Does your training feel like a struggle?

Abstract

GP training can be difficult for many reasons. In addition to the day-to-day challenges of clinical work, other problems can arise. There may be a health issue, relationship breakdown, bullying, or exam stress: these problems might be common, but the solution will be unique to each person. Sometimes we are aware of our problems but we do not know what to do. Sometimes we are aware of the problems, but we do not want to admit them to other people or, perhaps, even to ourselves. Sometimes we are unaware but others may notice. This article, written for associates in training (AiTs) and their trainers, is a guide to the problems that can arise for AiTs during their training. It covers what these might be, how they may be detected and what can be done about them.

The GP curriculum and training

Core statement 1: Being a general practitioner requires GPs to: know yourself and relate to others. It is relevant for a number of the core competencies within that statement: fitness to practice, working with colleague and in teams, and maintaining performance, learning and teaching. GPs are expected to:

Develop the attitudes and behaviours expected of a good doctor

Manage the factors that influence performance

Balance professional demands with personal ones appropriately

Recognise when struggling and in need of support

Be proactive in asking for help and willing to respond to it when it is offered

Common issues that can derail training

For most GP registrars, the 3 years of their training flies by with few major problems. A single major health or domestic issue may interrupt training for some time, but usually it is a combination of issues that cause the greatest problems. Box 1 contains some of the common issues that can derail training.

Box 1.

Common issues that can affect training.

• Life events such as illness, accidents, bereavements affecting you/your family/your trainer/the practice partners or personnel

• Personal issues around relationships, life partners, parents, children or other family members

• Chosen the wrong branch of medicine or even career

• Difficulties with your trainer/the practice/training arrangements

• A workload beyond your capacity or which seems unreasonable or unfair

• Unresolved personality traits: Perfectionism, chronic anxiety or fear of failure, an excessive need to succeed or be the best

• Making difficult transitions: Moving countries, unfamiliar surroundings, unfamiliar social and cultural norms

• Complaints, adverse incidents, or litigation

• Exam failure – either single or multiple

• Discrimination (direct or indirect)

There can be warning signs that these issues are starting to affect wellbeing. The list in Box 2 is by no means exhaustive, but many have been consistently identified by educators as symptoms of underlying problems (NACT-UK, 2013). Do you think any of these may apply to you?

Box 2.

Warning signs.

• Feeling constantly tired, irritable; having difficulty sleeping and/ or feeling anxious or on edge. Bursts of temper, shouting, feeling sensitive or ‘got at’

• Disappearing act: Not answering your bleep, coming in late, being off sick, not making it to meetings

• Drinking or smoking more. Using or feeling tempted to use drugs

• Not really getting anything done, even though staying late at work. Struggling with paperwork

• Struggling to write up the ePortfolio or do work-based assessments, missing deadlines for the educator supervisor review

• Failing to respond to emails (especially from educators or the scheme) in a timely manner

• Failing an exam or your educational supervisor is requesting a panel opinion

• Missing vocational training scheme half days, or feeling other things are more important to do in that time

• Finding consultations are going around in circles

• Getting into arguments with colleagues/ patients/ educators. Not accepting other points of view. Finding it hard to compromise or to prioritise

Often the ‘final straw’ is in itself not serious, but merely the precipitating factor coming after one or even several other recent problems. Case study 1 demonstrates how this can occur.

Case study 1. Martin ST2/3.

A little girl lost a limb secondary to a late diagnosis of septicaemia. A complaint was received. The first contact had been in A&E where Martin, in his ST2 year, had examined the child and discharged her. The parents had brought the child back the next day when she was admitted with sepsis.

On review by the hospital team it was agreed that Martin had managed the child appropriately. His records were exemplary. He had provided strong safety netting advice.

Martin discussed the case openly at the vocational training half-day session. He said that he had found it particularly difficult as a good friend at school had died of meningitis, and this was part of the reason why he had decided to become a doctor.

A serious incident report to Health Education England (HEE) triggered a one-to-one review with the Associate Dean (AD) who found that Martin seemed to be coping well. Martin was made aware of local support services that were available, but he felt he did not need them.

The complaint process was protracted and was still ongoing when Martin entered his ST3 year. He took his Clinical Skills Assessment for the first time in January and failed by four marks. This prompted a phone review from the AD to the trainer who said she was surprised because she thought that everything was OK. However, she did say that things had been busy at the practice, with a partner being off sick and a salaried GP having left.

