- Email: [email protected]
Working with underperformance in surgical training: Educational strategies for supervisors
Journal Pre-proof
Working with underperformance in surgical training: educational strategies for supervisors M. Bearman PII: DOI: Reference:
S1055-8586(20)30028-7 https://doi.org/10.1016/j.sempedsurg.2020.150908 YSPSU 150908
To appear in:
Seminars in Pediatric Surgery
Please cite this article as: M. Bearman , Working with underperformance in surgical training: educational strategies for supervisors, Seminars in Pediatric Surgery (2020), doi: https://doi.org/10.1016/j.sempedsurg.2020.150908
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
Working with underperformance in surgical training: educational strategies for supervisors Author M Bearman1 1
Centre for Research in Assessment and Digital Learning (CRADLE), Deakin University, Geelong, Australia.
Address for correspondence Professor Margaret Bearman Centre for Research in Assessment and Digital Learning (CRADLE), Deakin University, Geelong, Australia. Tel: +61 3 92468168 Email: [email protected]
Keywords Surgical Training, Underperformance, Managing the underperforming trainee,
Abstract Underperformance is a significant challenge for surgical educators. This paper outlines some educational
strategies
to
manage
the
very
complex
demands
presented
by
underperformance during training in the workplace. Preventative approaches include: setting expectations with early conversations; conscious attention to the workplace curriculum; and building trainee evaluative judgement through assessment and feedback. Once underperformance has been identified, other approaches including: developing a joint action plan; reducing or increasing feedback opportunities; and ensuring the trainee remains motivated. While these strategies cannot prevent failure, they offer the trainee opportunities to succeed.
Introduction Underperformance is one of the most difficult challenges for all health professional educators: clinical supervisors report the time, effort and concern involved in working with a learner who is not at the required level of competency and therefore may be a risk to patient safety1. However, many clinical educators don’t know what to do differently2 and see remediation as a means to scrape a pass3. This may be particularly compounded in surgical education where there can be an expectation that learning is best “under the gun”4. Paice5 outlines key areas of underperformance in surgical training. Early in the training, issues tend to be: “poor clinical assessment and diagnosis; poor communication with patients or colleagues; inadequate, inaccurate or illegible note-keeping; failure to follow protocols; inappropriate investigations; failure to recognize or respond to the urgency of a clinical situation and problems with carrying out practical procedures.” She notes that in
later years, underperformance tends to concern leadership, delegation, difficult situations and prioritising.
This is a complex array of challenges and can be compounded with
obligations to provide competent patient care, interpersonal workplace relationships and the distress and shame experienced by trainees when underperforming. It is therefore useful to have clear educational strategies for managing underperformance in order to provide opportunities for success. This paper frames underperformance as an educational concern. It is aimed at those responsible for training – either directly or indirectly – in order to help navigate the real complexities presented by underperformance. Invoking these strategies does not mean that underperformance is necessarily resolved, however they provide a means to promote success. A key underpinning principle is that trainees should take responsibility for their own learning, in partnership with supervisors. It is suggested that effective partnerships are best built upon foundational educational approaches that are put into place with all trainees. In this way, underperformance can be managed as part of the daily business of supervision, prevented as much as cured. To this end, this paper first describes foundational approaches, followed by a series of specific strategies to be utilised once underperformance becomes identified.
Preventative educational strategies One of the best ways to combat underperformance is to integrate core educational principles into all teaching. There are multiple reasons to take this preventative approach. Firstly, with better teaching, some deficits may be addressed before they become serious issues. Secondly, the expectations and ways of working established during business-as-usual can be drawn upon once it becomes established that underperformance is causing problems. Finally, by treating everyone the same in, surgical trainees who are identified as underperforming don’t have the sense that they are being treated as lesser. This paper describes three core educational practices that are particularly valuable. These are: setting expectations with early conversations; conscious attention to the workplace curriculum; and building evaluative judgement through assessment and feedback.
Setting expectations with early conversations Most models of clinical supervision suggest commencing a placement or rotation with an orienting conversation. These conversations are critical. They provide the opportunity to outline the supervisor’s expectations and also to build an ‘educational alliance’7 between supervisor and trainee. An educational alliance is not the same thing as a personal relationship; it occurs when the trainee perceives an interpersonal bond with the supervisor, a unity of goals and agreed path to reach these goals. In order to achieve this, both the supervisor and trainee must share their aspirations for the rotation or placement and ensure these are mutually agreed. Where possible, a plan should be outlined, associated with identification of the necessary milestones. One of the key points of these early meetings is outlining these expectations in sufficient detail. It can be surprisingly difficult to articulate what constitutes an acceptable performance in the workplace.
