Introduction

Medicine is a demanding profession with a long apprenticeship and rising demands due to demographic changes of increasing longevity, chronic illness, and shortage of a skilled workforce. Whereas most medical learners will complete their training without significant difficulties, approximately 6–9% will experience some problem during their programme [1,2,3]. Trainees have many demands made of them to concurrently work, study for postgraduate examinations, and do research and publish—all in a short time. There is now additional pressure from the demands of the COVID-19 pandemic and resultant overwork, safety issues, pressure, and burnout. Furthermore, specialty curricula are crowded and constantly expanding, while the time to train has not increased. Inevitably in such an arduous career, there will be some trainees who struggle and have performance problems.

Poor Performance Definition

Vaughn et al. define poor performance as “a learner whose academic performance is significantly below performance potential because of a specific affective, cognitive, structural, or interpersonal difficulty” [4]. Poor performance can also be defined as a consistent failure to meet specified standards following a period of sustained support, development, and investigation. The General Medical Council in the UK (GMC) defines under performance of doctors as those who persistently fail to comply with standards of good medical practice [5]. Therefore, it is a judgement against a standard and has to be based on unambiguous evidence that leaves little room for doubt, which is not always straightforward.

Why Do Trainees Struggle?

In the UK, the NHS Resolution Practitioner Performance Advice has taken over from the National Clinical Assessment Service (NCAS). Their joint experience has confirmed that the major areas of referrals regarding doctors’ performance fall into four spheres of health, behaviour, clinical knowledge and skills, and the working environment (Fig. 1) [6].

Fig. 1
figure 1

Adapted from NCAS poor performance

Full size image

Behaviour

This includes personal and professional behaviours, and there is much overlap between the two. Some examples of concern of personal conduct can be poor time management, dishevelled appearance, rudeness, loss of temper, racial and sexual harassment, downloading of pornographic images, dereliction of duty, feigning sickness in order to avoid difficult shifts, drug and alcohol abuse including drinking on duty, lack of motivation, and personal issues such as breakup of marriage, death in the family, and miscarriage.

Other examples of inappropriate professional conduct can consist of research misconduct, failure to take consent, and improper relationship with patients including sexual, as well as being aggressive towards patients and relatives. Further examples are lack of team work and interpersonal skills, disrespectful to other professions such as nurses, paramedics, physiotherapists, self-prescribing and falsifying prescriptions, fraud, and theft.

Poor Clinical Knowledge and Skills

Cognitive difficulties include lack of understanding of basic and clinical sciences, problems with interpretation of data, difficulty with technical skills, failing assessments, and little insight of how to improve knowledge and skills, often associated with technical mistakes leading to complications and affecting patient safety.

Health Problems

Trainees can suffer from failing physical and mental health. In addition, they are vulnerable to stress from poor career progression, failing postgraduate examinations, or family and personal issues. There is overlap with behaviour problems from drug and alcohol abuse. In the experience of the Severn Deanery Support Unit, UK, health factors and learning environment aspects were regularly under reported and often associated with competence concerns. It is important that all trainees are registered with a general practitioner and have access to timely medical care.

Environment

A good learning environment is essential for sound training, and its importance cannot be overemphasised. Trainees may fail if they are placed in circumstances where they are out of their depth and required to perform in situations beyond their level of competence. If the environment is unfamiliar, it may lead to poor performance, for example, if trainees are tasked to take responsibility for an inappropriate large number of inpatients to fit in with the rota design. There will be little time for reflection and learning, and menial tasks can lead to fatigue. A bullying culture destroys good will and motivation of the trainees to excel. Patients will also suffer as defensive medicine is practiced which can lead to patient safety concerns. System failures include lack of resources such as equipment, administrative support, and unrealistic work demands leading to a substandard working environment. All these are confounding variables including unclear standards and responsibilities.

Role of the Deanery, Hospital, the Royal Colleges, and the General Medical Council, UK

A systematic and structured approach to medical education and training should normally be in place. System issues are often difficult to identify and may not be recognised until a critical adverse incident occurs. In the UK, the Deanery has the responsibility for the training and education of postgraduate doctors, and the employer has the responsibility for employment issues, including discipline, performance, and health matters. The Royal Colleges do educate faculty through workshops about handling performance issues, but their main role is to determine the curriculum through specialist advisory committees which are responsible for postgraduate examinations which set the standards. The GMC will quality assure the Deanery to make sure that trainees and patients are supported and protected, and appropriate mechanisms are in place in the event of system or performance concerns.

