Background:

Trainees in Intensive Care Medicine (ICM) typically have the following characteristics:

• Aged between twenty five and thirty five
• A long record of examination success
• High personal, family and peer group expectations of success

They are in the late stages of psychological maturation and in this period fundamental alterations in behaviour are difficult to achieve, as are radical changes in career pathway. Since failure is unexpected and unusual in this group it is important to identify remediable causes of failure before considering a t rainee's removal from the training programme.

Underlying causes:

The underlying causes of difficulty may be related to personal, environmental or adaptive factors:

Personal causes

Personal causes have many origins and must be considered. They include:

• Illness, commonly psychological, but sometimes physical. Depression is not uncommon in this age group and professional demands may unmask obsessive compulsive disorder. Physical illness, though less common, may be masked, for example hypothyroidism.
• Injury, particularly previous head injury, may have limited the trainees physical capacity
• Indulgence: excessive use of alcohol, drugs and too active a social life may be a major factor in poor performance
• Insight, developing late, into what the trainee increasingly realises is the wrong choice of career, may manifest as failure to perform satisfactorily
• Internal conflicts owing to cultural dislocation or religious incompatibility with medical practice may be problematic
• Finally, difficulties in personal relationships may cause underperformance

Environmental causes

The environment for training and assessment is fundamental; failings in the trainee may in part be a consequence of the training environment. The training environment sets its own standards and should provide appropriate induction, supervision and teaching as well as feedback.

Adaptive causes

In general adaptive causes are more difficult to manage and are most often seen as a failure to integrate knowledge into clinical practice such as inappropriate ranking of differential diagnoses and poor choice of diagnostic tests.
Attitudes which are overly hierarchical, intolerant of advice and demonstrate poor leadership skills may stem from poor role models or a rigid personality.

Identifying the trainee in difficulty:

Impending failure may become manifest in different ways:

• Failure to acquire knowledge and skills in a timely manner
• Poor working relationships with colleagues and professional relationships with patients
• Inability to use knowledge appropriately in clinical situations

It would be naïve to suggest that each of these problems occurs in isolation. There is often overlap. The problems are often more obvious to the peers of the trainee than to the trainers and provide powerful support for multi-source feedback as an assessment tool. Not all problems are remediable, but all trainees have a right to expect that they will be explored and addressed before removal from a training programme.

In everyday practice, characteristics of a trainee in difficulty may include:

• Reluctance to ask for help - personal pride is put before the patient
• Poor or inconsistent communication skills
• A lack of responsibility
• A lack of reflective learning - inability to apply previous experiences to practice
• Frustration and anger
• A disregard for punctuality
• A lack of insight - failure to appreciate that there is a problem

Incidents during routine practice that raise concerns about a trainee can be considered as early warning signs. To identify trainees in difficulty & remediable causes, key questions to ask include:

• a) Is this an isolated incident or is a trend/repetition in evidence?
• b) Does the trainee have the insight to recognise the problem?
• c) Can the incident be turned into a learning opportunity?
• d) What questions does the case raise about the training environment?

Action:

A strategy to manage trainees in difficulty should be agreed at both national and local level, but action to address clinical incidents which raise concern should include:

• Focus on safety
• Ensure that the trainee knows how and when and who to call for help
• Discuss the event with the trainee and clarify how a similar incident would be handled next time (reflective learning)
• Can an incident be turned into a learning opportunity and linked to continuing professional development (e.g. a quality assurance project; a staff presentation)?
• Communicate that things are going wrong (early warning)
• Increase formal and informal monitoring, supervision and review of the trainee and the training environment

Clinical Scenarios:

Some examples of incidents during routine clinical practice that may indicate early warning signs of a trainee in difficulty, and the actions that may be taken to address these are available to view below:

Clinical scenario 1 - post operative haemorrhage
Clinical scenario 2 - infection control
Clinical scenario 3 - sedation & safety
Clinical scenario 4 - intubation
Clinical scenario 5 - epidural