FOCUSON:TRAINING

Managing trainees with diff|cultiesAlison Cooper.

RotherhamGeneral Hospitals NHS Trust,Moorgate Road, Rotherham, SouthYorkshire, S60 2UD,UK

Summary Early identif|cation of trainees with diff|culties allows relatively easy andeffective intervention for minor problems and for more serious problems facilitatesearly access to additional help. Ignored problems do not go away. Such trainees mustreceive appropriate guidance and support.�c 2003 Elsevier Ltd.Allrights reserved.

KEYWORDSeducation, professional;education, continuing;educationalmeasurement;training programs;anaesthesia

INTRODUCTIONAll consultants teach and train on a dailybasis. As part ofthis interaction with trainees, they observe and makejudgements about the performance of the trainee.Theyare well placed to identify problems early and anecdotalevidence suggests they often do so. Recently, in-trainingassessment has become more formalized, feeding intotheprocesses of appraisal, assessment and annual reviewfor trainees.The annualreviewprocess (RITA)was intro-duced to review progress in training for specialist regis-trars (SpR) and is soon to be extended to all senior houseoff|cers (SHO).1,2 One of the outcomes of the RITA pro-cess has been the identif|cation of a small number of trai-nees who have not made satisfactory progress.3 ForSpRs, this is around 3--4% (for all specialities). The rea-sons for the lack of progress are variable, but it is essen-tial that these trainees are helped and whereverpossible, the diff|culties are overcome. All consultantshave a role to play in this and trainers and trainees shouldbe encouraged to identify any diff|culties early and seekways to address them.

EDUCATIONALSUPERVISIONA department must provide a suitable environment fortrainees to learn effectively. All trainees require a nomi-nated educational supervisor. In a small department thismay be the college tutor; in a larger department a groupof consultantsmay take a small number of trainees each.The trainee needs to meet regularly with their educa-tional supervisor and establishing this good relationship

is key to dealing with any problems, which may arise. Aminimum of threemeetings is suggested:

* The initialmeetingwhen trainee and supervisor agreea personal learning plan for the trainee based on re-viewing previous progress, opportunities availableand training required.

* A midterm review to ensure that progress is occur-ring and if not identify problems and try to resolvethem.

* A f|nalmeeting to receive feedback and results of anyassessments.4,5

In our department, trainees on a 6-month placementare seen every 2months to achieve these aims.Timing ofmeetings needs to be appropriate for the training mod-ules so for example, in very short modules of one tothreemonths itmightonlybe reasonable to see a traineetwice.

EARLYIDENTIFICATIONOFTRAINEESWITHDIFFICULTIESWhen a structure is in place as part of a supportive edu-cational environment any diff|culties should be pickedearly. As an individual consultant may only work withany particular trainee intermittently it is essential forthe educational supervisor to collate the views of asmany colleagues as possible in order to obtain a reason-able representation of a trainee’s performance. Includingother senior professional staff such as nurses and operat-ing department practitioners (ODPs) will give anotheruseful perspective. Trainees should be aware of allmethods of assessment and feedback used within a

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Correspondence to: AC; E-mail: alison.cooper@rothgen.nhs.uk

Current Anaesthesia & Critical Care (2003) 14,178--182�c 2003 Elsevier Ltd. All rights reserved.doi:10.1016/j.cacc.2003.09.001

department. A problem reported by several differentstaff more genuinely reflects a real issue.

Trainees are often concerned that if theydo notgetonwith an individual then this will reflect badly in the feed-back. In practice such individual clashes are usuallyspotted and can be kept in context. Obtaining a wideview (ideally more than 10 opinions), asking the traineeto nominate individuals of their choice to provide feed-back and ensuring all reviewers take responsibility fortheir opinions are all important factors in obtaining reli-able feedback. It is absolutely essential that vague com-ments like ‘unsatisfactory’ be accompanied by adescription of the event so that this can be fully dis-cussedwith the trainee.

Concerns about an individual traineemaybe raised bycolleagues, other trainees, nurses, midwives or ODPsand should never be ignored.

