The Doctor in Difficulty

The term “Doctor in Difficulty” is one that will have different emotions attached to it depending on your experience. We used to just think about “trainees in difficulty” but then realised non-trainees are just as likely to be in difficulty and need some support.

A trainee in difficulty is a nationally accepted phrase used to describe a doctor or dentist on a postgraduate training programme, who, for whatever reason, needs extra help and support – beyond that which is normally required – to deal with an issue, or issues, that threaten to impede their progress towards completion of a postgraduate training programme.

A doctor in difficulty is someone who meets the criteria above, but who isn’t in a training programme.

A department in difficulty, in this context, would be a department with constant failure to provide a supportive educational environment.

The purpose of identifying a doctor as being “in difficulty” is not to label them; it is to aid the addressing of relevant issues so that they may flourish, complete training successfully, and continue to contribute to the work of the NHS.

When to Suspect

The 10 classic signs of a Doctor in Difficulty

• The “disappearing act” – disappearing, lateness, frequent sick leave.
• Low work rate – leaving late and still not achieving a reasonable workload.
• Ward rage – bursts of temper; shouting matches, real or imagined slights.
• Rigidity – poor tolerance of ambiguity, inability to compromise, difficulty prioritising, inappropriate ‘whistle blowing’.
• Bypass syndrome – junior colleagues or nurses find ways to avoid seeking the doctor’s opinion or help.
• Career problems – difficulty with exams, uncertainty about career choice, disillusionment with medicine.
• Insight failure – rejection of constructive criticism, defensiveness, counter-challenge.
• Lack of engagement in educational processes – fails to arrange appraisals, late with learning events and work-based assessments, reluctant to complete portfolio, little reflection.
• Lack of initiative or appropriate professional engagement – the trainee may come from a culture where there is a rigid hierarchical structure and trainees are not encouraged to question patient management decisions by senior colleagues, or demonstrate other healthy assertive behaviours.
• Inappropriate attitudes – the cultural background may be very strongly male-oriented and the trainee may not be used to working with females on an equal status basis.

From isolated incidents it is often difficult to know whether a doctor is in difficulty. It is important for all who work with the doctor to report incidents if and when they happen so patterns can be identified. Sometimes you might notice that doctors are always sick on day 12 of their rota pattern – this is likely to indicate the rota needs adjusting rather than the doctor needs extra support. Conversely, a doctor off sick roughly every month, might need to be encouraged to get a review of their dysmenorrhea treatment.

RCEMLearning image generated with Google Gemini

Management

The first time you might be involved with a TiD is when a problem happens – maybe a member of the extended team complains, or a patient asks why they’re waiting, or the doctor breaks down on shift. Your role as a supervising senior initially is not to investigate. You need to ensure safety of:

The patient – go and review them

The staff – support them by listening and providing necessary actions

Early identification of problems is important. Establish and clarify the facts with as many sources of information as possible. Remember, poor performance is a symptom and not a diagnosis.

Clear documentation of events is needed. It’s not always appropriate to document this on an e-portfolio. A password protected file emailed to yourself and the doctor may be sufficient.

Remember, patient safety comes first.

When speaking to the doctor, remain focused on the specific problem and refrain from generalised comment.

• Try to find positives
• Avoid ‘You’ and use ‘I’
• Explain how you are thinking
• Wait
• If you face hostility, state their feelings
• Avoid confrontation
• Use empathic assertion
• Active listening
• Control your anger
• Let their anger subside

I’m sure you’ve had lots of challenging cases and have different approaches to managing them. Here are a few we can think of, with suggested actions.

1. Leaves a shift sick but won’t say why. You suspect anxiety. This happens a lot and it’s not your place to investigate there and then. Be supportive. Ask them to let you know when they get home. Consider asking about their mental state if you are very concerned. Ask who is at home looking out for them. Inform the rota coordinator and their supervisor straight away, who can perform any necessary pastoral care.
2. Complaint of poor behaviour from a nurse. I’ve had complaints about doctors being slow, sleeping on tables, shouting at nurses, not moving from a computer etc. The first thing you have to do is decide if you have the capacity to deal with the problem there and then. Then it’s worth asking the doctor if everything is OK. Say someone is concerned you’re not yourself because of XYZ and take it from there. Let their supervisor know what you’ve discussed and update the nursing supervisor if necessary.
3. Slow doctor. This should always be discussed in a calm environment. Check the numbers before you speak to people about it – facts often don’t reflect reality. I always get the complainant to read this blog from St Emlyn’s and then reflect. The recent consultant strikes have highlighted how workloads have varied, and I think many consultants have been surprised at the inefficiencies of their department and hence the effectiveness of their residents. If you think someone is slow, their supervisor should be the one to address this with them and formulate strategies together to help. Sometimes benchmarking helps, sometimes an incentive. More often, it’s a chat about the role of the ED – what’s for us to do, and what’s for specialty teams to do.

There are more examples from ALIEM Cases – the approach is similar.

Causes

The causes of difficulty are many, but fall into these broad categories:

• Environment – home and work. There’s not always a lot you can do about this but talking through the problems often helps the doctor to find a solution. Less-than-full-time training may be needed.
• Clinical performance – capability and learning
• Health – physical and mental. You may not be the best person to talk about this, and you must always remember you’re their supervisor not their doctor. Refer to occupational health if needed, and signpost to Practitioner Health. Talk about reduced hours and sick leave if appropriate.
• Personality and behaviour
• Department in difficulty – the doctor and the department or their supervisor might not be a good fit, or the department might not be able to support their needs. Moving to a different area to start afresh might be the making of them.

When to refer to the GMC

If the doctor’s illness is impacting on their performance, and one or more of:

• Doctor’s ill health is posing, or may pose, a risk to patients.
• Doctor refuses or has failed to follow advice and guidance from their own doctor, occupational health or their employer.
• Doctor’s conduct has led to the involvement of the police and/or the courts, or has raised other concerns.

Discuss potential referrals with your hospital director of medical education, who will advise you to discuss with the GMC or Practitioner Performance Advice (formally NCAS) first.

References

1. Gray C. Overconfidence in the ED. St Emlyn’s; 2016.
2. NHS Resolution. Practitioner Performance Advice. London: NHS.
3. General Medical Council. Concerns about a doctor. London: GMC