Appendix A. Case studies

 

Andrea is part of the way through her first general practice term. At a peer learning workshop, Andrea mentions to one of the medical educators that she is enjoying general practice but having issues with time management.

How common are time management difficulties for a registrar in their first term?

Does the medical educator need to inform the remediation officer (RO) about the conversation with Andrea?

The educator decides to report her conversation to the RO. On face value, the educator says, Andrea appears to be having the usual settling-in problems for a first-term registrar. However, given that Andrea has spoken up, the educator wonders whether Andrea might need some support.

Should anything be done to assist Andrea?

The RO decides to investigate further. Andrea has recently had her first clinical teaching visit, so the RO looks at the report. The visiting medical educator has reported that Andrea is highly capable and progressing well; however, she is a ‘worrier’ and might benefit from some support.

Is there cause for concern? What should be done now?

The RO decides to speak to Andrea’s supervisor. The supervisor is surprised to receive a call from the RO. He reports that Andrea is coping but she is ‘sensitive’. He acknowledges that patients in that practice can be ‘difficult’ in that they have certain expectations and that Andrea may be struggling with this. Furthermore, he says that Andrea had spoken to him about reducing her hours to part time, and that he advised her against it. He believes that she underestimates her abilities.

What questions do the supervisor’s comments raise? What should the RO do now?

The RO decides to speak with Andrea.

What should the RO's approach be?

In the meantime, Andrea contacts the RO. She says that there has been a series of events in the preceding week that have caused her to become quite distressed. This has culminated in her having a ‘meltdown’ at work, just a few minutes ago, when her supervisor spoke to her curtly. She believes that there is a ‘personality clash’ between them. She doesn’t understand why her supervisor insists that she do things his way when she is capable of making decisions on her own. Andrea doesn’t want to rock the boat. She says she can ‘put up with the situation’ until the end of the term, which is four months away.

What are the concerns?

Should Andrea be allowed to ‘put up with the situation’?

Not long after Andrea has hung up, Andrea’s supervisor calls to report that Andrea has just had a ‘meltdown’ and that he doesn’t know what to do with her.

What should the RO do now?

The RO decides to meet with Andrea and her supervisor.

What should the RO's approach be in arranging a meeting?

How should the meeting be conducted?

The RO arranges a meeting with Andrea and her supervisor. Andrea is quite nervous about it. In the meeting, Andrea expresses her feelings of inadequacy because she can’t meet the standards of the clinic as well as her supervisor’s expectations. She feels intimidated. Furthermore, she reveals that this has brought back memories of being bullied when she was an intern.

How should the situation be managed? What are the management goals?

What about Andrea’s expectations of herself?

Malcolm is in his third general practice term. There have been no concerns regarding his clinical practice. In fact, several medical educators have commented that he is ‘high functioning’.

Malcolm complains to the remediation officer (RO) that his supervisor has shouted and berated him in front of clinic staff. He says that he does not wish to make a formal report nor that any further action be taken because he doesn’t want his supervisor to give him a bad report. Furthermore, he is ‘used to it’ because he has had similar issues at a previous clinic.

There have not been any previous negative reports about Malcolm’s current supervisor or the practice where he is now working.

What are the issues in this situation?

Does the fact that there have not been any previous reports about the practice or the supervisor make any difference?

What can be done with registrars who make a complaint ‘just for the record’?

Similarly, what can be done with supervisors who make a complaint about a registrar ‘just for the record’? Should supervisors be required to document concerns such as these in the registrar’s term report?

What should the RO do now?

Marguerite is in her first general practice term and is working part time. Midway through the term her supervisor calls the remediation officer (RO) to say that he is very concerned. His specific concerns are that:

• Marguerite is at medical student level with respect to her clinical skills and requires a lot of supervision
• despite regular tutorials, she is not studying and not retaining information
• she appears distracted and is not focusing on her work
• she seeks the supervisor’s advice very frequently and for very minor things that she has asked about before
• her physical examination skills are inadequate
• her progress is very slow.

How is the supervisor’s comment that Marguerite’s ‘progress is very slow’ to be interpreted?

How should the supervisor’s concerns be addressed?

The RO speaks with Marguerite, who reports that she:

• has a four-month-old baby who is very unsettled and won’t let her sleep at night; consequently, Marguerite is tired all the time
• lacks confidence
• has difficulty with managing uncertainty and finds it difficult to know what to do
• tries to study but can’t focus because she is so tired.

Is Marguerite’s tiredness sufficient to explain all of the supervisor’s concerns? Is more information required?

What should the course of action be now?