At a review with the AD at the practice a week later the trainer said that, on reflection, she had noticed that Martin seemed anxious about decision making, especially with children. She remarked that he seemed to not interact much with practice team. There was very little in his ePortfolio and he was not keeping up with his out-of-hours training. The programme director reported that Martin’s attendance at half-day release was erratic. At the meeting Martin told the AD that he was not sleeping well, was feeling anxious and did not have enough energy to do out-of-hours activities or write things in his ePortfolio. He added that his long-term girlfriend was threatening to leave him.

It also emerged at the review that Martin had had an episode of depression as a student and had needed to take a year out of his studies. He added that he was considering leaving medicine altogether. He said he did not blame the practice, but felt things had been very busy and that he had not wanted to add to his trainer's problems with his own concerns.

Martin was encouraged to take some time off sick. He attended his own GP. He also self-referred to the Practitioners Health Programme who offered medication and counselling.

In the meantime, the trainer, who now recognised that she had been distracted, worked with the AD and her trainers group to ensure that she and the practice were able to provide a more supportive training environment.

After a 4-month break Martin returned to work, to the same practice, on a less than full time basis (80%). The rest of his training went well. Towards the end Martin had four sessions of mentoring organised by the local Professional Support Unit. These helped him think through how he would manage his career long term.

Composite example to retain confidentiality.

Health issues

Physical and chronic health problems may affect us all, and in my experience most people cope remarkably well with their training, with often quite significant disabilities. I have worked with trainees with multiple sclerosis, severe depression and anxiety, lost limbs, and rheumatoid arthritis. All have successfully completed training and continued to work in general practice.

At times, coping with an episode of ill health has to be the priority. Continuing to work during these episodes may be detrimental to health and have a knock on effect on learning. Doctors take a third fewer days sick leave than others in the NHS (Oxtoby, 2015). When things are not quite right, you may believe that you can cope and feel guilty about leaving your colleagues in the lurch. Although you may be able to continue with your service commitments, you may lack the headspace to focus on learning. You might miss vocational training half day release, out-of-hours sessions and stop attending to the ePortfolio. At the time you will intend to ‘catch up later’, but that does not always happen.

Life events can lead to mental health issues, or a recurrence or emergence of an underlying tendency to anxiety or depression. These are likely to affect motivation, concentration and focus. In addition, if you start to struggle, and an educator puts you under further observational scrutiny, this may aggravate mental health problems. A cycle of further failure and further stress is established.

Systemic factors

There are many factors that may affect your ability to do your job and learn effectively that may not be under your control. The NHS, as a whole, is increasingly under stress. There may be gaps in the shift rotations, poorly functioning teams, and unexpected crises. You may be put under pressure to work in a way that you feel is unsafe or feel that patient safety is compromised. You may find it difficult to raise issues, as trainees are not in a position of power. However, you have a duty to be candid and you should document and report any situation you feel is unsafe (General Medical Council (GMC), 2018). Under the new contract you should also ‘exception report’ when your training is being compromised or you are being expected to work beyond your contracted hours (British Medical Association (BMA), 2018a).

We know that much of our learning comes from the culture of the organisation in which we are learning, this is often referred to as the ‘hidden curriculum’ (Bennett et al., 2015). Although many communities of learning are enabling, the culture of an institution may also be toxic. Although there may be no deliberate intention to undermine or even bully - aggressive and intimidating behaviour can be found at all levels (Launer, 2013). We all have a responsibility to explore and constantly challenge unconscious biases that may affect how we interact with people who are different from ourselves (Eddo-Lodge, 2017).

Problems with others in the workplace

It is not uncommon to have problems with other people at work. Relationships may be difficult and conversations can be difficult to interpret. How we understand something may not have been the intention of the other party. Misjudged behaviour will happen on both sides. Although a lot has been done to stamp out individual bullying and harassment it does, all too commonly, still exist. Some examples are given in Box 3.

Box 3.

Examples of bullying and undermining behaviour in training.

• Giving feedback that is poorly matched to the level, resilience or vulnerability of trainees

• Giving harsh, negative feedback with no opportunity for dialogue

• Criticism in the presence of others

• Shouting

• Over- or under-estimating a trainee’s level of competence and failing to provide appropriate experience to match it

• Not dealing with problems as they arise. Storing them up and feeding back too late so that changes cannot be made

• A lack of interest in a trainee’s need for support and development

• Demonstrating a belief that clinical service takes priority over educational needs

• Indifference to level of workload and not responding by attempting to lessen this where necessary

• Being unavailable and leaving trainees without adequate cover

• Belittling or marginalisation of junior doctors by other staff (such as midwives and senior nurses)

Source: Launer (2013).