A structured approach is critical to pick up early trainees in difficulty. This includes initiatives such as appraisals, 360-degree feedback, assessments, clinical governance, and a much greater emphasis on the quality of care to patients. Such a model in a simplified form can be adapted in those countries where a formal governance structure of training does not exist.

How Do Struggling Trainees Present?

Certain patterns will cause concern and alert the clinical and educational supervisor that all is not well. Behaviours and events that are of concern are summarised in Box 1 [7,8,9].

Box 1

How to Approach a Concern?

As an education supervisor (ES), clinical supervisor (CS) or a hospital director of medical education (DME) gets onto the concern early [7]. There is the need to be open and balanced in one’s views and acknowledge first what has gone well and achieved before raising concerns. The first thing to determine is whether there is a problem. If there is, then do not jump to conclusions based only on one side of the story. Clarify things and get both sides of the account. It is important that you are seen as someone who is honest and sincere in your efforts to resolve the issues in a supportive way. Be inclusive and make extensive notes of conversations, and if need be, record some statements verbatim in the witness’s own words. Performance matters must be dealt with as they occur and not at the end of a placement. Collect as much information prospectively as is feasible. Many problems can be resolved at local level, rather than involving a formal procedure. However, the principles of finding out the facts, using facts of the case and not opinions, constructive feedback and setting targets for improvement, and following these through, will still be necessary [8, 9].

Performance issues are usually complex and not related to a single domain. For instance, a poor learning environment may give rise to a competence/critical incident issue and stress affecting health, leading to a vicious circle of loss of confidence in decision making resulting in further poor patient management and individual anxiety. Therefore, it is important that when appropriate, the ES shares the problem with more experienced colleagues. Get advice from others—such as other trainers, speciality tutor, clinical tutor, training programme director, chair of the Speciality Training Committee, regional adviser, and the Associate Dean from the Deanery who is responsible for performance issues. Many Deaneries now have a trainee support unit who are highly experienced in handling complex performance issues and are readily available.

Trainee Management

Performance problems can involve high stakes decisions affecting careers and reputation both of the trainee and the institution, and ultimately, both trainees and patients can be at risk. Trainees and departments get badly damaged due to any delay. Every trainee has an employer who is normally the hospital or general practice where the trainee is based. In serious cases, the hospital medical director may need to become involved. It is essential to keep the employer informed.

Set joint objectives with the trainee and discuss how to achieve them and monitor progress. Objectives should be SMART (specific, measurable, achievable, relevant, and time-defined). Trainees themselves may come up with solutions and this should be acknowledged. Regularly review what has been achieved through assessment and appraisal. Complete the learning cycle by redefining the goals achieved and set new goals. Depending on the situation, there is a role for targeted training, occasionally relocating the trainee especially if there is a breakdown of relationships within the clinical team. In cases of ill health, then part-time training can be effective. Trainees can be sponsored to attend particular skills course to make up for lost time and deficient competencies. Lack of leadership and communication skills is often common. In order to improve leadership skills, trainees can be given appropriate responsibility within their limitations from such activity as organising on-call rotas and waiting lists, running the journal club, presenting at x-ray and pathology meetings, and short listing and attending core trainee interviews. Communication skills can be improved by encouraging trainees to carry active problem lists, make management plans, and improve time management. Specific clinical assessments such as case based reviews, direct observations of procedures, mini-CEX, and video recordings will give quality feedback regarding progress.

Most trainees with difficulties will readily acknowledge their struggle and accept appropriate help. Occasionally, the trainee may claim that they were completely unaware of any problem, and if they had been, they would have done something about it. It is unacceptable for a CS to raise concerns about a trainee in private, but at the end of year or placement assessment, mark him/her down as satisfactory. Honest appraisal is important to remediate a trainee and protect patients. Both the ES and the CS must take the trainee into their confidence, and the latter must be aware of the problems. There should be no end of placement surprises.

The ES will also need to be aware that occasionally they will be supervising trainees who are not only in difficulty but are difficult themselves. They may not acknowledge problems, nor agree to objectives, or may fail to recognise they are underachieving the standards expected, may be evasive, unreliable, and rude or any combination of the above [10]. Here, the role of the Deanery and the performance/support unit becomes crucial.

Giving Difficult Feedback

It is important to begin constructively and show empathy. Discussion should be backed with facts and evidence, and occasionally, trainee beliefs may need to be challenged by suggesting other perspectives. This is best achieved by using open, reflective, and reframing statements. The trainee does need to take professional responsibility for their decisions and make a success of the remediation plan [10].

