Identifying and Supporting Doctors in Difficulty – Bringing Research Into Practice

1. Identifying and Supporting Doctors in Difficulty – Bringing Research Into Practice Dr Mumtaz Patel and Dr Joanne Rowell Postgraduate Associate Deans, HEE NW

2. Outline of Session • Update on current research in this area and impact on practice (role of current and new assessment tools) • Understanding the reasons why trainees get into difficulty • Focus on how trainers can identify and manage trainees earlier. • Discuss strategies around optimising educational supervision (improving quality of ESR and “holistic educational supervision”)

3. Doctors in Difficulty (DiD) • Internationally – up to 10% of trainees fail to meet the standards of their training programmes (Tabby, 2011) • Nationally 2-6% of all doctors experience difficulty that raises concern about their performance (NCAS, 2006) Varies (NACT, 2008) • Doctors in the early stages of training are more likely to get into difficulty (Brennan, 2010)

5. Common Presentations Firth-Cozens, 2004

6. Patterns or repetitive behaviours (rather than one off incidents) Sudden out of character behaviour Sickness Serious one-offs that are rationalised by trainee Eg. a small lie Potential triggers of concern

7. Early Signs and Identification Paice, 2004

8. Previous DiD Research • Being a “good doctor” – more than technical and clinical competence, skills and knowledge (Cox, 2006) • Doctors can face difficulty from a variety of sources – influence their performance (Patterson, 2013) • Traditional and summative assessments of competence don’t reliably predict performance (Rethans, 2002) • Many have behavioural and professionalism issues – difficult to assess (Wilkinson, 2009) • Question arises how good are WPBA in predicting DiD?

9. WBPAs and DiD Miller’s Pyramid for assessment WPBA Value in predicting doctors in difficulty ? Professional authenticity

10. Previous DiD Research (2) • DiD behave differently from their peers (Barrow, 2005) • Key features described by Paice (2004) • Lack of insight • Rejection of constructive criticisms • Defensiveness, rigidity, with poor tolerance • Avoidance of challenging situations • WPBA by nature require trainees to proactively select challenging situations, be open to criticism.. • Raises the question whether DiD use WPBA differently

11. Previous WPBA in DiD Research • Mitchell (2011) • Retrospective observational study • 1646 Foundation trainees (92 DiD) • Overall lower mean CBD scores in DiD • Mean WPBA score - very weak predictive value • Mitchell (2013) • 76,115 WPBA in 1900 foundation trainees • 3 major themes – choice of .. • low difficulty assessments (CBD and mini-CEX) • familiar procedures (DOPS) • assessor profession and seniority (nurse and non-clinical)

12. Changes to WPBA - 2012 • In 2012, SLEs replaced traditional WPBA • SLEs use the established set of WPBA such as mini-CEX, CBD, ACATs greater emphasis on constructive feedback and action plans through free text • Key element of SLEs: - incorporate trainee reflection and structured feedback to drive learning - reduce the overall number of assessments - identify training issues earlier

13. SLEs and DiD Miller’s triangle for assessment • Supervised Learning Events (SLEs) • New WPBAs – 2012 • Identify training issues early • Value in predicting doctors in difficulty ?

14. Study Aim • Explore the value of the Supervised Learning Events in Predicting Doctors in Difficulty

15. Methods • 1. Retrospective case control study examining foundation trainee portfolios • 2. Qualitative interview based study looking at senior educators views of the value of newer WPBA in predicting DiD

16. Methods (1) Retrospective case-control study Subjects: NW Foundation School trainees (2012-3 cohort, n=1086). Data: All DiD N=71 Controls (same cohort) N=142 Anonymised E-Portfolios SLEs (Mini-CEX, CBD, DOPS, DCT), TAB and ESR Free text assessed qualitatively Coded blindly using GMC Good Medical Practice Guideline domains

17. Results: Prevalence of DiD 71 DiD from 1086 FY trainees = 6.5%

18. Binary logistic regressionDependent variable: Difficulty statusSingle covariate: Cumulative scores from GMC GMP Domains Sensitivity Specificity TAB ESR Mini-CEX

19. Fishers Association Test*Prediced DID estimated from the GMC GMP cumulative domain scores for each SLEResults – Association Analyses (Fisher’s test) TAB ESR Mini-CEX

20. Qualitative feedback of SLEs

21. Conclusion • TAB/MSF is the only SLE useful in predicting DiD • Educational Supervisor report plays a pivotal role in predicting and evaluating DiD • The SLEs are useful in predicting DiD but not used to their full potential with lack of constructive, especially negative feedback. • M Patel, S Agius, J Wilkinson, L Patel, P Baker, Med Ed 2016, 50: 746-756

22. Study 2… • Factors affecting whether WPBA predict DiD • Understand and explore the reasons around this

23. Methods (2) • Qualitative interview-based study involving senior staff from Health Education England North-West (HEE NW) actively involved in postgraduate medical education (n=15). • Semi-structured interviews conducted until data saturation achieved using Grounded Theory principles. • Thematic analysis done using the Framework method.