Expectations should almost always be underpinned by documentation. Paperwork is not always just a bureaucratic necessity; it can be an educational tool. While formal learning plans can be tokenistic: if the supervisor treats them seriously, it is more likely the trainee will as well. Whether there are formal processes or not, it is recommended that goals and expectations (both of supervisor and trainee) are recorded in an easily accessible place. This structured form of documentation can therefore be a genuine learning resource which can be revisited and adjusted throughout the term. The trainee can then look back on these conversations and self-assess against the standards and expectations; supervisors can review to make sure that their judgements of progress are appropriate.
Conscious attention to the workplace curriculum The workplace curriculum is generally formed by supervisors providing sequenced tasks of increasing complexity and responsibility 8. Most surgical supervisors do this tacitly: there is both an expectation of competency at a certain level and supervisors form judgements whether the trainee can in fact perform at this level. The value of mastery learning models, where learning is built in careful sequence of competencies, which build upon each other is well known in surgical simulation9. Therefore simulation can be used as an adjunct, as this type of careful sequencing may be more difficult to achieve in the workplace. However, it is worth considering with each trainee how the work they are asked to do can build challenge or consolidate learning, in order to meet the expectations outlined in the early conversations. Most clinical supervisors tacitly create a workplace curriculum: the easier tasks are learnt first, and then the more complicated one. The value of supervisors consciously thinking about how the sequence of complexity is to track if the trainee is meeting expectations. For
example, there may be a particular kind of jump in complexity – possibly of independence or a type of technical skill – that the trainee has particular trouble with.
Again tacitly,
supervisors usually know where these ‘pain points’ are within a workplace curriculum: they’ve experienced them themselves as well as supervised others through them. It is worth therefore asking supervisors to try to articulate the curriculum: to try and explicate both the sequence of activity and the particular issues that are frequently present problems. Thus, as mentioned, supervisors can consciously prepare for difficulties by directing trainees to particular forms of practice. This can include simulation, more consolidation work and purposeful observation of others.
Building evaluative judgement through assessment and feedback In addition to early conversations and sequences of tasks that build in complexity, supervisors can also seek to build a trainee’s evaluative judgement 10. Evaluative judgement is the ability to judge quality of the work of self and others; the trainee must come to understand for themselves what the standard of practice is, without being told. This is critical in surgical education because, as one study identifies the “inability to recognize limitations and ask for help was viewed as a particularly problematic and dangerous behavior in young surgeons”11. Surgical trainees have some sense of their standard of practice but the one way they can truly come to understand both how they are going and how to improve are through feedback conversations. While the formal conversations associated with workplace-based assessments are very important, surgical trainees find these of variable value for feedback12. Surgical trainees may seek out challenging feedback more informally13. These informal moments are particularly valuable and supervisors can initiate them. For example, when
observing or supervising in theatre, supervisors can invite trainees if there’s anything to be observed or commented upon; this sets up the space for a short conversation afterwards about what was noted. In order to build evaluative judgement, surgical trainees can benefit from opportunities to assess colleagues through purposeful observation. Providing peers with feedback information is a really valuable educational tool that is under-used in the health professions. There is an assumption that the value of peer feedback is with receiving the feedback information but from an educational perspective, the greater value is for the peer who is observing and formulating the feedback information. This also gives exposure to the tacit sense of quality and trainees can be oriented to consider how skills such as leadership and decision-making are manifest in others’ practice as well as their own.
Educational strategies specifically for underperformance The educational strategies described above provide a launching pad for specific tailored actions to help trainees overcome underperformance. If these are followed, all trainees will have been provided with clear and documented expectations, an agreed sequence of activities that match these standards and rich opportunities for assessment and feedback. By contrast, the following educational strategies are particular intended to help redress small and large deficits. These may be issues which might be the product of circumstance (eg lack of exposure in previous rotations, family or personal issues or health challenges) as well as deficits in skills. Addressing underperformance is not easy to enact; part of the challenge with underperformance at a senior level is they it tends to be with respect to tacit professional skills. These are most difficult to describe and acknowledge and the trainee may have passed many rotations without being told that they have a problem 14,15. Here are
three approaches that can be critical for working with underperformance: joint development of a plan; expanding or reducing feedback information; and encouraging trainees to stay motivated. There are no recipes here: each requires a degree of thoughtfulness and skill in negotiating what to do next.
