The term "difficulties", of course, is a euphemism for "you're at risk of getting kicked off the training program". This chapter specifically applies to the prevailing conditions of the local (CICM) training program and therefore policy-specific issues are not going to be internationally portable, but the discussion of remediation and the basic approach to a floundering trainee probably have some external validity. This has never come up in the exam papers, but it may appear as a possible question in the future. 

Specific resources for this topic include:

What contributes to the success of trainee who has no difficulties? Karnik et al (2015) performed an analysis of fellowship candidates, both successful and non. The following trends were observed.

 Exam success is more likely when...

  • you work in a C24 unit
  • you are of Australian or NZ origin
  • you did a local primary exam (especially the College of Physicians - 100% of them seem to get through the fellowship exam)

Trainee with difficulties

Our tender loving college has issued forth an edict on how one might deal with the trainee who is for whatever reason not coping with the demands of the training program. In brief, the following steps are followed if the trainee continues having difficulties, and these difficulties persist without improvement despite intervention:

  • Formal meeting with the supervisor of training
    • Achievable goals and timeframe agreed upon
  • If the goals are not met, the College Censor is contacted to recommend remedial measures. According to the CICM document, they may recommend "a career change, on a temporary or permanent basis."
  • Disciplinary action is usually handled by the Medical Board.

What is the trainee entitled to?

  • A support person at the formal meeting
  • Formal notification of the steps being taken by the college
  • Appeal of any decision made by the college.

So, your trainee is useless

And somebody has complained to you about it. This is the unenviable position of a Supervisor of Training. A possible CICM SAQ on this topic might one day arise. It would go something like "You're the SOT in a Level 3 ICU and the nurses have made a complaint against one of your trainees. Describe how you would manage this situation." 

What to do? A helpful HETI guide for directors of prevocational training has a nice flowchart to guide management. It is not specific to ICU trainees, but that is not essential. 

Assess the concerns

So, exactly how is the trainee having difficulties? Of what does the concern consist? A range of possible ways to fail needs to be examined. Broadly, the possibilities lie in four major categories:

  1. Patient safety 
  2. Trainee safety
  3. Misconduct
  4. Failure to progress through training

Preliminary assessment of concerns needs to first identify whether the trainee is guilty of something sufficiently heinous to merit mandatory reporting to AHPRA, namely:

  • practising while intoxicated by alcohol or drugs 
  • sexual misconduct in the practice of the profession 
  • placing the public at risk of substantial harm because of an impairment (health issue), or 
  • placing the public at risk because of a significant departure from accepted professional standards.

If it's none of those things, everything becomes more difficult (as the SOT it's now your job to deal with this, rather than leaving everything to AHPRA or the police). 

Investigate

If the difficulties are in the form of some sort of professional concern (eg. poor performance in some aspect of their work) then some objective evidence would be helpful. If the trainee is accused of never washing their hands, ask somebody to audit this objectively. If the trainee has been repeatedly unsuccessful in some procedure or another, find out whether there were patient factors involved. And so on. As the college themselves put it, "training departments should have regular, structured, and accountable processes for gathering feedback on trainee performance in a sensitive manner" as opposed to a rumour mill. This step  corresponds with Step one from the college document.

Interview the trainee 

This corresponds with Step two from the college document. It is an important step, as it offers a chance to validate one's concerns (and it may also generate new concerns). Listen and assess,  recommends the HETI document. Also, a documented meeting is helpful for the future. For one, it makes the college think you are doing something about these difficulties. It also allows the trainee to demonstrate that they have had appropriate support.

Most of all, the intrview allows the trainee to address the issue before it is brought any further. For example, the trainee whose professional conduct is questionable will have opportunity to discuss how they plan to lift their game, eg. "I promise to stop constantly propositioning the female nursing staff" etc. The trainee has a right to respond to any concerns raised and present their side of the story.

Potential problems? There are many. For instance, lack of insight might completely derail the interview process. There may be hostility, tears, rambling disclosure of comically irrelevant personal information, or all of the above. The worst ones are the quiet ones who listen carefully to everything, and then go away and kill themselves.

Action plan

This is some sort of remediation. The action plan needs to be:

  • Specific (i.e. no nebulous appeals, eg. "improve self confidence")
  • Measurable
  • Achievable
  • Relevant
  • Timed (i.e. a time frame needs to be in place)
  • Agreed upon by the trainee and the SOT

The college have a format for their trainee action plans, as described in Step three from the college document.

Review

The progress or completion of this action plan needs to be made the subject of another meeting with the trainee. As the matter may be resolved, this often does not happen. If the matter has not resolved, the review meeting is a good opportunity to revise the action plan and to create a new one if need be.

If satisfactory resolution cannot be achieved, the SOT must inform the College. 

College involvement

Things get worse from here. As the trainee has continued to underperform, the college needs to get involved. This could be a good thing (eg. where the trainee requires resources which are not available locally) but frequently it is not. The trainee interview is held again, but this time with the Regional/National Committee Chair. This is the sort of meeting where the trainee may wish to bring a support person. It ias the last opportunity to get things resolved at the local level.