The RO decides to observe Marguerite’s consulting, and he notes the following:

• While there were some issues with Marguerite’s clinical skills, they were certainly not as bad as her supervisor had reported.
• Marguerite called her supervisor for advice on every consultation.
• The supervisor would tell Marguerite what to do rather than guide her to problem solve.

Is Marguerite lazy?

How can we know whether Marguerite is capable?

If Marguerite is capable, is she then also remediable? What is the plan of management now?

Should Marguerite be required to take time off until her home situation is in order and she is less stressed?

Theo is a part-time registrar in his first general practice term. Close to the end of the term, a distressed supervisor reports to the remediation officer (RO) that he doesn’t know what to do with Theo. Despite having spoken to him several times, Theo has not acted on any of the feedback that he has given him. The supervisor says that he has serious concerns about Theo’s knowledge, clinical reasoning, documentation and, most of all, his behaviour.

How would you respond to the supervisor?

Why has the supervisor left it till the end of the term to report his concerns? What other information is required?

What is the management plan from here?

Other than quoting the rule book, how can unprofessional behaviour be addressed? Can such behaviour be changed?

Samantha is in her third general practice term. Her supervisor reports the following concerns about Samantha to the remediation officer (RO):

• Her progress notes are poor (scant statements about the presentation, diagnosis and management).
• She is not checking the results of investigations.
• She has a tendency to ring her specialist friends for advice rather than take her questions to her supervisor.
• Even when she does ask questions of her supervisor, she doesn’t appear to follow the advice that is given.
• She is prescribing drugs of addiction inappropriately.
• Her billing is sometimes inappropriate.

Supervisors are familiar with clinical skills issues such as these, and are generally capable of managing them. Why has this supervisor resorted to speaking to the RO?

The supervisor reports that she tried to speak to Samantha about these issues but Samantha became quite defensive to the point that the discussion broke down. Consequently, the supervisor does not want to engage with her again. In fact, she has been actively avoiding Samantha. Furthermore, the supervisor believes that Samantha’s concern for her patients borders on the inappropriate. As an example, Samantha has given her mobile number to a few patients ‘in the event of an emergency’. Also, patients from Samantha’s previous posts have followed her to the current practice even though they have quite a distance to travel.

What are the issues here?

Has Samantha crossed professional boundaries? How should the various issues be addressed?

The RO decides to get more information. Reports on Samantha’s progress in her previous terms have all been satisfactory. They report that ‘Samantha establishes good rapport with her patients … is well liked … friendly, chatty manner … shows concern for her patients … management, on the whole, is appropriate’. The RO also speaks with Samantha. Samantha becomes very defensive, saying that ‘other doctors in the clinic do worse things than me. Why should I be targeted like this when I am the only one in this clinic who cares about the patients?’
Have the issues/concerns changed?

What should the course of action be now?

How should Samantha’s comments regarding the other doctors in the practice be addressed? Should the supervisor be included in the discussion between the RO and Samantha?

Evan is a part-time registrar. His first general practice term was uneventful, and he is now six weeks into his second term. He has contacted the remediation officer (RO) because he is feeling anxious and worries about his patients, particularly about missing something. He says he is not coping. Because a couple of doctors are away, he has had to manage an increased patient load. He is quite exhausted by the end of the day and he doesn’t know what to do.

How would you respond to Evan?

How would you explore Evan’s anxiety?

Do you require any other information?

Evan describes always feeling a little anxious and having a tendency to worry. His anxiety has been exacerbated, he says, by having little or no time to discuss patient presentations with his supervisor. He is also feeling distressed about the future. His partner stopped work recently to look after their children, aged three and five years. They recently bought a new house and are experiencing financial stress.

Is there anything else that you would say to Evan now?

Should he be encouraged to take time off to address his anxiety?

Evan’s supervisor reports that Evan is asking questions for just about every patient. This is an extra pressure for the supervisor because he is also trying to cope with an increased patient load. The supervisor acknowledges that the patients are complex and difficult to manage; however, Evan appears to ask questions because he is an excessive worrier, not because he doesn’t know. The supervisor asks you whether Evan is intending to take time off because, if he is, he won’t allow it.

How do you respond to the supervisor? How should the situation be managed?

Marion has failed her written exams for the third time. While she only ‘just missed out by 0.1%’ with the first sitting, her scores in the subsequent sittings have been consecutively lower (2% and 5%). She cannot understand why she has failed, because certainly with the second and third sittings she ‘studied very hard’.

Her supervisor is equally dismayed. He cannot understand how ‘a good and capable doctor’ can fail.

What are possible explanations for Marion’s repeated exam failure? Could these exam failures have been prevented?