24. Activity • On a score of 1-10 how effective do you think the current or new WPBA at evaluating: a) Clinical competence b) Performance c) Professionalism d) Predicting doctors in difficulty • Which WPBA/SLE do you think are better/worse? • What factors affect whether WPBA predicts DiD?

26. Results – Thematic analysis • Types of WPBA • (TAB)(MSF) useful and specific but not sensitive; rest of limited value. • Content and Quality of WPBA • poor owing to lack of detail and discriminatory value. • Assessor critique • time constraints affecting trainer engagement, WPBA completion and quality of feedback often poor especially lacking negative feedback. • Trainee critique • trainee bias with choice of assessors/cases; trainees lacking understanding of WBPA and use incorrectly.

27. Results – Narratives… Theme 1 • MSF/TAB gives a good perception of the trainee in the holistic sense and picks up behavioural and professionalism issues very well (P6) • MSF encompasses the breadth of consultant opinion and contextualise individual areas to give an overall opinion of a doctors performance (P15) • SLEs are similar to older WPBA but less of a tick-box exercise with more free-text (P4) • SLEs.. They have just changed the name with a few more free-text boxes but are useless if they are not completed properly (P11)

28. Results – Narratives… Theme 2 • WPBA are as good as the information you put in.. The process is good but they are not used as they should (P11) • Feedback given to trainees is really important but is often poor, overwhelmingly positive and not constructive (P3) • Failing the failures rarely happens … failures need to be discussed openly as a profession (P14)

29. Results – Narratives… Theme 3 • Many trainers are not engaging with WPBA and still see it as a tick-box exercise … WPBA need to be ubiquitous and accepted by all (P2) • Less time pressure will improve willingness to engage with the process and improve completion of the WPBA (P9) • Hawk versus dove effect with some assessors being very harsh with their marking and others quite lenient (P15)

30. Results – Narratives… Theme 4 • Trainees can be a little contrived as they can choose consultants who are sympathetic and less likely to give them negative feedback (P4) • Trainees could see the first 5 patients in clinic or a ward round and then the WPBA are done.. This would make the assessment for valid and less artificial (P13) • Trainees select assessors who will be kind to them and behave with them in such a way to create an impression they want assessors to see (P14)

32. Recommendations… What next… • Greater use of TAB with more structured feedback • Improve quality of ESR with better triangulation of information from WPBA. • Improving training of trainers/trainees to enhance engagement and improve quality of WPBA and ESR completion and feedback.

33. Subsequent Research • Assessment of Quality of ESR has now been initiated during ARCPs using a standardised framework. • Following individual formative feedback to ES, we have shown significant improvement in quality of successive ESR. • More detailed reports synthesising evidence from a number of sources • More constructive feedback to trainees with clear suggestions of learning outcomes to be achieved and incorporated in the trainee’s PDP. • Increase in the excellent grading in reports

34. Examples of Good Quality ESR

35. Results

36. ESR Feedback – Trainer perceptions • Qualitative assessment of the feedback from ES was overwhelmingly positive. • Structured form and individual formative feedback very helpful. • Many commented just knowing what domains need to be addressed and completed was really useful • No negative comments of the structured form or feedback received • Other than one who mentioned that the time constraints affected the quality of their ESR

37. Conclusion • Simple structured form to assess quality of ESRs during ARCPs can provide: • Useful formative feedback to educational supervisors • Significantly improves quality of successive ESRs • Recommendations include: • Rolling this process across all medical specialties • Larger programmes such as CMT and Foundation

38. Steps to take this forwards.. This work has now been rolled out: • Regionally through School of Medicine at HEE NW. • Nationally through the Renal SAC and JRCPTB through External Advisor Training • Working to roll out to Foundation through Horus • Added in trainee feedback of quality of ESR in 2016 • Started to assess quality of SLEs in 2016

