1. “NFD- Below expectations”

2.  To explore the tricky area of trainees with borderline performance  To explore the use of IUP’s to help identify and address concerns  Consider the importance of documenting this in e-p

3.  Important that trainees are aware there is a potential concern and are given the opportunity and support to address it as early as possible(ideally before it becomes a significant problem).  Essential to be able to demonstrate(by documenting in e-p) that the above has occurred and the issue has resolved (or not)  Important that trainees don’t come to final panel and get an unsatisfactory outcome having no idea that this is going to happen.  Essential to ensure those who aren’t fit to practice don’t get through WPBA and gain a CCT just by passing their exams.

4.  Postgraduate school of primary care (PGSPC): 485 GP trainees across the whole HENE area (ECGPTP :35)  Outcome 4’s: Aug 11-12 3(0.6%) Aug 12-13 17(3.5%) ECGPTP:0 (3.5% =1 trainee)  Aug12-13 observed sig more trainees being referred to panel, sig more outcome 2 and 3 being given at earlier stage of training (though very few from EC ) ECGPTP currently: 2x outcome 3’s,last year 1x outcome 3  Increasing numbers of appeals so increasing importance of robust evidence in e-p  Appeals rarely lead to a change in the outcome where the evidence is robust

5.  Increasing expectation for GPR to provide good quality evidence to support ES conclusion  Increasing confidence in use of WPBA as an evidence based tool to ensure that trainees unfit to practice do not achieve CCT simply by passing AKT and CSA  Increasing expectation of EP evidence that SMART feedback has been given to address issues  Increasing identification of struggling trainees earlier on  Increasing expectation that lack of evidence,poor quality of reflection or poor engagement with e-p will lead to a “below expectations” conclusion in the relevant competency  Occasions at final panel where an ES has marked NFD for several competency areas but concluded satisfactory progress.  Occasions when several areas marked “below expectations” but no request for panel opinion(identified by random sampling)  Occasions where there is clear evidence of trainee being “below expectations” in a particular area but their ES marks them as NFD-meets expectations  Some ES’s not sure what to put if believe trainee if performing fine in WPBA but failing exams

6.  Assessment: in the context of Supervised learning events(SLEs)is a key component of the clinical learning environment  Formative: Assessment for learning  Key element-reflection on structured feedback in the context of Supervised learning events(SLEs):helps trainee learn and develop  Summative: Assessment of learning(or performance(AoPs):Provides evidence for judgements on their progression in the competencies required

7. Supervised Learning Events(SLEs)  will use established tools  should ideally be related to feedback from previous SLE’s  Indicating the level of performance is an important part of feedback and supervisors should record levels of attainment using the anchor statements developed for this purpose(Competency Framework)

8. The purpose of the SLE is to:  Act as a learning aid  Highlight achievements and areas of excellence  Provide immediate feedback and suggest areas for further development  Demonstrate engagement with the educational process

9. The challenges:  Difficult to know where certain behaviours fit and whether they are important  Evidence is difficult – not sure what to do/ how important it is  When does evidence of negative behaviour become significant and how do we document it?  How many times in poor performance do people say…’well we already knew that…’ Indicators of potential underperformance “IPUs”

10.  Is doctor-centred  Doesn’t give the patient time and space when this is needed  Can’t keep to time  Fails to engage adequately with the portfolio e.g. the entries are scant, reflection is poor, plans are made but not acted on or the PDP is not used effectively  Misses or ignores significant cues  Informal feedback from colleagues raises concerns  Uses stock phrases or inappropriate medical jargon rather than tailoring the language to the patients’ needs and context  Treats the disease, not the patient  Approach is disorganised, chaotic, inflexible or inefficient  Works in isolation (sits in their room most of the day working)  ‘Dumps’ on colleagues  Lets referrals pile up or fails to write up home visits that day  Records show poor entries e.g. too short, too long, unfocused, failing to code properly or respond to prompts  Doesn’t think ahead, safety net appropriately or follow-through adequately  Examination technique is poor  Dogmatic or closed to other ideas

11.  These behaviours are indicators of potential underperformance (we all exhibit such behaviours from time to time)  They will be common is ST1  They need to be seen repeatedly and in differing contexts before professional judgements can be made as to their significance

13.  Identify behaviours that may cause concern (IPU’s)  Discuss with the trainee using the competence framework  Document if appropriate  (use educators notes or a word document depending on the level of concern)

14.  Being explicit with the trainee is important  Discussing it together, you can see it and see where it fits. This makes it much  easier to have the discussion: -We all do this sometimes -This is normal at your stage -This is becoming an issue -Do you recognise this behaviour/concern?  These are the things that you need to do to improve this aspect  Let's review this with an SLE to see if it's still a potential/real issue for you/others  Reflect and review progress using a variety of tools (and SLEs)  Decide whether it's still an issue  Document

15.  When do you reach this threshold?  When do small things (IPU’s) become performance issues?  When do you decide a cluster of issues in one competency area represents “NFD-Below expectations” in an ESR?  When do you decide that “NFD-Below expectations” in a number of competency areas requires a panel opinion or represents unsatisfactory progress?  How do we decide whether this is important and what action to take?  (Highlight and reflect-is this a training issue or a performance issue that needs action?)  Educator’s notes - date stamp and gives you a timeline but when do you decide when to use this?  Essential that trainees are familiar with the competency framework, empowered to self-assess and work towards improvements