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.