INITIALMANAGEMENTWhen a concern is raised, this should then be discussedwith the trainee at the earliest opportunity, not in an ad-versarial manner, but in a non-judgemental supportivemanner.The trainee should be encouraged to give theirown narrative of the event, to reflect on it and considerwhy others may be concerned. The trainer should tryand explore specif|cally where the diff|culties lie, whichmay not be immediately obvious. For example, a yearone SHO whowas described as aggressive and arrogantby theatre staff when on-call, was reported by consul-tants as very bright and making good progress whenworking supervised. Discussions with the trainee re-vealed considerable anxiety about performing on-callduties due to his relative inexperience, so he would getangry when asked to prioritize and plan emergencywork.Knowledge, skills and attitudes all required atten-tion to help resolve this problem. In discussing these is-sues with the trainee the trainer must give constructivefeedback, seeking to support activities performed wellin addition to identifying areas that couldbe donebetter.This type of open and constructive dialogue requirestrust and respect on both sides.

EXPLORINGUNDERLYINGPROBLEMSFor convenience I have separated these into knowledge,skills and attitudes but in reality problems are usually amixture of all three.However, in planning a strategy forimprovement it often helps to break down the diff|cultyinto smaller componentparts, presentingmoremanage-able goals for a trainee to achieve.

Trainees with diff|culties often lose all conf|dence intheir own ability to improve and the trainer must set aplan of small targets initially.

Knowledge

A good knowledge base is very important for the safeconduct of anaesthesia and it is important that from thevery start an SHO is encouraged to acquire the appro-priate knowledge by consultants.6 Sometimes the f|rstintimation of a problem is failure at the Primary exam.All trainees should receive a copy of the Royal CollegeofAnaesthetists (RCA) curriculum anduse this as aguideto learning in addition to reading around the clinicalwork. Practicing Multiple Choice Questions (MCQ), vi-vas, and mock Objective Structured Clinical Examina-tions (OSCE) helps to establish the level of detailrequired and trainees should participate in these mocksfrom the beginning of their training. Including traineeswho have recently passed the examination in these ses-sions reinforces the level of knowledge required. In ourdepartment weekly teaching topics are chosen and pre-sented by the trainees to their peers, who are thenasked to constructivelycriticize. Aconsultantwill attendto facilitate this process but not necessarily to act as theprovider of all information. Senior trainees are expectedto act as examiners in mock vivas and OSCE exams, of-ten using questions they had in their own exam. Again,this helps to identify the standards,whichmaybediff|cultfor a traineewho has revised in isolation.

Where repeated examination failures occur the trai-ner will need to discuss the problemwith the trainee ingreater detail to try and get some insight intowhere theproblem lies. Feedback from the examination, if avail-able, is helpful. Sometimes exam technique is the pro-blem rather than actual knowledge and the trainerneeds to separate out these two issues.The trainer mayneed to set specif|c exercises for the individual to assessthese issues, such as essays and short answer questionsto look at the structure and content of the answers, set-ting MCQs and going through them and taking practicevivas and clinicals.These activities are very labour inten-sive and the trainer will need the help of other consul-tants to provide this level of practice.

Trainees with particular diff|culties with oral and pre-sentational skills alone may benef|t from additional sup-port from other professionals and in theTrent Deanerywe are very fortunate to have access to a Guidance andSupport unit, which can helpwith these skills.

Where the trainer identif|es def|cits in knowledge itmaybe necessary to look at theway inwhich the traineelearns and their style of learning.We need to encouragedeep learningrather than superf|cial or strategic learningby always relating the learning back to the clinical workand the professional requirements of doing the job.Theaims of learning must be made explicit. Sometimes

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trainees feel it is enough to be able to do the job, butwe must demonstrate that a deeper understanding isalways required. Consultants can reinforce this type oflearning in the course of every day work by askingquestions about why we do things the way we do andencouraging trainees to ask questions about our ownpractice.

Skills

Anaesthetists use a wide variety of skills in the perfor-mance of their clinical duties.These can be convenientlydivided into two categories, technical and non-technical.6

Technical skills

Trainees need to be taught how to perform a practicalprocedure correctly on the f|rst occasion that theyare taught. Therefore the teacher must be an expertand so skilled that they can anticipate, avoid and rescuethe trainee and the patient from any possible problemthat may be encountered. In practice this means consul-tants only teaching skills they are fully conf|dent withthemselves.

When a trainee presents with problems performingpractical tasks it may be because the original teachingdid not address basic skills in an organized and struc-turedmanner andbadhabits havebeen allowed to devel-op. It is also important to remember that traineesacquire competence in practical skills at varying ratesand there may be marked variation between individuals.This needs to be taken into account.

