It is pertinent that all possible steps are taken to identify and act on early signs, triggers and symptoms of progression issues. In most cases issues are detectable and early identification prevents an issue from escalating to a more serious situation.
Doctors' performance may be affected by a variety of issues:
- Predisposing factors e.g. previous ill health, personal issues
- Precipitating factors e.g. acute events, social isolation
- Perpetuating factors e.g. chronic ill health, organisational issues
Early identification will reduce the potential risks to the trainee, to the colleagues, the patients and also the organisation. The evidence on prevention of issues suggests that good induction properly constituted teams, together with effective educational supervision reduces stress and potential difficulties.
Underlying reasons and explanations
Successful remediation or support for doctors in training requires an accurate understanding of the underlying reasons for the difficulty. This increases the likelihood of being able to tailor subsequent intervention to the individual's circumstances, personality, abilities or learning style (e.g. McManus et al, 2004).
- Why is it happening to this trainee?
- Why now?
- Why here in this placement?
There may be any number of reasons for an individual to underperform:
- Capacity - a fundamental limitation that will prevent them from being able to do their job (e.g. mental or physical impairment). If so, then change of role or job may need to be considered.
- Learning - a skills deficit through lack of training or education. In these cases, skills-based education is likely to be appropriate, provided it is tailored as closely as possible to the individual learning style of the doctor and is realistic within existing resources.
- Motivation - a drop in motivation through being stressed, bored, bullied or overloaded - or being over motivated, unable to say no, anxious to please, etc. In these cases some form of mentoring, counselling or other form of support may be appropriate and/or addressing organisational issues like workload, team dysfunction or other environmental difficulties that may be affecting motivation.
- Distraction - something happening outside work to distract the doctor; or a distraction within the work environment (noise or disruption; team dysfunction). The doctor may need to be encouraged to seek outside professional help if the problem is outside work.
- Health - an acute or chronic health problem which may in turn affect capacity, learning or motivation. Occupational Health may have a role here; or the doctor may need to be encouraged to visit his or her GP.
- Alienation - a complete loss of any motivation, interest of commitment to medicine or the organisation, leading to passive or active hostility, "sabotage" etc. This cannot generally be rectified and damage can be caused to others (patients and colleagues) and to the organisation if allowed to continue for too long. The doctor should be moved out of the organisation, with whatever support or disciplinary measures may be deemed appropriate.