39. ESR feedback –Trainee perceptions

40. Quality of SLEs

41. SLE Quality form

42. Qualitative Feedback - SLEs • Qualitative assessment of the feedback from trainers and trainees was positive • Welcomed feedback and found it useful • Useful to know what domains being assessed and how to improve quality • Many trainees felt SLEs not much different than traditional WBPA • Still seen as tick-box exercise • Not done in timely fashion • Poor quality feedback and not very formative

43. Steps to take this forwards.. This work has now been rolled out: • Regionally through School of Medicine at HEE NW. • Nationally through the Renal SAC and JRCPTB through External Advisor Training • Working to roll out to Foundation through Horus • Added in trainee feedback of quality of ESR in 2016 • Started to assess quality of SLEs in 2016 Workshops set up and delivered to trainers and trainees at induction/meetings to improve engagement and quality of completion of ESR/WPBA/SLE

44. DEMEC 2015 • My work presented alongside other DiD work • East Midlands Group – Sathya Naidoo.. • Showed WPBA (ESR, MSF, PSQ) reliably predicted poor performance (exams, additional training time at ARCP) in GP trainees • Developed assessment tool (matrix) to identify struggling trainees early • Intervention with targeted questionnaire to identify what factors contributing to their difficulty • Providing support early to reduce longer term problems and improve outcomes

45. Developing Assessment Tool to Identify DiD (collaboration East Midlands Group) • Our study has shown TAB and ESR to be strongly predictive of DiD; Mini-CEX weakly positive • Qualitative data but can numerical assess (0,1,2) on no, some or major concern • Easily retrievable from Horus • FPAT selection scores – quantitative from application can be evaluated for predictive value • Can be factored into a “risk” assessment tool for predicting DiD

46. Current Research in Progress Doctors and Dentist Review Group Study HEE NW • Analysing the DDRG/Foundation DiD cohort to look at the patterns of referral, process of management, outcome of each case and see whether it does what it is intended to. • Assessing individual cases to evaluate whether earlier intervention could have altered outcome. • Evaluating the support provided to trainees referred to the DDRG/Foundation DiD and the trainees’ perception of the support received. • Collaborative work with GMC – DiD longer term outcomes

47. Current Research in Progress • SLE feedback – foundation trainee perceptions of feedback with actual feedback (MSc project) • Foundation trainees from HEE NW (75-80) • 4 centres – questionnaire based study and focus groups around educational supervision, use of portfolios, SLE feedback • Anonymised SLEs from trainee portfolios- evaluate actual feedback • Trainee perception of value of WPBA in predicting DiD (Medical Education Fellow project) • Higher speciality trainees in HEE in NW (80) • Questionnaire based and focus groups • Assesses trainees perceptions how struggling trainees can be identified and supported earlier

48. Collaborative Research • JRCPTB – Clinical Lead for Quality • Recently analysed 6 key quality datasets for 29 medical specialties and 3 subspecialties • Analysed E&D data for over 15,000 trainees for all 9 protected characteristics • Compared outcomes (Recruitment, ARCP, MRCP, PYA outcomes, New Consultant Survey, GMC NTS) by specialty and deanery • Mapped across the GMC themes for standards of Med Education • To publish Summer/Autumn 2017 • GMC – Differential Attainment • Understanding the barriers to progression • Educational environment and culture huge issue • Importance of a more holistic approach to educational supervision M Patel, S Agius, Med Ed 2017, 51: 342-350

49. GMC Fair Training Pathways for All • Being ‘different’ to the majority was perceived to be one of the most significant risks to progression - such as inexperience with UK systems and/ or cultural norms. More significant for IMGs than for BME UKGs. • Being able to personally influence change affects perceptions of how difficult or easy it is to tackle risk. Easier to tackle at personal, organisation level rather than regional, national level • Perceived barriers to challenging risks included - lack of knowledge or understanding about differential attainment; lack of available information or evidence about good practice; and sensitivities about race. • Attitudes towards asking for and accepting are changing; a range of interventions and good practice are already taking place across postgraduate education and employers, including training for trainers and examiners, and training and support for trainees; transparency around data and engagement with stakeholders, and designing recruitment and assessments to minimise bias. http://www.gmc-uk.org/about/research/30991.asp

50. Summary… • Brief overview of some of the evidence around identifying and supporting trainees early • Given you a flavour of some of the previous and current research work in this area and how these can be applied in practice • Ultimately … identifying trainees at risk earlier, understanding the reasons why they are struggling, earlier interventions and support, will ultimately help improve their outcomes…