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): –Total2400 –Foundation 825 –GPVTS610 –Secondary ST1/2430 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

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.

Number Total referred (based on current data) 64 Achieve CCT7 Progress in programme15 Remain in programme13 Leave programme11 Active case

resolution of cases All 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’

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?