Trainees in difficulty: five part action plan for clinical supervisors

2013 Queensland Clinical Educator of the Year and newly appointed Cognitive Institute Associate Medical Director, Dr Stephen Walker, shares his insights on supporting clinical trainees to reach their full professional potential

While being a supervisor is commonly an extremely rewarding part of our roles in healthcare, there are times when it doesn’t all go so smoothly as we are faced with someone who is struggling for whatever reason. The issue might be one of underperformance where the trainee is not meeting the expected standards, or of a doctor ‘in difficulty’ where they may be performing well but we can see something is wrong, or even both.

We need to pinpoint the issue and manage it while ensuring our patients are safe and clinical work is able to continue to the appropriate standards.

A plan of action can be described in five elements, in which we can find parallels with the clinical process.

Element 1: Define the problem

This is like the history, examination and investigation we apply in our daily practice. Information is collected from multiple sources; our observations, those of others, chart review, conversations with previous supervisors and of course the trainee themselves.Possible issues might include:

Within the trainee:

• Knowledge/skills/attitude
• Mental or physical wellbeing
• Personal stress

Within the supervisor:

• Failure to provide orientation
• Not providing feedback
• Inadequate time
• Lack of supervisor skill
• Unrealistic expectations/ no clear benchmarks

Within the system:

• Rostering/workload/fatigue
• Requirement to working beyond abilities
• Variable clinical exposure
• No standardised competency measures

Indeed the issue can often be multifactorial.

Element 2: Confirm the diagnosis (the differentials)

Is this underperformance? Is the issue with the trainee alone? Is this a doctor in difficulty? What do we believe is the root cause? As we do with our patients, we need to have this as clear in our mind as possible before we move to how we manage or treat the problem.

Element 3: Management plan

Issues of knowledge and skill might respond well to further education and training through coursework, tutorials etc, while attitude and behaviour issues need a different approach that includes setting clear boundaries and expectations, role modelling, and mentoring. Referral to an external agent might be required for personal and health issues. Possibly we need support and training as supervisors, or the system needs some modification eg, roster changes.

As with the management plans we design for our patients, it is imperative the trainee is involved and agrees with what is planned. With no agreement and ‘buy in’ the likelihood for success is low.

Element 4: Follow up

Having put in place some interventions we need to have thought out how we will monitor progress. Have our interventions worked? What measure do we use to track success? Is there a need to modify the plan to keep on track?

Element 5: Documentation

Like good clinical notes, we need to not underestimate the value and importance of good documentation that includes the issues identified, the evidence we have collected, the interventions and monitoring and a clear timeline for following up.

Finally

I think it is reasonable to say we are all keen for our trainees to progress well and the good news is that there is evidence to suggest that structured interventions do make a difference with approximately 90% of underperforming trainees succeeding in their career progression.

Finally, it is important to remember as supervisors we are not on our own. There is support available to us through our colleges, from other experienced supervisors in our own or other disciplines and education workshops for us to develop our skills in the areas of supervision and intervention.