In dealing with diff|culties with practical skills,most hospitals have access to staff and facilities to helpand a structured approach can be adopted.Where skillscan be taught and practised in a skills laboratory ona mannequin this provides an opportunity to revise theunderlying knowledge, demonstrate the anatomyand the technique and explain any related physiologyand pharmacology without the distraction of a live pa-tient.Once this basic level has been achieved the traineecan then move back to real patients and again astructured approach is very appropriate. Neverassume a trainee has all the correct information toperform the task well, even fairly experienced SHOsmay not have been taught and are sometimes tooembarrassed to ask.

Non-technical skills

Often when trainees present with diff|culties in the clin-ical context there is no obvious problemwith knowledgeand technical skills but with much more subtle beha-vioural aspects of performance. Just as we wish to en-courage appropriate development of knowledge andpractical skill so we need to be explicit about these

other aspects of behaviour, such as an awareness ofhow the patient is doing, anticipation and avoidance ofproblems, smooth management of a crisis, and an abilityto work well within the team and get the best from col-leagues. Recent work has identif|ed four main skill cate-gories that give us a useful shared vocabulary to describethe sorts of behaviour which good training should en-courage in trainees.

Initial evaluation of this skills taxonomy has been veryfavourable and itwas perceived as being a useful additionto the anaesthetic curriculum. I have included a brief de-scription but for more detail the reader is referred to arecent publication.7

Taskmanagement. Management of resources and orga-nization of tasks to achieve goals, be they individual caseplans or longer term issues.

Teamworking. Working with others in a team context,in any role, to ensure effective joint task completion andteam satisfaction, the focus being particularly on theteam rather than the task.

Situation awareness. Developing and maintaining anoverall dynamic awareness of the situation based onper-ceiving the elements of the theatre environment; pa-tient, team, time, displays, equipment, understandingwhat they mean and thinking ahead about what couldhappenwith these in the near future.

Decision-making. Making decisions to reach a judge-ment or a diagnosis about a situation, or to select acourse of action, based on experience or new informa-tion under both normal conditions and in timepressuredcrisis situations.

To be good anaesthetists, trainees need to developthese skills and whilst explicit discussion of these skills isrelatively uncommon in anaesthesia, it is common inother high-risk industries. For trainees with diff|cultiesinperformance, breaking these issues down into compo-nent parts provides a manageable framework for bothtrainee and trainer to tackle.Trainees will often say thatthey have been told that their decision-making was pooror that they have failed to deal appropriately with a pro-blem. But these comments alone are not suff|cient andthe trainer needs to help the traineereview their perfor-mance and understand why they had not made a gooddecision or dealt with a problem appropriately.

The influence of the behaviour of consultants is veryimportant in developing good behaviour in trainees andshould not be underestimated. Within a departmentthere are often key individuals whose benef|cial effectsin this respect can be very helpful.

Attitudes

Until recently, the acquisition of appropriate pro-fessional attitudes by doctors in training has beenassumed, rather than explicitly addressed. However,changing expectations both within and outside the pro-

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fession means this assumption can no longer be made.The Royal College of Anaesthetists, in its recent docu-ments has addressed the issue of attitudes directly, anddescribed appropriate professional behaviour in somedetail. Most importantly, the College also requires us astrainers to assess attitudes, stating clearly ‘Each hospitalor school is free to assess attitudes and behaviour in theworkplace as it chooses, but such an assessmentmustbedone’.

Assessmentof attitudes shouldbe a routinepartof as-sessment in theworkplace for all trainees, not just thosewe are concerned about. Ideally, this should not involve alarge amount of extrawork, and should reflect the activ-ity of the trainee fairly and their interaction with otherstaff. For about 5 years we have used a form of 360 de-gree review to provide information about attitudes andprofessional behaviour in the workplace to supplementthe informal feedback which has always been given tothe tutor. This process involves sending a short form toall consultants, senior nurses on labour ward, intensivecare, the acute pain team and senior ODPs for each trai-nee. This generates approximately 15 snapshots of eachindividual and is particularly useful at picking up attitudeproblems. This type of assessment is used as a revalida-tion tool in Australia, and has also been validated in resi-dency training programmes in the USA.8 All trainees areaware that this process will occur.9

The information generated from this process isused to inform the regular meetings between traineeand educational supervisor. This conf|dential interviewis primarily an educational and supportive process andis non-judgemental. It provides for the trainee a safeenvironment inwhich to discuss the results of the reviewprocess and any problems that have been highlighted.Preparation for this interview by both trainee andtrainer improves the value of this interview andwould include arrangingbleep free time in a quietprivateenvironment. Asking the trainee to self-assess his orher own knowledge, skills and attitudes prior tothe meeting is also very helpful. This can then becompared with the results of feedback given tothe educational supervisor and any differencesdiscussed.

