EM Training Support Unit: experience of doctors in difficulty

Dr Jo Jones

Associate Postgraduate Dean

Secondary Care lead for TSU

Outline

• Description of the TSU

• Data from TSU work 2005 on

• Sharing learning from our experience

TSU – Acknowledgements

• System developed by Jo Jones, Val Evans, Kevin Hill in close liaison with Ian Aston (OH ) since about 2003/4

• Others involved : (Viv Purkiss) Caroline McCarthy

• Data provide by the TSU team

• Careers Team

Where do we operate?

• East Midlands Deanery: Leicester, Nottingham, Derby

• Trainee numbers ( approx):– Total 2400– Foundation 825– GPVTS 610– Secondary

• ST1/2 430• ST3+ 547

How do we work (1)?

• Underlying principle of TSU is that we assist the trainee and faculty in managing a situation

• See the trainee in context of:– their training programme– their health– the interacting factors around them- e.g life

out side medicine– current specific performance problems

How do we work? (2)

– TSU is embedded within local training context: • school structures of TPD, HoS, and an external

AD; • within an employing Trust• Linking with Specialist OH advice• Lead ADs with TSU overview of management

processes

– Offering arms length short-term work focused interventions

– Supporting ‘faculty’ in managing the situation

TSU is ‘dynamic’

• We are constantly reviewing and so learning:

– enhancing paperwork and tools– types of interventions and providers– confidentiality/legal/ ethical aspects– communications with trainees– interactions with schools and AD– feedback of learning into the Deanery

Total number of referrals per year

0

20

40

60

80

100

120

140

2005 2006 2007 2008 2009 2010 2011

Referrals by Grade

0 20 40 60 80 100 120 140 160

Med Stud

FY1 & 2

ST1 & 2

ST3

ST4 +

Referrals by Speciality

0 20 40 60 80 100

Anaes

Em

GP

Histo

FP

Student

Med

O&G

Paed

PH

Psyc

Rad

Surg

Support Options

0 50 100 150 200 250

Other

MSF

Social. Asssertive

SLDS

Lang

Career

Comm skill

EP +OP

Counsel

OH

Coach

Outcome data

• Some cases are prolonged so data per year difficult to estimate

• Success may be that a trainee decides that the specialty- (or more rarely, medicine is not for them) as well as ‘back on track for their original career aim.

2005-2007 Number

Total referred (based on current data)

64

Achieve CCT 7

Progress in programme 15

Remain in programme 13

Leave programme 11

Active case 18

2005-2007

2008

2009

resolution of casesAll 2009 cases

‘Simple’ scenario (1)

• Many trainees will have transient minor difficulties, recognised by supportive trainers and limited impact on overall pattern of training-within ’normal range’

• Others will have need for TSU assessment; maybe identified via ARCP.

• Often uni-dimensional: e.g. confidence, personal issues, language, cultural adjustment to UK/NHS, communication, exam skills, time management, short-term health issue, clash with individual trainer

‘Simple’ scenario (2)

• Problem identified and acknowledged mutually by trainer and programmes- part of an educationally minded culture; timely and transparent

• Written deanery action plan; clear learning targets within programme- readily back on track

• Trainee→ problem identified→ objectives set→ simple intervention→ back on track

Describing ‘Complex’ Situations(1)• Currently about 30% of all TSU referrals • Trainer perspective:

– difficult to articulate trainee’s needs or targets– across a number of less precise domains -

underlying difficulty in clinical practice in real life ; case load, prioritisation, managing uncertainty

– trainee may be said to’ lack insight’/ reluctant to own responsibility

– maybe anxious to seek resolution when feeling de-or unskilled to solve this problem ; falling back on linear approach

Describing Complex situations- 2• Trainee perspective:

– feel singled out– set constantly moving targets– maybe ‘high stakes’ ( self image, first ‘failure’ status

including visa)- and nowhere else to go?– interacts with health; stresses increase the

performance problems

Lack of clarity / high stress all round may lead to potential for miscommunication on all sides

Managing Complex Situations• Engagement • Multiple perspective- taking • Manage with a small team • Communication/documentation: timely clear for all • Relevant interventions -key outcome is changed

performance not the detail of the intervention ( confidentiality)

• Overview- timelines and histories• Health- relevance to assessments and training• Open expectation as to what is meant by ‘success’

Referrals by Grade

0 20 40 60 80 100 120 140 160

Med Stud

FY1 & 2

ST1 & 2

ST3

ST4 +

Questions raised by the ‘complex’• Medical school: Selection? Professional vs

graduate? Or alternative paths in a medical degree? • Transitions: student to professional/ employee;

supervised to independent (ST3/4 selection)• WBPA- assisting or exacerbating? making MSF more

robust? ‘global’ qualitative assessment- how do we assist trainee’s thinking: use of reflection?

• The elephant in the room?- ‘capability’ to think as an independent practitioner ( a ‘cul de sac’ in practice)

• How far do we go? effective use of resource• When is intervention counterproductive? • Alternative medical career pathways?