Adverse events, complaints and litigation

Even when one is in the best of health and life and love are wonderful, incidents at work may also de-rail you (Cohen, 2017). There are adverse and significant events, complaints, potential litigation and GMC referrals. We live in an increasingly litigious world, and living through an investigation of any sort is enormously stressful (Bourne et al., 2015). You may be feeling increasingly worried about how to reflect in your ePortfolio about incidents, fearing that such reflections could be used in court against you (Cohen, 2017).

Assessments

Developing the craft of a GP requires multiple skills, and thus the examination framework for a GP is complex. Failure to progress in any of the competency areas in the work-based assessment or the external elements (applied knowledge test (AKT) and clinical skills assessment (CSA)) can be an amber flag to educators that there are difficulties and may trigger an educational assessment by either the programme director (PD) or patch associate director (AD).

CSA failures are not uncommon. In my experience, working as the lead for trainees who need support in South London, many of those who fail do so by only a few marks, and they usually pass the second time around. Repeated failures can be related to life events and health issues, or associated with language difficulties, subtle misunderstandings of cultural issues or an inflexibility in consulting style. A skilled educator should be able to detect and advise you on these issues.

Dyslexia

In my experience a common reason for failure of the AKT is stealth (or previously unknown) dyslexia. Dyslexia is rarely a factor in the CSA exam. Doctors are highly intelligent and resourceful, so dyslexia will often go unnoticed through school and even at university. A differential between clinical and written skills, poor engagement with the ePortfolio, and difficulties with organisation at work are often seen in retrospect. There may be a history of struggling with multiple-choice exams, difficulty with spelling or written work generally. The classic reading difficulties are often not apparent (Locke et al., 2016). The AKT seems to pose a particular difficulty if you do have dyslexia, although it is not clear exactly why this is and further research is needed. However, it is reassuring that most doctors with appropriate dyslexia support and additional time manage to pass the AKT and achieve their Certificate of Completion of Training (Asghar et al., 2018).

Managing uncertainty

General practice is an uncertain place. One of the major roles of a GP is to manage risk and uncertainty. Many registrars find the transition from hospital to general practice difficult, but most come to terms and even come to relish managing risk. For a very few, practicing general practice may just feel too unsafe. You may worry, spend hours going through things, become unable to finish consultations, stay late, and fear that you do not know enough. This can soon lead to burn out.

What can you do?

If you feel that you have a problem, what is to be done? Box 4 offers an approach that may be helpful. Prepare to work through it after reading the rest of this article.

Box 4.

What can you do?

1 Is there really a problem or do I just think that I have one?

a. Who do I trust that can I check that out with?

2. If after talking to a trusted other it seems my perception is true, consider:

a. What are my options?

b. Who can tell me about options that I do not yet know about?

3. I am pretty sure I have a range of choices - how do I choose? Ask:

a. What are the likely consequences of each?

b. Who can counsel* me if necessary?

4. I now think I know what I need to do. Ask:

a. What is my plan?

b. Who else needs to know about this?

*Good counsellors do not tell you what to do. They enable you to make a decision that is your choice and right for you

You are unique and the solution you need is not likely to be the same as that needed by another person, even if they have or have had the same problem. Take time to work out the one that suits you. Hopefully, you will feel able to talk to one of your educators - either your clinical or educational supervisor or your PD. You should always have a choice of people with whom you can talk. The conversations you have may be enough in themselves or will be a starting point for getting more help and support for your unique solution. You may already be well aware of some of the options available to you. You should be aware that educators may discuss learners confidentially with one another in Trainer workshops; the focus of these conversations is to enable the educator to reflect on their own difficulties and develop a deeper understanding (Launer, 2016).

The following subsections summarise some of the things your educators might suggest, or that you could discuss with them.

Time out

Do take time off if you are sick or not coping rather than attempting to struggle on. You will be paid and will be given an extension to finish your training. This will give you the space to attend to the issues and to put things in place for your return to work. Register with a GP, who can help you access NHS services. In addition your PD or AD will be able to tell you about local resources, some of which are specifically for doctors. The GP Health Service offers support for GP trainees in England who are experiencing mental health concerns or addiction problems (GP Heath Service, 2018). The Practitioners Health Programme (PHP) provides a large range of resources for those in training (including mindfulness and exam stress Cognitive Behaviour Therapy), although access to some services may depend on where you live. Detailed information and resources are available on the PHP and the BMA websites (BMA, 2018b; PHP, 2018).