Fortunately for the vastmajority of trainees, attitudeproblems are relatively minor or transient. Commonlystresses like exams or moving house cause diff|culties,which are self-limiting and would previously havebeen ignored. Now a much more proactive approachis recommended and providing constructive helpwhere possible should avoid long-term problems.This does not mean that the educational supervisorhas to personally provide all this. Their role is toencourage the trainee to seek help and facilitate accessto that help. For example, if the trainer is concernedabout the health of a trainee and their ability to performthework as a consequence, then the appropriate profes-

sional to make that assessment of the trainee would beeither the trainee’s general practitioner or the occupa-tional health physician, not the trainer. The trainer canfacilitate this process.

Various types of problems are seen and there issome pattern to them, related to the expectationsof the grade. For example,Year1SpRsmay f|nd diff|cultyunderstanding and meeting the expectations ofothers and learning to manage more junior colleagues.Year 2 SpRs have diff|culties relating to examinations,learning to teach others, time management andresearch requirements; Year 3 SpRs have diff|culty withflexibility and managing pressure and stress; Year 4 withbalance of home,work and life;Year 5withbeingmarket-able as a consultant, identifying their style andpriorities.Whilst these represent a very small number of trainees(4--5%) constructive help not only avoidswastingmoney,but also avoids the destructive effects on that individual,the team and the patients.

Serious attitude problems are not common and maynot be easy to sort out without external help. It is abso-lutely essential for such a trainee to have a good relation-ship with their educational supervisor in order to workon such issues and for the trainer to be able to refer suchan individual to an outside source of help. In theTrent re-gion, the Career Guidance and Support unit provides in-dividual counselling tailored to the needs of each trainee.This help is extremely valuable, particularly when careerchanges may be contemplated. Expert help is also avail-able from the clinical tutor in each Trust and from thePostgraduate Dean’s off|ce.

Very occasionally an issue will arise which causes theeducational supervisor to believe that patients are atrisk. When this occurs the needs of the patient takepriority and patients must be protected. The traineemay need to be instructed toworkonly with direct con-sultant supervision and the clinical tutor and Postgradu-ate Dean must be involved immediately in the decisionand planning of remedial training. Removing the traineefrom the service element of the postwill protect the pa-tients but is very damaging to the trainee unless stepsare taken to plan the way forward.There is usually alsoan immediate problemwith service commitments and insome cases Deanswill fund such a trainee for a period ofremedial training as a supernumerary, allowing locumsto be appointed. Such training needs to be carefullystructured so that the trainee fully understands the aimsand the progress required and regularly reviewed.

REFERENCES1. Department of Health. A Guide to Specialist Registrar Training.

London: DoH, 1998.

2. Department of Health. Unfinished Business. London: DoH, 2002.

3. Arkell R. Personal communication, 2002.

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4. Cooper A. The future role of appraisal in anaesthesia [Dissertation

for Med Degree]. University of Sheffield, 1999.

5. The Standing Committee on Postgraduate Medical and Dental

Education. Appraising doctors and dentists in training: a working

paper for consultation. SCOPME, London, 1996.

6. Greaves J D, Dodds C, Kumar C M, Mets B, eds. Clinical Teaching:

A Guide to Teaching Practical Anaesthesia. Lisse: Swets & Zeitlinger

Publishers, 2003.

7. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R.

Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a

behavioural marker system. Br J Anaesth 2003; 90(5): 580--588.

8. Jolly B, Grant J. The Good Assessment Guide. London: The Joint

Centre for Education in Medicine, 1997.

9. Ramsey P G, Wenrich M D, Carline J D, Inui T S, Larson E B,

LoGerfo J P. Use of peer ratings to evaluate physician performance.

JAMA 1993; 269(13): 1655--1660.

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