The next step is a meeting with the College Censor. The Censor's nest is in Melbourne and the trainee will need to travel there to meet them. The objectives of this meeting are "further discuss the unresolved issues, ensure remediation plans are in place and to discuss the possibility of additional training". That's very similar to the aim of the previous meetings, which (if we ended up at this stage) have been unhelpful.  How this is supposed to benefit is unclear from the college document, but it seems to be an additional (non-punitive) step along the path, and is therefore a useful barrier standing between the underperforming trainee and the end of their ICU career.

The last step is a Training Performance Review. This is an independent review of the trainee's progress which is organised by the college. The college thereby outsource the decision regarding the removal of that trainee from the program. It is unclear what sort of body performs the TPR, but the ultimate outcome is either  going to be "please continue with remediation", "defer training while undergoing remediation" or "remove from program". The latter is subject to appeals, and another interview with the college is possible during which the trainee can bring forth some sort of "exceptional extenuating circumstances" which might apply.

References

CICM policy document T-13 (2010): "GUIDELINES FOR ASSISTING TRAINEES WITH DIFFICULTIES"

CICM "Statement on the Practice of Intensive Care Medicine and the Older Intensive Care Specialist"

Skowronski, George A., and Carmelle Peisah. "The greying intensivist: ageing and medical practice–everyone’s problem." Medical Journal of Australia 196 (2012): 505-507.

Finucane, Paul M., et al. "A comparison of performance assessment programs for medical practitioners in Canada, Australia, New Zealand, and the United Kingdom." Academic Medicine 78.8 (2003): 837-843.

Papp, Klara K., et al. "The effects of sleep loss and fatigue on resident–physicians: a multi-institutional, mixed-method study." Academic Medicine 79.5 (2004): 394-406.

Dawson, Drew, and Kathryn Reid. "Fatigue, alcohol and performance impairment." Nature 388.6639 (1997): 235-235.

Landrigan, Christopher P., et al. "Effect of reducing interns' work hours on serious medical errors in intensive care units." New England Journal of Medicine351.18 (2004): 1838-1848.

Macas, A., et al. "Stress and fatigue among anaesthesia and intensive care doctors in Lithuania." Critical Care 14 (2010): 1-1.

Parshuram, Christopher S., et al. "Fellowship training, workload, fatigue and physical stress: a prospective observational study." Canadian Medical Association Journal 170.6 (2004): 965-970.

CICM Policy Document IC-5: "Guidelines on the Health of Specialists and Trainees".

Schattner, Peter, Sandra Davidson, and Nathan Serry. "Doctors' health and wellbeing: taking up the challenge in Australia." Medical journal of Australia181.7 (2004): 348-349. Irritatingly, this one is not available as full text, and the abstract merely states that "promoting psychological wellness in doctors requires tailored interventions".

Fortunately, the AMA has some Resources on doctors' health for Australian doctors which contains a comprehensive list of references.

Venkatesh, Bala, and Andrew Turner. "The intensive care workforce summit." Critical Care and Resuscitation 17.2 (2015): 73.

Karnik, Amod, Bala Venkatesh, and Daniel Angelico. "Analysis of performance and predictors of success in the final fellowship examination of the College of Intensive Care Medicine." Critical Care and Resuscitation 17.1 (2015): 47.

Bevan, Rob, Balasubramanian Venkatesh, and Ross Freebairn. "The intensive care medicine workforce in Australia and New Zealand: oversupplied or underdemanded?.Critical Care and Resuscitation 17.2 (2015): 141.

Panagioti, Maria, et al. "Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis." JAMA Internal Medicine (2016).

Maslach, Christina, Susan E. Jackson, and Michael P. Leiter. "Maslach burnout inventory." Evaluating stress: A book of resources 3 (1997): 191-218.

Reader, Thomas W., Brian H. Cuthbertson, and Johan Decruyenaere. "Burnout in the ICU: potential consequences for staff and patient well-being." Intensive care medicine 34.1 (2008): 4-6.

Elpern, Ellen H., Barbara Covert, and Ruth Kleinpell. "Moral distress of staff nurses in a medical intensive care unit." American Journal of Critical Care14.6 (2005): 523-530.

Corley, Mary C., et al. "Development and evaluation of a moral distress scale." Journal of advanced nursing 33.2 (2001): 250-256.

Bakker, Arnold B., Pascale M. Le Blanc, and Wilmar B. Schaufeli. "Burnout contagion among intensive care nurses." Journal of advanced nursing 51.3 (2005): 276-287.

Verdon, M., et al. "Burnout in an ICU nursing team." Intensive Care Med (2007).

Poncet, Marie Cécile, et al. "Burnout syndrome in critical care nursing staff." American journal of respiratory and critical care medicine 175.7 (2007): 698-704.

Embriaco, Nathalie, et al. "High level of burnout in intensivists: prevalence and associated factors." American journal of respiratory and critical care medicine 175.7 (2007): 686-692.