Developing a plan to address underperformance with the trainee If the supervisor is having regular feedback conversations with trainees, then concerns should be raised in these general forums. However, the focus should be not just telling the trainees what is wrong but coming to a joint understanding about what to do next. Without this, there is no way for the trainee to know how to improve. The original and documented expectations of the placement are invaluable so there is clarity about what the problem might be but once this is established, the bulk of the conversation should be on the activities needed to resolve the problem. Re-negotiating tasks and goals may take more than one meeting: it can take some time to establish what the challenges are and how to overcome them. However, if the trainee has had exposure to an assessment rich environment, they may well have observed others’ work and therefore know the standard they are supposed to be at. The supervisors’ key role as a teacher is to identify opportunities that will build the skills required. This may mean more time in simulation or completing easier tasks or performing more complex tasks but under more supervision. There is a very big difference here between technical insufficiencies, where the general consensus is that they can be overcome through sequences of tasks of increasingly complexity, and more tacit forms of practice such as leadership and prioritisation. These latter tasks present challenges as professional skills are so tacit that development is difficult; often they are only noticed in their absence. In these
instances, articulation of the problem is difficult, a diverse range of feedback information may assist. It is always important to separate the problem from the person. When underperformance is a problem, the supervisors’ interpersonal relationship with the trainee must be maintained so that the trainee can be open and willing to change. Ideally, the trainee will not feel under attack; be included in a joint plan to improve may help reduce negative emotions. If the trainee feels that the supervisor is wanting them to succeed, then it is much easier for them to be motivated. Framing the conversation towards a statement of where the trainee needs to be and jointly constructing a plan to get there can provide both assurance that the supervisor is there as an educator and that the trainee also has a role to play within any plan to improve.
Expanding or decreasing feedback information A reported response to underperformance is to give more of the same feedback information2. A more useful strategy is to provide different approaches to feedback. If a supervisor has already said what the problem is and the trainee hasn’t changed what they do, then there is no point in saying it again in exactly the same way. There are two opposing tactics to undertake in this circumstance and the supervisor must use their judgement (possibly in consultation with the trainee) as what to do next. The first possibility is to decrease the information flowing to the trainee. Sometimes, when a trainee is underperforming, they are already in overload and too much information means they cannot prioritise and focus their attempts to improve. The second possibility is to increase the breadth of feedback. This may mean asking others’ to observe the trainee and equally, asking the trainee to observe multiple others. In this way, the trainee is exposed to
different modes of practice that may help them find an alternate way to understand the problem.
Encouraging trainees to remain motivated One of the biggest challenges with underperformance is the necessary means of dealing with it – more oversight and threat of failure - leads to a fundamental lack of motivation and therefore an unwillingness to confront some of the challenges facing them6. A key principle in working with underperformance, is that as far as possible, trainees must be given the scope to take responsibility for their own training and the opportunity to excel. This means that trainees should be consulted and genuinely given opportunities to contribute to their own remediation. It can also be helpful to ask trainees to repeatedly do things that they can already do, to ensure that they are succeeding at some things rather than constantly working on things they cannot do. Another technique which may help is to use ‘intellectual candour’16, where the supervisors provides information about their own deficits in order to model how to manage and work with underperformance. This may help trainees understand both the possibility to overcame deficits and some insights into how it is done.
Managing failure Sometimes trainees do not meet expectations and therefore must fail. Passing someone who is underperforming does not help anyone: patients, the profession or the trainee themselves. At this stage in training, failure can be devastating. However, a series of constant conversations with associated formal documentation is key here. As trainees and supervisors jointly document action plans and articulated expectations, then trainees may come to know whether they are meeting the standard and why. By constantly working with the trainee to have input into the plan for managing their problems allows them to have the
best form of success but also allows them to own any failures rather than have it ‘done to them’.
