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Training dispute perspectives

Jun 16, 2016

“Allegations of poor performance and bullying are often enmeshed … Supervisors who are responsible for giving feedback report being concerned that they are open to allegations of bullying; trainees report that supervisors are often ill-equipped to provide constructive, timely and detailed feedback without bullying.”1

Claims of bullying, discrimination and harassment in college training programs concern everyone in the medical profession. The issues involved are often complex and rarely one-sided. The following scenario illustrates some of the possible complexities – it is a compilation of several scenarios with details changed to ensure privacy. Two doctors – one senior, one junior – and an Avant employment lawyer comment on the scenario. 

The scenario  

Dr Shore*, an overseas-trained doctor, was nearing the end of her specialist training when there was a patient incident. The patient, who was particularly vulnerable, reacted badly to what she felt was an inappropriate comment. 

Dr Shore’s supervisor believed the incident was because of cultural differences and suggested that she increase her exposure to popular culture to improve her fluency in the Australian vernacular.  

Dr Shore had several other clinical incidents including misreading pathology results and errors in ordering medication. Her supervisor says he discussed them with her and was concerned at her response.  

He raised these issues with the college’s director of training, with whom he trained. Together they prepared a remediation plan to address Dr Shore’s communication skills without inviting her input. 

Dr Shore disputed the need for remediation. She argued that she had treated patients with varying educational and language levels in all her previous rotations and no concerns had been raised. She claimed the clinical incidents were minor, that she was being unreasonably targeted, and that any errors were due to the toxic environment and difficulties with her supervisor. 

On further investigation, previous rotation reports had noted concerns with Dr Shore’s communication skills and ability to accept feedback, but all reports rated her progress as satisfactory or better. 

Eventually Dr Shore was suspended from the training program. She accused her supervisor of bullying and harassment and lodged complaints of discrimination against her supervisor, the hospital, the area health service, the director of training and the college. 

A legal perspective: Sonya Black, Special Counsel ­­– Employment, Avant 

A 2015 Royal Australasian College of Surgeons report indicated 49% of surgical fellows, trainees and international medical graduates reportedly having been subjected to bullying, discrimination or harassment. Thankfully, the “culture of silence” about this is starting to break down.

Both trainees and supervisors contact Avant for assistance, so we see disputes from both perspectives and across all specialties. We also see the distress these disputes cause for both supervisors and trainees, and the impact on their health and wellbeing and ability to safely care for their patients.

Performance management is difficult and time-consuming. Supervisors often feel ill-equipped, which might mean performance management is not done well or avoided altogether during a rotation. But if issues are left unchecked they can become difficult to address. The trainee is likely to feel aggrieved, and be resistant to feedback, when issues suddenly come up that have never been raised before.

On the other hand, some trainees are given constructive feedback but they choose to disregard it.

Where members of the college have longstanding professional relationships, trainees can perceive themselves as outsiders, and it can start to feel like a conspiracy. It is not uncommon for bullying to be raised.

One thing we do is to help people understand the distinction between reasonable performance management, poor performance management, communication issues and bullying in the legal sense.

Trainees often come to us late in the process when they have already been denied procedural fairness and natural justice. While it can seem threatening for a trainee to seek legal advice, doing this early provides support and a fresh perspective. I cannot stress enough the importance of procedural fairness and natural justice. Trainees are entitled to legal advice (as are their supervisors) and they are entitled to procedural fairness regardless of the merits of their case.     

The trainee’s perspective: Dr Amanda Brownlow 

A consequence of aiming to select more empathetic, better-rounded people as trainee doctors, is that trainees are now older and more mature, often graduates of other disciplines and with previous careers. By the time we get to registrar training, we have invested significantly in our careers, often have large educational debts, and financial and family commitments … and failure just isn’t an option.

Supervisors are also affected by these changes and others – hospitals have restricted doctors’ hours and the trend towards part-time work for trainees comes with a loss of opportunities for learning and team continuity. Ultimately the responsibility for the patients we “learn” on rests with our supervisors who have to weigh up their responsibility to teach us with their duty of care to their patients.

When things go wrong in training it is stressful for both trainee and supervisor. No one wants to pursue legal avenues. Unfortunately though, with so much at stake, trainees sometimes feel they are left with no choice.

It is essential to improve pathways for supervisors and trainees to resolve concerns about training. Supervisors need to act thoughtfully but swiftly. The trainee needs to be given the opportunity to be actively engaged in the process to avoid them feeling as if they have been denied natural justice. The perceived power imbalance between the trainee and their college is one reason trainees end up engaging legal assistance. 

Underperforming trainees should be identified early in their career with improved constructive communication from supervisors when a trainee’s performance is consistently “only just” satisfactory. Early intervention is preferable to waiting for inevitable training failure.

Dr Brownlow is a GP registrar and a member of Avant’s National Advocacy Stakeholder Committee and National Doctor in Training Advisory Council.   

The supervisor’s perspective: Dr Ian Incoll 

My first impression is that this sounds familiar. Miscommunication between patient and doctor happens all the time … but the subsequent dialogue is what determines the consequences. This emphasises the importance of early training in communication and cultural competence.

Reference to “other clinical incidents” is unfortunately also common in these situations, and often these incidents haven’t been documented or discussed with the trainee when they happened. Failing to raise such issues does not provide natural justice for the trainee, it exacerbates their lack of insight”, breaches procedural fairness and is likely to be in breach of the college’s policies.

Feedback should be provided soon after the observed behaviour, by a trusted teacher, and with explicit plans for improvement. Creating a remediation plan without the trainee’s involvement denies the trainee the opportunity to explain their version of events or influence the proposed plan. Pointing out recorded but unresolved issues many rotations later, blind-sides the trainee.

A supervisor’s “failure to fail” a trainee can arise from insufficient faculty development, support or lack of process. Trainees work in a high-stress environment and are usually high-achievers. Feedback that creates cognitive dissonance with their self-perceived performance is very likely to evoke an even greater stress response. A trainee’s claim of resulting distress is valid.

The psychological and physical health of the trainee must be considered, as must the involvement of their treating practitioners (if any and only with the trainee’s consent). The training organisation’s duty of care to the trainee should remain paramount.

Dr Incoll is an orthopaedic surgeon and Vice President and Dean of Education of the Australian Orthopaedic Association, a Clinician Educator, and a Program Advisory Board member for the International Conference on Residency Education. He is a member of Avant’s National Advocacy Stakeholder Committee. 

Towards a resolution  

Avant’s Doctor in Training Advisory Council and National Advocacy Stakeholder Committee are looking at these issues and Avant continues its discussions with the Committee of Presidents of Medical Colleges, several colleges, and their education officers, to share experiences and deepen our mutual understanding of the underlying causes.

A workshop was recently held with the colleges to share expertise in employment law, medical education, trainee supervision and relationship management. The workshop aimed to develop solutions for the profession to reduce or resolve complaints, and to support supervisors and trainees through coaching, mentoring and managing performance.

*Names have been changed.

1Expert Advisory Group on discrimination, bullying and sexual harassment advising the Royal Australasian College of Surgeons.  

Read the full issue of Connect. 

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We welcome your feedback on this article – email the Editor at: editor@avant.org.au