Is there an underlying clinical skills issue? How should the situation be managed?

Mikhail is an overseas-trained doctor who is now in his third general practice term. His supervisor is angry because he finds Mikhail difficult and argumentative. They frequently clash and Mikhail has often shouted, in front of staff, that he won’t be told what to do. According to the supervisor, ‘Mikhail doesn’t understand Australian general practice’. He says that Mikhail is intolerant of his patients because ‘they present with minor ailments, they ask too many questions and they don’t follow instructions’. The practice staff report that patients don’t rebook appointments with him.

Reports from Mikhail’s previous general practice terms state that his clinical skills and knowledge cannot be faulted and that he has a very good command of the English language.

When contacted, Mikhail doesn’t deny that he has behaved in this way to his supervisor. He is frustrated because his supervisor doesn’t give him credit for his abilities, the patients at the clinic are ‘spoilt’ and staff members are racist.

Why has the situation escalated to such serious proportions? What are the issues? For Mikhail? For the supervisor?

How should the situation be managed?

Sandrine is a general practice registrar in her second general practice term. Midway through the term, the supervisor reports several concerns to the remediation officer (RO) regarding Sandrine, including:

• significant knowledge deficits
• clinical skills at the standard of a medical student
• inability to perform basic procedures such as suturing, administering injections and immunisations, dressings
• a number of patient complaints.

Is this information sufficient to act on?

On further questioning, the supervisor adds the following:

• He is devoting extra time in tutorials with Sandrine, as well as answering her many questions regarding patients during consultations.
• While no specific complaints have been made, patients have been unwilling to see Sandrine again and certain doctors have been worrying that the reputation of the clinic will be affected.
• The practice manager reports that Sandrine’s cultural background prevents her from engaging with patients in the same way that previous general practice registrars have.
• The problem with procedures was discovered when the practice nurse happened to be away.

What judgements have been made? What should be done now?

The RO visits the practice and speaks to the supervisor, the practice manager and Sandrine. Sandrine had not been told that the RO would be visiting and she is visibly distressed when she sees the RO.

How should this situation be addressed?

Sandrine is reassured by the RO that the purpose of the visit is to ascertain what the issues are and how best to support her in her training. Sandrine says that the practice manager is racially prejudiced against her and doesn’t book patients with her on purpose.

Does this information change anything?

How should Sandrine’s claim be addressed?

An experienced medical educator attends on a different occasion to observe Sandrine’s consulting and assess her clinical skills. Following this, concerns regarding Sandrine’s clinical skills are confirmed (although they are not as bad as initially reported by the supervisor). The RO decides that she would benefit from a remedial term.

Should Sandrine remain in her current practice for the remedial term?

The RO decides that it is in Sandrine’s interests to be placed elsewhere. Because a suitable practice isn’t immediately available, she is obliged to take leave. However, the opportunity is taken to commence tutorial work immediately. Sandrine is motivated to improve. She engages in all the educational activities and progresses well. At the end of the remedial term she undergoes an assessment of her clinical skills. From the assessment it is determined that Sandrine has progressed well and that there are no outstanding concerns.

What should be done in the event that Sandrine had not progressed in her clinical skills?

Hans was accepted into a rural pathway and he completed his first general practice term in a remote country town. Because of a change in personal circumstances, he moved to the city and is now in a general pathway. At the time of transfer, no reports regarding his progress were available. The administration staff handling the transfer report that Hans ‘has attitude’.

Does it matter that no past reports are available?

What significance do you place on the comment made by the administration staff?

The supervisor and the visiting medical educator report that Hans’s clinical skills are appropriate for his level of training and that he is progressing satisfactorily. However, the supervisor reported one incident of ‘significant disagreement’ with Hans, but when that is followed up by the remediation officer (RO) , the supervisor reports that ‘it has been resolved’. Periodically, there are reports from different medical educators that Hans has ‘attitude’ and is sometimes rude.

Is there anything that should be done about Hans’s ‘attitude’?

At the end of the second term, Hans takes two weeks’ holiday. While on leave, Hans has a fall, fracturing his elbow. He returns after an absence of two months. Several weeks later, a concerned supervisor reports to the RO that Hans:

• is taking sick days very frequently and that this is disruptive to the practice
• often appears to be very tired and not focused on his work.

The supervisor wonders whether Hans might be taking strong analgesia, which might be impacting negatively on his cognition.

How should this situation be managed?

The RO meets with Hans and reports the supervisor’s concerns to him. Hans confides that he is having significant problems because of his injury (complications of the fracture as well as chronic pain). He has to take opioids for pain sometimes, but never when he is at work. When his pain is very bad, he stays home or he leaves early from work.