Conclusions This very short paper has presented some educational strategies about what to do about underperformance in surgical trainees. It has described general approaches to education. These require both skill and time. However, the investment in both acquiring educational skills and the time spent on educating trainees are more than made up for by the reduction in time working with underperformance. These strategies allow a supervisor to better manage underperformance and provide a more rewarding educational experience for the supervisor.
References 1.
Clinical Supervisor Support Program Discussion Paper In: Australia HW2010.
2.
Bearman M, Molloy E, Ajjawi R, Keating J. ‘Is there a Plan B?’: clinical educators supporting underperforming students in practice settings. Teaching in Higher Education. 2012:1-14.
3.
Cleland J, Leggett H, Sandars J, Costa MJ, Patel R, Moffat M. The remediation challenge: theoretical and methodological insights from a systematic review. Medical Education. 2013;47(3):242-251.
4.
Musselman LJ, MacRae HM, Reznick RK, Lingard LA. ‘You learn better under the gun’: intimidation
and
harassment
in
surgical
education.
Medical
Education.
2005;39(9):926-934. 5.
Paice E, Orton V. Early signs of the trainee in difficulty. HOSPITAL MEDICINELONDON-. 2004;65(4):238-238.
6.
Bearman
M,
Castanelli
D,
Denniston
C.
Identifying
and
working
with
underperformance. In: Delany C, Molloy E. Learning and Teaching in Clinical Contexts. Chatswood, NSW: Elsevier; 2018. 7.
Telio S, Ajjawi R, Regehr G. The “educational alliance” as a framework for reconceptualizing
feedback
in
medical
education.
Academic
Medicine.
2015;90(5):609-614. 8.
Billett S. Learning in the workplace: Strategies for effective practice. Crow's Nest; NSW: Allen & Unwin; 2001.
9.
Schwab B, Hungness E, Barsness KA, McGaghie WC. The role of simulation in surgical education. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2017;27(5):450-454.
10.
Boud D, Ajjawi R, Dawson P, Tai J. Developing evaluative judgement in higher education: Assessment for knowing and producing quality work. Abingdon: Routledge; 2018.
11.
Hoops HE, Burt MR, Deveney K, Brasel KJ. What They May Not Tell You and You May Not Know to Ask: What is Expected of Surgeons in Their First Year of Independent Practice. Journal of Surgical Education. 2018;75(6):e134-e141.
12.
Gaunt A, Patel A, Royle J, et al. What do surgeons and trainees think of WBAs and how do they use them? The Bulletin of the Royal College of Surgeons of England. 2016;98(9):408-414.
13.
Gaunt A, Patel A, Rusius V, Royle TJ, Markham DH, Pawlikowska T. ‘Playing the game’: How do surgical trainees seek feedback using workplace‐based assessment? Medical education. 2017;51(9):953-962.
14.
Scarff CE, Bearman M, Chiavaroli N, Trumble S. Keeping mum in clinical supervision: private thoughts and public judgements. Medical education. 2019;53(2):133-142.
15.
Yepes-Rios M, Dudek N, Duboyce R, Curtis J, Allard RJ, Varpio L. The failure to fail underperforming trainees in health professions education: A BEME systematic review: BEME Guide No. 42. Medical teacher. 2016;38(11):1092-1099.
16.
Molloy E, Bearman M. Embracing the tension between vulnerability and credibility:‘intellectual candour’in health professions education. Medical education. 2019;53(1):32-41.
Working with underperformance in surgical training: educational strategies for supervisors M. Bearman PII: DOI: Reference:
S1055-8586(20)30028-7 https://doi.org/10.1016/j.sempedsurg.2020.150908 YSPSU 150908
To appear in:
Seminars in Pediatric Surgery
Please cite this article as: M. Bearman , Working with underperformance in surgical training: educational strategies for supervisors, Seminars in Pediatric Surgery (2020), doi: https://doi.org/10.1016/j.sempedsurg.2020.150908
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
Working with underperformance in surgical training: educational strategies for supervisors Author M Bearman1 1
Centre for Research in Assessment and Digital Learning (CRADLE), Deakin University, Geelong, Australia.