What Does a Trainee Support Unit Do?

A trainee support unit has expertise in many areas and is in a non-threatening environment. They can get urgent occupational health assessment and psychometric tests, obtain human resources advice, explore career options, and offer language and communication skills training, counselling, and mentoring, and there is a convergence of experts in a single centre to take charge of the case management. More sophisticated assessments such as high-fidelity simulations for diagnosis can also be arranged as well as monitoring remediation. Early data analysis in the Severn Deanery trainee support unit from 2010 to 2012 (where DS was the postgraduate dean) showed that at the point of referral clinical competence, issues were overstated, and system errors and health problems are under-reported. On assessing the trainees’ clinical competence issues reduced from 61 to 49%, health as the major factor increased from 45 to 48%, work environment factors increased from 24 to 32%, and home environment concerns from 13 to 21%. In terms of known outcomes of Severn trainees from the early review of 2009–2012, out of 106 trainees who were referred 44 did well; 15 required long-term ongoing support; 7 changed speciality; 6 resigned; 14 had left the Deanery area, and this is a weakness that these trainees could not be followed up; 5 were removed from training; and 4 changed to a career outside medicine. Foundation doctors (20%) were the largest group referred followed by Medicine (10%) and then surgery (7%) [11].

Impact of COVID-19 Pandemic Burnout on Trainees

In response to the current COVID-19 pandemic, major changes resulted in the placements of trainees and shift patterns due to the volume of infected cases of COVID-19 admitted. Hospitals are forced to cancel routine surgery and admissions and deploy trainees in unfamiliar roles and tasks of unscheduled and acute care, beyond the scope of their primary speciality [12]. These problems were further accentuated, as colleagues themselves became infected, and along with close contacts, had to be treated and quarantined resulting in a shortage of medical manpower and issues with supervision [13]. This at times led to up to 45% of trainees experiencing symptoms of burnout [14]. Burnout is usually caused by excessive and prolonged stress and its defining characteristics overlap with some of the poor performance features described above, mainly emotional exhaustion, depersonalization, depression, diminished sense of personal worth, suicidal ideation, and medical errors [15]. It is recognised that physician burnout and suicide are twice that of the general public [16]. Therefore, it is essential to mitigate this by cultivating a supportive workplace culture and reducing trainee stress. ES and CS need to be cognisant of the increasing demands being made of trainees currently which can result in burnout. In contrast, a positive feature of the COVID-19 pandemic has been the unique training experience including dealing with acute care crisis of pandemics, reorganisation of healthcare, and the use of technology enhanced learning [14]. Trainees also learnt of how different professionals with different skill sets and professions come together to solve complex healthcare problems.

There is now more awareness of developing resilience in trainees [17]. Resilience is defined as the process of adapting well in the face of adversity. Four factors help trainees to develop resilience:

  • The capacity to make realistic plans and take steps to carry them out.

  • Developing a positive view of yourself and confidence in your strengths and abilities.

  • Enhancing skills in communication and problem solving.

  • Increasing the capacity to manage strong feelings and impulses.

Challenges for the Educational Supervisor and the Director of Medical Education

In investigating a performance concern particularly in a complex or serious scenario, there are searching questions that will challenge the ES and the DME [7, 11, 18]. Such as what are the boundaries of your role? What is legitimate for you to enquire about from the trainee or from others? What can you share with others, and what records should you keep? What is confidential and how much of the trainee’s reflective notes in the portfolio can be accessed and disclosed? Here, the experience of the hospital medical director, the Deanery, and occasionally the GMC can be helpful. It is incumbent on the investigating officer to create a learning culture which is positive and where success is valued.

Summary and Learning Points

  1. 1)

    Performance issues are common, but complex due to overlap of the 4 domains of behaviour, clinical knowledge and skills, health, and the learning environment.

  2. 2)

    All problems need to be tackled early, and the Deanery and the employer (hospital or general practice) must be informed.

  3. 3)

    Records from witness statements and any incidents must be in writing.

  4. 4)

    For complex and difficult problems, other more experienced colleagues from the institution and Deanery should be involved.

  5. 5)

    Assessments should be honest, balanced, and shared with the trainee, so there are no surprises at the end of the clinical placement.

  6. 6)

    COVID-19 pandemic demands on trainees can have detrimental effects of burnout.

  7. 7)

    Medical curriculum should include enhancing resilience in trainees.

  8. 8)

    Patient safety must always be the primary consideration.