1. The GP Trainee in Difficulty

2. Prevalence 6-9% Lack of knowledge 48% Poor judgement 44%
Inefficient use of time 44%
Attitudinal, interpersonal conflict, family stress, psychiatric illness, substance abuse

3. A tidy model and strategy for helping the registrar in difficulty?
Afraid not!
Disjointed selection of thoughts and observations

4. A fine judgement….
To support a registrar and help them through a difficult time, or your duty to avoid perpetuating a problem….
…..what really is in their best interest???
Crucial to this is deciding if there really is a problem or not, which is not easy

5. Anticipated progress
Performance
Time

6. …having identified that there is/may be a problem….
1. Inform/involve course organiser, partners, registrar etc.
2. Make a diagnosis – characterise the problem
3. Structured intervention

7. 1. Inform and involve (responsibilities)
Education provider (your practice) - employment law, educational responsibilities, safety etc.
VTS – as above, counselling, psychology involvement, careers advice etc.
Deanery – governance, financial
NCAS – performance assessment
GMC – fitness to practice

8. 2. Characterise the problem
Describe and diagnose

9. Often intuitive sense of ‘something wrong’, but characterising the problem is much less easy

10. How do you characterise the problem?
What is the problem? (may be really difficult to answer)
History of the learner – academic, social and psychological
History of the problem
Is it a problem that needs to be fixed?
Ascertain the learners views and insight into the problem
Where does the problem lie?

11. What’s the problem?
Superficial description – what is a symptom and what is a diagnosis?
Poor performance is a symptom, not a diagnosis
Deeper diagnosis may be a lot more difficult – may be multi-factorial

12. To maximise learning… Time Guidance Problem solving ability Intellect
Organisation
Reflection
Memory
Facilities
Concentration
Relate learning to experience
Strategy for learning
Grounding knowledge
Commitment
Opportunity
Interest
Stimulation/challenge
Imagination
Motivation
Incentive
Absence of confounding factors
Insight
Willingness
Just get on with it!!

13. Environment and tools for learning and development of knowledge.
Grounding knowledge
(knowledge)
Concentration
Memory
Intellect
Problem solving ability
Organisation
Reflection
Imagination
Insight into own ability
Strategy for learning
Relate learning to experience
(skills)
Motivation/incentive
Commitment
Willingness
Interest
(attitudes)
But environment also important…
Opportunity
Guidance
Time
Facilities
(learning/educational environment)
Absence of confounding factors
(psychological, social, physical environment)

14. Where does the problem lie?
Steinert 2008:BMJ 336,
Where does the
problem lie?
Unsupportive
Overly critical
Unreasonable expectations
Disinterested
Non challenging
Failure to meet learner’s needs
Teacher
Work
(e.g. workload, unsupportive staff)
Social
(e.g. marital, financial)
Personal
(e.g. substance abuse, illness)
Training
(e.g. unsupportive VTS, lack of guidance)
Knowledge
Skills
Attitudes
Learner
Environment

15. Going to focus on problems with the learner
(because that is the subject of this workshop)

16. Models of learning Androgogy Experiential Learning Theory
Bloom’s Taxonomy

17. Androgogy vs. pedagogy Pedagogy Androgogy Need to know
Know that they must know what the teacher teaches
Need to understand relevance before learning
Learner’s self-concept
That of a dependent personality
Responsible for own decisions and actions
Role of experience
Experience of limited value to learning process
Value and use own experiences in learning
Readiness to learn
Ready to learn what the teacher tells them
Ready to learn what they need to know
Orientation to learning
Topic oriented learning
Life centred, problem centred learning
Motivation
External motivation (exams etc.)
Internally motivated (self improvement etc)

18. Experiential learning theory
Jung
Kolb
Honey and Mumford

19. How do we learn? The Learning Cycle Concrete Experience Feeling
Accommodating
(feel and do)
HM - Activist
Diverging
(feel and reflect)
HM - Reflector
MB – Feeling-thinking scale
how we think about things
Perception Continuum
Active Experimentation Doing
Reflective Observation Reflecting
Processing Continuum
how we do things
MB – extroversion-introversion scale
Converging
(think and do)
HM - Pragmatist
Assimilating
(think and reflect)
HM - Theorist
Abstract Conceptualisation Thinking

20. Blooms taxonomy 3 domains – cognitive, psychomotor, affective
Hierarchies in each domain, starting with most basic, ascending to most developed

21. Bloom’s Taxonomy – cognitive domain
High cognitive
demand
Evaluation
Fully functional knowledge
Learner has to make deep
connections and meaning
Synthesis
Analysis
Application
Low order skills
These are a means to
achieving fully functional
knowledge
Comprehension
Low cognitive
demand
Knowledge

22. Levels of cognition Cognitive level Sample activities Evaluation
Appraise, critique, evaluate, justify
Synthesis
Compose, create, design, devise
Analysis
Compare, contrast, differentiate, relate
Application
Demonstrate, construct, prepare, predict
Comprehension
Summarise, interpret, explain, translate
Knowledge
Recall, reproduce. identify, match

23. 3. Structured intervention

24. Structured intervention
Directed at the source of the problem (learner,
environment, teacher) and to the nature of the problem
Change the environment (training practice etc.)
Change the trainer
Draw up a learning contract
Define objectives, communicate expectations
Additional teaching/support, mentoring
Counselling, sick leave
Further information gathering (psychology report, previous teachers, etc.)
Reduce workload
Protected time
Regular feedback on progress against agreed objectives
Dismissal…..in association with careers advice, support, constructive feedback etc., etc!

25. Learning plan/contract
States…
What will be learned
How it will be learned
What resources are needed
How learning will be measured
How long it will take
Joint responsibility, between trainer and registrar

26. What have I been doing differently?
Informed partners and PM but no other staff
Contract of educational objectives
Monthly review of performance compared to agreed objectives
Doing greater proportion of seminars myself
Fewer topic based seminars and more seminars focused on eP and PDP
More proactive in teaching, rather than reactive
Very specific learning tasks, in small chunks, working up the cognitive ladder of Blooms taxonomy, but tending to stick at lower end of cognitive hierarchy
Tendency to challenge more and take less for granted
Review all consultation records
Screen all referrals before sending
Markedly reduced registrar workload
Few home visits
All Cuedoc shifts supervised
More joint surgeries
More proactive in seeking feedback from colleagues
Exhaustive record of discussions from structured teaching sessions
Documentation in form of daily diary
Switch emphasis from training in general practice to training to learn and study

27. Contract of educational and performance objectives
Undergo assessment by educational psychologist
CBD every month
COT every month
All referrals to be recorded on eP
Weekly joint consulting session
All learning points to go onto learning log
All learning objectives onto PDP
All PDP entries to be SMART
Self appraise at least one video every week and record on eP
(Takes a lot of time though)

28. Evidence and objectivity at all stages
Documentation and record-keeping
Regular appraisal and feedback
Fairness
Confidentiality
90% of problem learners succeed after structured intervention

29. Trainers responsibilities
Raise concerns
Clarify nature of the problem
Manage safety
Maintain confidentiality
Design and deliver intervention
Measure outcomes
Give feedback
To trainee - to train, not to assess (formative not summative)
To scheme/deanery - to give objective feedback, backed up by comprehensive documentation

30. Other considerations….
Your own workload
Partners workload
Reimbursement