Address for correspondence Professor Margaret Bearman Centre for Research in Assessment and Digital Learning (CRADLE), Deakin University, Geelong, Australia. Tel: +61 3 92468168 Email: [email protected]
Keywords Surgical Training, Underperformance, Managing the underperforming trainee,
Abstract Underperformance is a significant challenge for surgical educators. This paper outlines some educational
strategies
to
manage
the
very
complex
demands
presented
by
underperformance during training in the workplace. Preventative approaches include: setting expectations with early conversations; conscious attention to the workplace curriculum; and building trainee evaluative judgement through assessment and feedback. Once underperformance has been identified, other approaches including: developing a joint action plan; reducing or increasing feedback opportunities; and ensuring the trainee remains motivated. While these strategies cannot prevent failure, they offer the trainee opportunities to succeed.
Introduction Underperformance is one of the most difficult challenges for all health professional educators: clinical supervisors report the time, effort and concern involved in working with a learner who is not at the required level of competency and therefore may be a risk to patient safety1. However, many clinical educators don’t know what to do differently2 and see remediation as a means to scrape a pass3. This may be particularly compounded in surgical education where there can be an expectation that learning is best “under the gun”4. Paice5 outlines key areas of underperformance in surgical training. Early in the training, issues tend to be: “poor clinical assessment and diagnosis; poor communication with patients or colleagues; inadequate, inaccurate or illegible note-keeping; failure to follow protocols; inappropriate investigations; failure to recognize or respond to the urgency of a clinical situation and problems with carrying out practical procedures.” She notes that in
later years, underperformance tends to concern leadership, delegation, difficult situations and prioritising.
This is a complex array of challenges and can be compounded with
obligations to provide competent patient care, interpersonal workplace relationships and the distress and shame experienced by trainees when underperforming. It is therefore useful to have clear educational strategies for managing underperformance in order to provide opportunities for success. This paper frames underperformance as an educational concern. It is aimed at those responsible for training – either directly or indirectly – in order to help navigate the real complexities presented by underperformance. Invoking these strategies does not mean that underperformance is necessarily resolved, however they provide a means to promote success. A key underpinning principle is that trainees should take responsibility for their own learning, in partnership with supervisors. It is suggested that effective partnerships are best built upon foundational educational approaches that are put into place with all trainees. In this way, underperformance can be managed as part of the daily business of supervision, prevented as much as cured. To this end, this paper first describes foundational approaches, followed by a series of specific strategies to be utilised once underperformance becomes identified.
Preventative educational strategies One of the best ways to combat underperformance is to integrate core educational principles into all teaching. There are multiple reasons to take this preventative approach. Firstly, with better teaching, some deficits may be addressed before they become serious issues. Secondly, the expectations and ways of working established during business-as-usual can be drawn upon once it becomes established that underperformance is causing problems. Finally, by treating everyone the same in, surgical trainees who are identified as underperforming don’t have the sense that they are being treated as lesser. This paper describes three core educational practices that are particularly valuable. These are: setting expectations with early conversations; conscious attention to the workplace curriculum; and building evaluative judgement through assessment and feedback.
Setting expectations with early conversations Most models of clinical supervision suggest commencing a placement or rotation with an orienting conversation. These conversations are critical. They provide the opportunity to outline the supervisor’s expectations and also to build an ‘educational alliance’7 between supervisor and trainee. An educational alliance is not the same thing as a personal relationship; it occurs when the trainee perceives an interpersonal bond with the supervisor, a unity of goals and agreed path to reach these goals. In order to achieve this, both the supervisor and trainee must share their aspirations for the rotation or placement and ensure these are mutually agreed. Where possible, a plan should be outlined, associated with identification of the necessary milestones. One of the key points of these early meetings is outlining these expectations in sufficient detail. It can be surprisingly difficult to articulate what constitutes an acceptable performance in the workplace.
Expectations should almost always be underpinned by documentation. Paperwork is not always just a bureaucratic necessity; it can be an educational tool. While formal learning plans can be tokenistic: if the supervisor treats them seriously, it is more likely the trainee will as well. Whether there are formal processes or not, it is recommended that goals and expectations (both of supervisor and trainee) are recorded in an easily accessible place. This structured form of documentation can therefore be a genuine learning resource which can be revisited and adjusted throughout the term. The trainee can then look back on these conversations and self-assess against the standards and expectations; supervisors can review to make sure that their judgements of progress are appropriate.