How should this situation be managed, particularly as Hans has confided personal information to the RO? Should Hans be compelled to take time off to address his medical concerns?

The remediation officer RO decides to observe Hans’s consulting. With the first few patients, the RO notes minor memory lapses with the history-taking, a tendency to order investigations excessively and to refer early. The last patient presents with asthma and in a moderate degree of respiratory distress. Hans immediately becomes very flustered, has difficulty deciding what to do (prevaricating between trialling him with nebulised salbutamol first and immediate referral to hospital). After some searching he finally finds the nebuliser, at which point the supervisor has already taken over because the patient is in considerable respiratory distress.

How should the situation be addressed with Hans?

The RO tells Hans that his management of the asthma patient was less than satisfactory, that for his stage of training he should have been able to manage the situation with ease and that it could only be inferred that his cognition is significantly affected by his medical problem.

Hans’s response is that he was flustered because he felt that he was ‘under intense scrutiny’. He also adds that the supervisor stepped in unnecessarily.

In light of this, has the RO been overcritical of Hans?

What should be done with Hans now?

Hans is advised to take extended leave from the training program and not to return until his medical issues are under better control.

Is there anything else that should be done? Would it be useful to:

• have an independent person observe Hans’s consulting?
• obtain information from Hans’s treating doctors regarding his medical conditions and fitness to practice?

With respect to the concerns about patient safety and Hans’s work impairment, is there a requirement for:

• the RO and the RTO to report the concerns to AHPRA?
• Hans to self-report?

Hans is told that when he is ready to return to training, he will have to undergo a clinical skills assessment to ascertain his safety to practise, and, specifically, that he will have to demonstrate that there will be no concerns regarding his cognition.

Two years later, Hans wishes to return to training. He presents a certificate of fitness to practise from his treating pain specialist.

Should the clinical skills assessment still be conducted?

Hans undergoes the clinical skills assessment. He completes a multiple choice paper and role-plays a number of clinical cases. He performs poorly with the clinical cases where significant cognitive lapses are noted. His level of skills is found to have regressed and to be below the standard that he had achieved just before the time of his injury. It is determined that he is unsafe to practise, even under close supervision. Consequently, he cannot re-enter the program.

Is this judgement fair to Hans?

Maryse is a general practice registrar working part time in her first general practice term. After only two months into the term, she takes time off for health reasons. She returns 18 months later to continue her training in a different practice. A few weeks later, her supervisor contacts the remediation officer (RO), expressing his concerns about Maryse’s clinical skills. He says that she is requiring a lot of assistance with almost every patient that she sees. She lacks confidence and appears not to retain what she has learnt because she frequently asks the same questions that she has asked before.

The RO attends the practice, observes Maryse’s consulting and confirms the supervisor’s concerns. The RO's opinion is that Maryse requires formal remediation because her skills are well below the expected standard. At this visit, the supervisor also reveals to the RO that Maryse has conditions on her registration because of a medical condition. For reasons of confidentiality however, he is unable to tell the RO what the medical condition is.

Should the RO (and for that matter, the RTO) be told what Maryse’s medical condition is?

How does knowing/not knowing affect the course of action?

The RO provides Maryse with feedback on her clinical skills and expresses his concerns. In fact, he says, compared to when she first commenced her training, her skills have regressed significantly and she will require extra assistance if she is to attain the expected standard for her level of training.

Could the regression in Maryse’s skills be attributed purely to her 18-month absence form training?

Maryse says that she recognises that there is room for improvement in her skills and she is quite happy to receive assistance. The RO asks Maryse whether there might be a reason, such as a medical condition, to explain why her skills have fallen so far behind.

Is it appropriate for the RO to be asking Maryse about her medical condition?

Maryse says that she took time off from training because of a medical condition; however, she has fully recovered and while she is taking medication, it is not affecting her. The only condition on her registration is that she be under supervision.

Should the RO ask Maryse for more information about her medical condition?

How does having/not having more information assist/hinder the RO in managing the situation?

Maryse commences her remedial term. Four weeks into the term, her supervisor and the medical educator providing her with educational support report to the RO that Maryse has made minimal improvement. The RO provides Maryse with this feedback and asks Maryse whether she can account for this and whether her medical condition might be impacting on her ability to progress. Maryse is offended and states quite clearly that her psychiatrist has told her that it has nothing to do with her medical condition and that it is all purely educational.

How should the RO act now?

Scenario

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
• behaviour
• 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).

The assessor:

• 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.