Appendix A. Case studies

 

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 ME 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?

Thank Evan for discussing this with you.

Check what he needs immediately: facilitated discussion with practice, time to see GP, engagement with a psychologist, leave, opportunity to debrief in a safe environment, increased access to supervisor, reduced hours, or patient load, Establish a close follow up plan.

How would you explore Evan’s anxiety?

Cautiously and with a clear understanding of role. In this space the role of the ME or TC is to explore all the issues and encourage/assist the registrar to seek appropriate help from their GP or psychologist. The opportunity to discuss his anxiety should be offered, but it should be respected if Evan chooses not to share.

Do you require any other information?

Review of Evan’s WBA’s, engagement with the training program and performance in ‘out of practice’ education.

Supervisor feedback about Evan’s in practice performance.

Any other social, health or cultural factors that may be impacting Evan if he is willing to share them.

Evan describes always feeling a little anxious and tending 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?

Thank Evan for trusting you and sharing this information.

Acknowledge how all these issues are likely to affect his anxiety and confidence.

Reassure him that you are there to help and ask him what he thinks could be helpful.

Offer other suggestions as appropriate once Evan’s ideas have been explored. 

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

Taking time off may exacerbate Evan’s anxiety particularly about financial issues. It is reasonable to ask Evan for a clearance letter from his GP stating that he is fit to continue working with his current level of anxiety. Despite this Evan should be made aware that taking time off to manage his anxiety is an option for him.

Evan’s supervisor reports that Evan is asking questions for almost 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?

Acknowledge the supervisor’s concerns and current overload.

Identify that Evan’s wellbeing and safe learning is the primary concern.

Seek viable solutions from the supervisor/practice manager to reduce the load on Evan

Consider reviewing the supervisors informal teaching skills e.g. 1 minute preceptor

Check in with Evan to check on how supported he feels

Facilitate discussions between the supervisor and Evan to address the current issues if possible.

Continue to support Evan and the supervisor. 

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 explanations for Marion’s repeated exam failure?

Could these exam failures have been prevented?

• Inadequate preparation
• Time management issues
• Knowledge gaps
• Reading and question interpretation issues
• Clinical reasoning difficulties
• Not changing approach to study in each exam cycle
• Performance anxiety
• Personal issues
• Lack of exposure to common presentations

Intervening after the first exam fail may have been helpful.

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

Perform Post Exam Reflection Training Advice Meeting Identify issues.

Consider specific feedback from assessment team as has failed exam 3 times.

Consider practice and work hour adjustments.

Involve in RACGP exam prep and exam support resources-e.g. SAPT (Self-Assessment Progress Test), PESIP (Post Exam Support Intensive Program)

Consider FLI or remediation term.

Consider Communication Skills Specialist input.

Consider learning disorder/ADHD/ASD assessment and special arrangements that may assist Marion to perform in the exam.

Consider psychological/pastoral support. 

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?

Cultural mismatch - Mikhail may be used to a more transactional approach than a patient centred approach.

Difficulties receiving feedback-Mikhail may interpret feedback as criticism.

Role conflict or uncertainty-Mikhail may have difficulty understanding the GP registrar role.

Professional communication concerns.

Supervisor may not be giving feedback about what Mikhail is doing well.

Supervisor hasn’t asked for help with his communication with Mikhail earlier.

Practice processes and/or patient demographics may be poorly suited to Mikhail’s consulting style.

Is Mikhail in the right specialty-might he be more suited to Emergency Medicine or ICU

The comments about racism must be explored and taken seriously.

How should the situation be managed?

Further information needs to be gathered from the supervisor and Mikhail.

If possible, a mediated discussion should take place to identify whether this working relationship can be salvaged.

Consider ME direct observation of Mikhail’s consulting.

Consider career counselling.

Consider whether a change of practice is beneficial for all concerned.

Consider FLI or remediation for professionalism issues.

Provide support to both the supervisor and Mikhail.

Consider whether the practice/supervisor needs remediating.

Consider whether the practice/supervisor and Mikhail require cultural safety training.

Sandrine is a general practice registrar in her second general practice term. Midway through the term, the supervisor reports several concerns to the ME 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
• several patient complaints. 

Is this information sufficient to act on?

Several significant concerns have been raised. Further exploration of the situation is required.

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?

Judgements

Cultural issues are causing difficulties in the consultation.

The practice nurse has been covering for Sandrine.

Sandrine asking lots of questions means she has knowledge gaps.

The next step would be to check in on Sandrine and get her version of events.

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

How should this situation be addressed?

Check with Sandrine whether it would be okay to meet with her now or whether the meeting should be rescheduled.

Meet with Sandrine by herself initially.

Outline the purpose of the meeting and identify that the goal is to support Sandrine’s training and wellbeing.

Sandrine is reassured by the ME 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?

This needs to be taken seriously and explored further.

How should Sandrine’s claim be addressed?

Ask Sandrine to explain her concerns further.

Ask Sandrine whether there are any other explanations for the behaviours she is experiencing.

Explore whether these issues also occurred in Sandrine’s 1st GP term.

Review available WBA to see if any concerns have been previously identified.

Check on Sandrine’s wellbeing and whether she is safe to continue at the practice while the issues are further explored.

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 ME decides that she would benefit from a remediation term. 

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

This should be discussed with Sandrine initially.

If she does not feel culturally safe within the practice, then she should be moved.

The ME 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 remediation 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 if Sandrine had not progressed in her clinical skills?

Consider any factors that may have hindered her progress e.g. settling into new practice, personal or health issues.