Conscious attention to the workplace curriculum The workplace curriculum is generally formed by supervisors providing sequenced tasks of increasing complexity and responsibility 8. Most surgical supervisors do this tacitly: there is both an expectation of competency at a certain level and supervisors form judgements whether the trainee can in fact perform at this level. The value of mastery learning models, where learning is built in careful sequence of competencies, which build upon each other is well known in surgical simulation9. Therefore simulation can be used as an adjunct, as this type of careful sequencing may be more difficult to achieve in the workplace. However, it is worth considering with each trainee how the work they are asked to do can build challenge or consolidate learning, in order to meet the expectations outlined in the early conversations. Most clinical supervisors tacitly create a workplace curriculum: the easier tasks are learnt first, and then the more complicated one. The value of supervisors consciously thinking about how the sequence of complexity is to track if the trainee is meeting expectations. For
example, there may be a particular kind of jump in complexity – possibly of independence or a type of technical skill – that the trainee has particular trouble with.
Again tacitly,
supervisors usually know where these ‘pain points’ are within a workplace curriculum: they’ve experienced them themselves as well as supervised others through them. It is worth therefore asking supervisors to try to articulate the curriculum: to try and explicate both the sequence of activity and the particular issues that are frequently present problems. Thus, as mentioned, supervisors can consciously prepare for difficulties by directing trainees to particular forms of practice. This can include simulation, more consolidation work and purposeful observation of others.
Building evaluative judgement through assessment and feedback In addition to early conversations and sequences of tasks that build in complexity, supervisors can also seek to build a trainee’s evaluative judgement 10. Evaluative judgement is the ability to judge quality of the work of self and others; the trainee must come to understand for themselves what the standard of practice is, without being told. This is critical in surgical education because, as one study identifies the “inability to recognize limitations and ask for help was viewed as a particularly problematic and dangerous behavior in young surgeons”11. Surgical trainees have some sense of their standard of practice but the one way they can truly come to understand both how they are going and how to improve are through feedback conversations. While the formal conversations associated with workplace-based assessments are very important, surgical trainees find these of variable value for feedback12. Surgical trainees may seek out challenging feedback more informally13. These informal moments are particularly valuable and supervisors can initiate them. For example, when
observing or supervising in theatre, supervisors can invite trainees if there’s anything to be observed or commented upon; this sets up the space for a short conversation afterwards about what was noted. In order to build evaluative judgement, surgical trainees can benefit from opportunities to assess colleagues through purposeful observation. Providing peers with feedback information is a really valuable educational tool that is under-used in the health professions. There is an assumption that the value of peer feedback is with receiving the feedback information but from an educational perspective, the greater value is for the peer who is observing and formulating the feedback information. This also gives exposure to the tacit sense of quality and trainees can be oriented to consider how skills such as leadership and decision-making are manifest in others’ practice as well as their own.
Educational strategies specifically for underperformance The educational strategies described above provide a launching pad for specific tailored actions to help trainees overcome underperformance. If these are followed, all trainees will have been provided with clear and documented expectations, an agreed sequence of activities that match these standards and rich opportunities for assessment and feedback. By contrast, the following educational strategies are particular intended to help redress small and large deficits. These may be issues which might be the product of circumstance (eg lack of exposure in previous rotations, family or personal issues or health challenges) as well as deficits in skills. Addressing underperformance is not easy to enact; part of the challenge with underperformance at a senior level is they it tends to be with respect to tacit professional skills. These are most difficult to describe and acknowledge and the trainee may have passed many rotations without being told that they have a problem 14,15. Here are
three approaches that can be critical for working with underperformance: joint development of a plan; expanding or reducing feedback information; and encouraging trainees to stay motivated. There are no recipes here: each requires a degree of thoughtfulness and skill in negotiating what to do next.
