Unable / refuses to communicate with colleagues Intolerant of other professional viewpoint

b. Team Working Does not know the members of the team in which they work Does not partake in team meetings Does not know what skills other team members have Delegates tasks to other members of the team for which they don’t have the appropriate skills Bullies or harasses her colleagues Can’t work to a common goal – selfish, inflexible

c. Referral and handover

Doesn’t pass on information to colleagues about at-risk patients Dismisses patients requests for a second opinion Refers patients for care which they should be able to provide Does not provide information in a referral that enables the second opinion to give appropriate advice

Competenta. Communication

Listens to colleagues, accepts the views of others Able to communicate effectively with other members of the team & inter-professional communication (nursing staff / social services / coroner) Able to communicate effectively with other teams (hand over) Able to communicate effectively with GP colleagues -(telephone referrals ‘on take’) -written communication (discharges) Able to present a case clearly b. Team working

Attends & contributes to team meetings Knows how to contact team outside meetings Ensures satisfactory completion of reasonable tasks by the end of the day / shift Arranges cover for duties with colleagues Flexible – ability to change in the face of a valid argument a. Referral and handover

Knowledge of roles & responsibilities of team members & other professionals in patient care, able to involve them in care appropriately Accompanies referrals with the information needed by the second opinion to make an appropriate and efficient evaluation of the patients problem

Performancea. Communication

Able to bring together views for a common goal b. Team Working

Anticipates problems for next shift & takes pre-emptive action Able to lead and facilitate team meetings Able to facilitate change Team goal is put before personal agenda Able to facilitate the development of colleagues c. Referral and handover

Where appropriate feeds back to specialists views on the quality of their care Uses handovers systematically for training other doctors and nurses.




5 Teaching and Training

Incompetent

TeachingNo interest in teaching, mentoring and/or supervising more junior doctors / medical students Few teaching skills Presentations Absent themselves at the last minute, poor preparation and structure

Competent

TeachingBeginning to develop teaching skills, supervising more junior doctors & medical students PresentationsGives presentations to small groups e.g. journal club

Performance

TeachingActively involved in teaching, enthusiastic, able to motivate Clear demonstration of teaching skills PresentationsConfident, embraces new technology Able to present material using different media


6 Probity / professional behaviour:Trustworthiness, honesty, confidentiality, ethics, dress code, manners, punctuality, time management

IncompetentPoor attitude / approach in above areas, possible concerns... Fails to make care of patient first concern Own beliefs prejudice care Abuses position as doctor Seeks inappropriate personal gain in pursuit of practice Carelessly attaches her name to certificates or documents Provides false information on such documents Persistently failing to cope with own work, despite advice, support and extra clinical help Fails to involve patients in decision making

CompetentReasonable approach / attitudes in above areas… Recognises own limitations – seeks advice if unsure Accepts professional regulation Punctual Attends to detail Respects living wills & advance directives Knowledge of legal responsibilities & ability to complete death certificates Only shares clinical information, whether spoken or written, with appropriate individuals or groups Needs occasional help with organisation and prioritisation of tasks Mostly re-prioritises appropriately and usually calls for help when falling behind.

PerformanceExcellent attitude / approach in above areas, a credit to the profession. Coaches F1 trainees in these attitudes Patient care a priority Seeks constructive criticism & changes performance as a result Fosters trust amongst others & promotes sensitivity to others feelings & needs Prioritises and re-prioritises appropriately Delegates or calls for help in a timely fashion when he/she is falling behind




7

Health: This section should be used if there are any health issues which have influenced the doctor’s progress in the foundation programme

Concerns No concernsOften off sick No explanation Often coincides with duty Genuine health issues used to justify underperformance

Rarely sick Always explains and apologises Genuine health issues never used to justify underperformance


Appendix D: Checklist for Adult Dyslexia




Appendix E: Role of educational supervisor in the revalidation of trainees As ES your role is to support the revalidation of trainees by:

• ensuring the ES report for ARCP is sufficiently comprehensive and clear to be used in triangulation about fitness to practise

• including a statement in the ES report for ARCP about your knowledge of their involvement in conduct, capability, serious untoward incidents, significant event investigation or complaints as a named individual

• helping trainees to understand the PGMDE process for revalidation and what is required of them (http://www.oxforddeanery.nhs.uk/revalidation.aspx)

• Role model of good appraisal • Encouraging trainees to document their reflection • Communicating concerns any concerns about fitness to practise in a timely

manner and to the appropriate people



http://www.oxforddeanery.nhs.uk/revalidation.aspx


Appendix E:

Role of educational supervisor in the revalidation of trainees As ES your role is to support the revalidation of trainees by:

• ensuring the ES report for ARCP is sufficiently comprehensive and clear to be used in triangulation about fitness to practise

• including a statement in the ES report for ARCP about your knowledge of their involvement in conduct, capability, serious untoward incidents, significant event investigation or complaints as a named individual

• helping trainees to understand the deanery process for revalidation and what is required of them (http://www.oxforddeanery.nhs.uk/revalidation.aspx)

• Role model of good appraisal • Encouraging trainees to document their reflection • Communicating concerns any concerns about fitness to practise in a timely

manner and to the appropriate people


Notes



Notes



Postgraduate Medical & Dental EducationThe Triangle, Roosevelt Drive,

HeadingtonOxford

OX3 7XPTel: 01865 740601

www.thamesvalley.hee.nhs.ukwww.oxforddeanery.nhs.uk


http://www.thamesvalley.hee.nhs.uk