Discuss with Sandrine whether general practice is the career she wants and offer career counselling if appropriate.

Consider whether a further learning intervention is warranted.

Consider whether patient safety concerns necessitate a withdrawal from training

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 concerns regarding his progress had been noted in his record. The administration staff handling the transfer report that Hans ‘has attitude.’ 

Does it matter that no past reports are available?

Yes-it is in Hans best interests that all information about his training journey to date is available to his current training team.

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

It is a subjective statement without supporting evidence and needs to be disregarded for now.

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 ME, 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’?

There are now 3-4 sources reporting that Hans has ‘attitude’. It is reasonable to ask the supervisor and MEs to explain their concerns in more detail. An ME ECT visit would be reasonable to consider.

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 ME 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?

A decision needs to be made immediately regarding whether it is safe for Hans to continue seeing patients while the situation is further explored.

The ME needs to meet with Hans to discuss these concerns as a priority.

The supervisor should discuss the situation with his MDO to determine whether there is mandatory reporting requirements.

The ME 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 takes opioids for pain sometimes, but never when he is at work. When his pain is 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 ME? Should Hans be compelled to take time off to address his medical concerns?

The ME should request that Hans not work until he sees his GP and has a clearance to continue working from his GP.

Options for his ongoing training should be discussed if he is medically cleared.

• Reduced hours or days
• Further Category 1 leave
• Educational intervention with increased supervision while he returns to work.

The information that Hans has shared should be treated confidentially unless there is concern that Hans is a risk to himself or others in which case confidentiality can be breached to ensure safety.

The ME decides to observe Hans’ consulting. With the first few patients, the ME 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 patient should be handed over to the supervisor.

The ME should debrief with Hans, clearly outlining the concerns they have observed with Hans’ consulting today.

The ME 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. Considering this, has the ME been overcritical of Hans?

The explanation that Hans has provided does not negate that there was clearly a significant patient safety issue in the consultation. Whether due to performance anxiety, knowledge gaps or medication side effects the patient safety issue is paramount.

What should be done with Hans now?

Hans needs to be put on leave immediately.

Ongoing support for Hans must be provided while the next steps are sorted e.g. regular welfare checks from the training team, RLO support, EAP support.

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

With respect to the concerns about patient safety and Hans’s work impairment, is there a requirement for the ME/RACGP to report the concerns to AHPRA?

The ME should seek legal advice from their MDO regarding the need to mandatorily report. If the ME is advised that a mandatory report is not needed and the training team is considering a voluntary AHPRA report this must be discussed with the legal team at the RACGP.

Hans should be encouraged 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?

Yes - this is essential.

Hans undergoes the clinical skills assessment. He completes a multiple-choice paper and role-plays several 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?

Yes, Hans is at considerable risk of further patient safety incidents and is not performing at an acceptable level for a registrar in GP training.

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 ME, expressing his concerns about Maryse’s clinical skills. He says that she is requiring a lot of assistance with most patients 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 ME attends the practice, observes Maryse’s consulting and confirms the supervisor’s concerns. The ME’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 ME that Maryse has conditions on her registration because of a medical condition. For reasons of confidentiality however, he is unable to tell the ME what the medical condition is.

Should the ME be told what Maryse’s medical condition is?

Maryse must disclose her publicly available AHPRA conditions to the training team. This is non-negotiable and the failure to disclose can be grounds for Academic Misconduct. She is entitled to privacy about her medical condition however the training team may be able to better support her through training if they are aware of the health issues and how they impact Maryse.

Regardless of whether the diagnosis is disclosed, an assessment of Maryse’s ability to meet training program requirements with her current conditions must be undertaken and training halted if her conditions are incompatible with her being able to meet training program requirements e.g. unable to work more than 14.5hrs a week (minimum training requirement 14.5hrs a week) or gender restrictions or unable to see children.

A medical clearance for Maryse to return to work is required from her treating team. 

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

Not knowing her diagnosis may limit the support that can be offered to Maryse by the training team. Appropriate adjustments to training may not be suggested or offered.

The ME 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?

It is possible, particularly if Maryse has not kept up with any reading/study in the previous 18 months. However other potential causes should also be considered and explored.

Maryse says that she recognises that there is room for improvement in her skills and she is quite happy to receive assistance. The ME 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 ME to be asking Maryse about her medical condition?

It is appropriate to ask as part of an assessment to support Maryse’s return to practice. Maryse may or may not choose to share and this must be respected. However, Maryse must be asked about her registration conditions and how they impact her ability to practice. She should be informed that it is a requirement to inform the training program about any addenda on her registration and any changes to those addenda.

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 ME ask Maryse for more information about her medical condition?

The ME could let Maryse know that sharing more about her medical condition may help the team support Maryse better, but that she is entitled to her confidentiality. It is reasonable for the ME to ask for a medical clearance to say that Maryse is fit to be at work.

Maryse commences her remediation term. Four weeks into the term, her supervisor and the medical educator providing her with educational support report to the ME that Maryse has made minimal improvement. The ME 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 ME act now?

The ME needs to clearly outline the areas of concern with Maryse’s performance and the interventions already instituted.

They should further outline the changes that need to be seen within a given time limit for the remediation to continue.

Maryse need to be made aware of the consequences of not meeting these milestones which may include.

• Further Category 1 or 2 leave.
• Review of the current remediation plan and adjustment if new concerns are identified.
• Withdrawal from training

Maryse should be offered career counselling to see if another aspect of medicine is more suited to her interests and skills.

Maryse should be offered pastoral support e.g. ME, RLO, EAP