Nidhi is in her third general practice term. Soon after commencing it, her supervisor terminates her employment because he considers her ‘unsafe to practise’.
The remediation officer (RO) is called to investigate.
How should the RO proceed?
Specific information required:
- details of what has transpired
- further evidence
- other examples that support the concerns
- any conflicting information
- anything that can be said in favour of Nidhi.
The RO asks for more information. The supervisor reports that there were quite serious concerns about Nidhi’s management of two patients, including:
- inability to provide adrenaline in a timely manner to a patient experiencing anaphylaxis
- poor clinical reasoning and decision making (believing that the patient had asthma rather than anaphylaxis)
- no awareness of her limitations (attempting an excision of a skin lesion, one requiring a skin flap, but having not done one before and without consulting the supervisor)
- inability to reflect on the above incidents and recognise her errors.
What other information would be useful?
Enquiry should be made about the following areas where problems might exist:
- knowledge and clinical skills
- health and personal issues.
Enquiry should also be made about Nidhi’s training history (all reports, past concerns, clinical capability and progress to date).
Information from Nidhi’s previous general practice terms identifies:
- that she took time off, for family reasons, at the end of her second general practice term, and returned after six months’ absence to commence her third term
- no particular issues with her clinical skills prior to going on leave; she appears to have been well-functioning and progressing satisfactorily.
What about Nidhi’s perspective?
This should always be considered. Nidhi may feel that she has been dealt with unfairly or that she has been misrepresented.
Nidhi accepts that she made errors of judgement with the two patients in question, but she plays them down. She says that she has difficulty with being assertive in consultations and that with new patients she is unsure of their agenda. Nidhi also accepts that home life has been stressful lately but denies suggestions that her family circumstances may be impacting on her performance.
How concerning is this?
Would an assessment of clinical skills be helpful here?
The situation is concerning because:
- of the nature of the incidents
- sufficient cause for the regression in Nidhi’s skills has not been established
- of Nidhi’s lack of insight and her inability to reflect on her performance.
An assessment would be useful in order to:
- obtain a clearer picture of what her clinical skills are like
- determine whether she has the capability and the will to change
- inform a Remediation Plan.
An expert is called to conduct a formal assessment of Nidhi’s skills and to make appropriate recommendations.
What about Nidhi’s perspective?
Does Nidhi understand the seriousness of the concerns? Is she aware that an assessment is proposed and, if so, does she agree to it? What are her thoughts and concerns?
Nidhi is quite happy to undergo an assessment and she is keen to be assisted in whatever way necessary because she wants to finish her training and be a good general practitioner.
What should be assessed?
Should it be a focused or comprehensive assessment? What other questions need answering?
This will depend on what the issues/concerns are. It may be that the identified concerns require clarification or that all issues affecting performance require elucidation (eg knowledge, skills, insight, attitudes, health and personal problems).
The goals of the assessment are to:
- assess Nidhi’s clinical skills and determine whether they are commensurate with her stage of training
- determine the level of Nidhi’s skills and whether they are remediable (if deficiencies are identified)
- make recommendations that will assist Nidhi to further improve her clinical skills and inform a Remediation Plan.
Will this be a fair test?
Validity and reliability of the testing are important:
- Will the registrar have opportunity to demonstrate their abilities adequately?
- What are the criteria for benchmarking?
- What is the experience of those making observations and judgements?
- What opportunities are there to triangulate information (eg independent assessors in the entire assessment, medical educator participants acting also as observers, independent assessors of the video-recorded consultations, feedback from simulated patients)?
Have any untoward effects of the assessment been considered?
All assessments are stressful and this should be acknowledged. Measures for mitigating the effect of stress on performance should always be considered.
What information will Nidhi be given during, and at the completion of, the assessment?
Feedback should be an integral component of all assessments. It is important that what is communicated during the assessment does not contradict anything that is said later.
Nidhi is given feedback on her performance after the first role-play session. This gives her the opportunity to put some of those suggestions into practice in the second role-play session.
At the completion of the assessment, the assessor provides Nidhi with overall feedback (what has been done well, and aspects of her clinical skills requiring attention).
- determines that Nidhi is remediable and makes recommendations with respect to a Learning Plan
- recommends reassessment once the remedial term has been completed
- writes a formal report.
Should the full report be made available to Nidhi?
Yes. Transparency is important.
Who makes the decisions about the action that will be taken? How are decisions communicated?
While decisions will be based largely on the findings of the assessment, they should not preclude the consideration of new information or new developments.
Decisions should be acted upon in a timely manner.
The decision is made to place Nidhi under remediation. Nidhi accepts the Remedial Plan and signs an agreement with respect to the outcomes for the remedial term and, depending on the outcomes, the actions that may be taken.
At the completion of the term, Nidhi undergoes reassessment. The assessor determines that Nidhi has not progressed and that further remediation would not be of benefit.
What should be done with Nidhi now?
Decisions should not be based on the assessment alone. It is important to take into consideration all documented information from all supervisors and educators involved in the remedial term.
A decision is made to remove Nidhi from the training program.
How should the situation be managed? What recourse does Nidhi have now? Should Nidhi be provided with counselling?
Nidhi should be given information about the training organisation’s appeal policy and her available options.
If Nidhi is removed from training, she should be offered career counselling.