Occupational health services

Engage with occupational health. It is important that your educators do not see you as their patient. It sounds simple, but it is an easy trap for doctors to fall into when dealing with other doctors and leads to confusion. Occupational health is able to provide information and support for changes to your training and any adaptations that you might require. The most common adjustment is working less-than-full-time. Another option is an intra- or inter-deanery transfer, so that you can continue training nearer to where you live, or nearer to someone for whom you have caring responsibilities. Taking time out-of-programme for up to 2 years can be organised. The details of how to arrange these changes will be available on your local Health Education England (HEE) website.

Professional support unit

Many HEE regions have a professional support unit (PSU). Among other things, they may provide confidential individual assessments, access to coaching and mentoring, and sometimes language support. They may run courses such as communication skills, AKT, CSA, exam stress or resilience training.

Dyslexia assessment

The process to obtain a dyslexia assessment varies depending on your region, but will usually be available through the HEE PSU. Dyslexia is counted as a disability, and reasonable support and adjustments will be made to enable training to be completed. This will usually include extra time for exams and one-to-one support with a dyslexia tutor. If the diagnosis is made late, an extension to training can be recommended by the Annual Review of Competence Panel so further exam attempts can be made and the doctor can embed new learning and coping strategies.

Letting people know that the problem is not you

The new junior doctors’ contract seems to be having some impact on workload, but it still seems that many trainees are reluctant to exception report, especially in the GP environment (BMA, 2018a). The annual GMC survey also helps to provide regular feedback on the quality of the jobs. Half-day release will help you benchmark what is a reasonable workload. Your PD can support you in talking to clinical supervisors or trainers about workload and work stress. This can lead to job reviews and ultimately, if no changes are made, the removal of the training status of a post. In critical situations, Registrars can be moved to safer environments. Bullying and harassment is often complex, and a variety of approaches may need to be taken, especially where this is systemic (Launer, 2013). It is important that you know that HEE takes accusations seriously and will investigate thoroughly.

Managing significant events

If an AiT is involved in a significant untoward incident or GMC referral this should trigger a referral to their revalidation officer (the dean of their local HEE chapter). The patch AD will offer support and ensure that local processes are providing what is needed. Your GP trainer will provide support in answering complaints with help from the defence organisations if required. In hospital posts, immediate help will be provided by your clinical supervisor (CS) and the hospital legal team, but you should always let your educational supervisor and PD know so that they too can provide support and advice.

Educational assessment

Difficulties developing craft skills, failure at exams or concerns expressed by the trainer will require a comprehensive educational assessment. The PD or AD will normally carry this out in the workplace. The assessment will usually include a one-to-one discussion with the trainee and trainer/CS and a discussion together. There may also be some observation of the trainee; by either viewing a video or a live consultation. The assessment will usually result in an educational prescription and suggestions for further help. Practice-based initiatives might include drawing up a learning contract, defining objectives, communicating expectations, reducing workload, giving additional support, different teaching approaches, more protected time and regular feedback against agreed objectives.

Dangers of the ePortfolio

It remains extremely unlikely that written reflections in the ePortfolio will be used against you (Launer, 2018). The Academy of Royal Medical Colleges has provided recent interim guidance on this area and is working widely with all interested parties, including the GMC, to produce one comprehensive set of guidance (Academy of Royal Medical Colleges, 2018).

Conclusion

The difficulties discussed in this article will hopefully be temporary, although they may be longstanding. This is why it is important that you do two things regularly: one is to take time out to reflect and have a look at yourself, your lifestyle, your pre-occupations, your behaviour and your habits. The other is to seek out and listen to feedback about yourself: from your life partner, your friends and, especially, from your educators. You may not like what you hear, you may disagree with it, but do give it thoughtful consideration.

This review of the multitude of issues and difficulties that could affect your training may look pretty scary. Be reassured: although difficulties are common serious ones are rare. Everyone concerned with your training is intent on maintaining your wellbeing and wants you to succeed. Their intent is to help you to find the right niche for you in this wonderful profession. Stay with it and take heart!

KEY POINTS

Anyone can need extra support: Do not be ashamed to ask for or accept help and do it early

Your educators are there to support you and if they cannot help they will know someone who will be able to do so

An episode of difficulty is not a life sentence; if you never struggle with anything you will never learn the skills required to deal with adversity in the future

People get into difficulty for multiple and complex reasons

Conversations about difficulties need to be skilled and neutral; inviting change and unique solutions

Not everything can be changed, so focus on those factors that can be

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