Developing a plan to address underperformance with the trainee If the supervisor is having regular feedback conversations with trainees, then concerns should be raised in these general forums. However, the focus should be not just telling the trainees what is wrong but coming to a joint understanding about what to do next. Without this, there is no way for the trainee to know how to improve. The original and documented expectations of the placement are invaluable so there is clarity about what the problem might be but once this is established, the bulk of the conversation should be on the activities needed to resolve the problem. Re-negotiating tasks and goals may take more than one meeting: it can take some time to establish what the challenges are and how to overcome them. However, if the trainee has had exposure to an assessment rich environment, they may well have observed others’ work and therefore know the standard they are supposed to be at. The supervisors’ key role as a teacher is to identify opportunities that will build the skills required. This may mean more time in simulation or completing easier tasks or performing more complex tasks but under more supervision. There is a very big difference here between technical insufficiencies, where the general consensus is that they can be overcome through sequences of tasks of increasingly complexity, and more tacit forms of practice such as leadership and prioritisation. These latter tasks present challenges as professional skills are so tacit that development is difficult; often they are only noticed in their absence. In these
instances, articulation of the problem is difficult, a diverse range of feedback information may assist. It is always important to separate the problem from the person. When underperformance is a problem, the supervisors’ interpersonal relationship with the trainee must be maintained so that the trainee can be open and willing to change. Ideally, the trainee will not feel under attack; be included in a joint plan to improve may help reduce negative emotions. If the trainee feels that the supervisor is wanting them to succeed, then it is much easier for them to be motivated. Framing the conversation towards a statement of where the trainee needs to be and jointly constructing a plan to get there can provide both assurance that the supervisor is there as an educator and that the trainee also has a role to play within any plan to improve.
Expanding or decreasing feedback information A reported response to underperformance is to give more of the same feedback information2. A more useful strategy is to provide different approaches to feedback. If a supervisor has already said what the problem is and the trainee hasn’t changed what they do, then there is no point in saying it again in exactly the same way. There are two opposing tactics to undertake in this circumstance and the supervisor must use their judgement (possibly in consultation with the trainee) as what to do next. The first possibility is to decrease the information flowing to the trainee. Sometimes, when a trainee is underperforming, they are already in overload and too much information means they cannot prioritise and focus their attempts to improve. The second possibility is to increase the breadth of feedback. This may mean asking others’ to observe the trainee and equally, asking the trainee to observe multiple others. In this way, the trainee is exposed to
different modes of practice that may help them find an alternate way to understand the problem.
Encouraging trainees to remain motivated One of the biggest challenges with underperformance is the necessary means of dealing with it – more oversight and threat of failure - leads to a fundamental lack of motivation and therefore an unwillingness to confront some of the challenges facing them6. A key principle in working with underperformance, is that as far as possible, trainees must be given the scope to take responsibility for their own training and the opportunity to excel. This means that trainees should be consulted and genuinely given opportunities to contribute to their own remediation. It can also be helpful to ask trainees to repeatedly do things that they can already do, to ensure that they are succeeding at some things rather than constantly working on things they cannot do. Another technique which may help is to use ‘intellectual candour’16, where the supervisors provides information about their own deficits in order to model how to manage and work with underperformance. This may help trainees understand both the possibility to overcame deficits and some insights into how it is done.
Managing failure Sometimes trainees do not meet expectations and therefore must fail. Passing someone who is underperforming does not help anyone: patients, the profession or the trainee themselves. At this stage in training, failure can be devastating. However, a series of constant conversations with associated formal documentation is key here. As trainees and supervisors jointly document action plans and articulated expectations, then trainees may come to know whether they are meeting the standard and why. By constantly working with the trainee to have input into the plan for managing their problems allows them to have the
best form of success but also allows them to own any failures rather than have it ‘done to them’.
Conclusions This very short paper has presented some educational strategies about what to do about underperformance in surgical trainees. It has described general approaches to education. These require both skill and time. However, the investment in both acquiring educational skills and the time spent on educating trainees are more than made up for by the reduction in time working with underperformance. These strategies allow a supervisor to better manage underperformance and provide a more rewarding educational experience for the supervisor.
References 1.
Clinical Supervisor Support Program Discussion Paper In: Australia HW2010.
2.
Bearman M, Molloy E, Ajjawi R, Keating J. ‘Is there a Plan B?’: clinical educators supporting underperforming students in practice settings. Teaching in Higher Education. 2012:1-14.
3.
Cleland J, Leggett H, Sandars J, Costa MJ, Patel R, Moffat M. The remediation challenge: theoretical and methodological insights from a systematic review. Medical Education. 2013;47(3):242-251.
4.
Musselman LJ, MacRae HM, Reznick RK, Lingard LA. ‘You learn better under the gun’: intimidation
and
harassment
in
surgical
education.
Medical
Education.
2005;39(9):926-934. 5.
Paice E, Orton V. Early signs of the trainee in difficulty. HOSPITAL MEDICINELONDON-. 2004;65(4):238-238.
6.
Bearman
M,
Castanelli
D,
Denniston
C.
Identifying
and
working
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