Field Guide for Supervisors of Medical and Dental ... - Oxford Deanery

Health Education Thames Valley 

Field Guide for Supervisors of Medical and Dental 

trainees working in the Oxford Postgraduate Medical 

& Dental Education (PGMDE) programmes 

(excluding training in General Practice) 

Jane Siddall, Associate Dean for Educator and Faculty Development 

John Derry, Director CDU and Associate Dean 

Tony Jefferis, Deputy Dean 

Simon Street, GP Associate Dean 

Greg Simons, GP Associate Dean 

Chris Morris, Associate Dean for Quality 

Amit Gupta, Associate Dean for International Medical Graduates 

First Edition April 2013 

This edition is valid until September 2013. New editions will be 

online at the Oxford PGMDE website. 

First edn. Field Guide for Supervisors: Oxford PGMDE Apr 2013 

49087 Ox PGMDE Handbook v4.indd 1 16/04/2013 09:57

This handbook has been produced using material from the Gold Guide, 

(4th edition, 2010) 

GMC guidance (The Trainee Doctor, July 2011 and Tomorrow’s Doctors, 

Oct 2011) 

NACT guidance (Managing the Trainee in Difficulty, 2008), 

The Oxford PGMDE workshops for both Clinical and Educational 

Supervisors 

‘Best practice’ from Employment Tribunal experience, (August 2011). 

The UK Foundation Programme Reference Guide, (July 2012). 

Oxford PGMDE Policies (2012) 

NHS Medical Careers website (2012) 

The British Dyslexia Association (2012) 

The Equality Act (2010) 

This first edition will be updated with feedback from users, and whenever 

there is a national change of significance. The most up to date iteration 

will be found on the deanery’s website in the Education section. 

If you have any comments about material, which you believe should be 

in this handbook, but is not, please email me at 

jane.siddall@thamesvalley.hee.nhs.uk 

Jane Siddall 

Associate Dean for Educator Faculty Development 



Contents 

Introduction and Background ...................................................................... 4 

Chapter 1: Definitions and Differences ....................................................... 6 

Chapter 2: What are the ‘essential’ responsibilities of 

Clinical Supervisors? ...................................................................................... 8 

Chapter 3: Feedback on performance ....................................................... 11 

Chapter 4: The International Medical Graduate trainee .......................... 14 

Chapter 5: ‘Something isn’t right’ .............................................................. 16 

Appendices 

A: ARCP outcomes 

B: Generation Y: what they expect 

C: The Oxford PGMDE Descriptors of Behaviour 

D: Adult checklist for Dyslexia 

E: Role of educational supervisor in the revalidation of trainees 

Oxford PGMDE polices are accessible from the home page of the deanery’s 

website at www.oxforddeanery.nhs.uk 

Policies that may be especially useful include 

• Policy for approving and recognising medical and dental trainers 

(covers training requirements, time, duties etc, found in the Educator 

Development section) 

• Equality and Diversity 

• Bullying and Harassment 

• IMG policy 

• Less than fulltime training 

• Trainee in difficulty / Supporting the Trainee 

And can be found in the ‘About Oxford Deanery section’ of the website 

First edn. Field Guide for Supervisors: Oxford PGMDE Apr 2013 3 


Introduction 

Forward by Postgraduate Dean: 

“The expectations on those who undertake roles in medical and dental 

education have increased significantly in the last few years. There is now a 

requirement for us to properly induct, plan, assess, deliver specific curriculum 

objectives and vitally, record many aspects of doctors/dentists’ performance 

during their training. There is abundant evidence that well-trained and 

supported clinicians work safely; those who are not supported in this manner 

are more likely to be involved in adverse events which may damage their 

professional standing, the reputation of the department, Trust or training 

programme as well as result in harm to patients. 

I am delighted that our team of Associate Deans have produced this field 

guide for trainers in medical and dental practice across our patch. It is 

intended to be a ‘Quick Look Book’ to help busy clinical and educational 

supervisors navigate through an increasingly complex training landscape. It is 

not, however, a replacement for training in effective supervision.” 

Background 

Dr Michael Bannon 

Postgraduate Dean 

There are comprehensive national frameworks for Foundation, General Practice 

and Specialty Trainees, and local PGMDE policies, which can be accessed on 

the internet. Most, if not all, can be seen by visiting the deanery’s website at 

www.oxforddeanery.nhs.uk and clicking on the relevant school tab. The new 

Foundation handbook can be downloaded from the Foundation Programme 

NHS website at http://www.foundationprogramme.nhs.uk 

Why is training (and support) for trainers important? 

During 2012 the GMC opened a consultation on the recognition and approval 

of non-GP trainers. The outcome of the consultation was published in August 

2012 as the GMC ‘Approving and Recognising Trainers: the Implementation 

Plan’. Trainers must have training, and have been updated as required under the 

PGMDE’s policy for Approving and Recognising Medical and Dental trainers. 

The GMC plan relates to: 

• Named educational supervisors in postgraduate training 

• Named clinical supervisors in postgraduate training 

• Lead co-ordinators of undergraduate training at each local education 

provider 

• Doctors responsible for overseeing students’ educational progress 

for each medical school. 

4 



Other doctors whose practice contributes to the teaching, training or 

supervision of students or trainee doctors, on a more sessional or occasional 

basis, such as senior trainees and most specialty doctors who observe practice 

are not included in the GMC plan, but the PGMDE has commissioned training in 

supervision for such staff. 

The GMC trainer standards 

The GMC already has existing standards for postgraduate training set out 

in The Trainee Doctor (in section 6 of the 2011 publication) and for 

undergraduate education in Tomorrow’s Doctors. These address 

• The differing levels of supervision trainees require during the entire 

postgraduate training programme, (6.29 to 6.31) 

• The expectation that the Postgraduate Medical education team will 

support the trainer and that job plans will factor time for the trainer to 

facilitate trainee development (6.32-6.36) 

• The expectation that trainers understand the structure and purpose of 

the training programme, and their role in training (6/38- 6.39) 

• And for GP training, section 6.37 stipulates that GP trainers must be 

trained and selected in accordance with the Medical Act 1983. 



Chapter 1 

Definitions and Differences 

Definitions 

The GMC has defined the roles of both clinical and educational 

supervisors, which are: 

Named clinical supervisor: a trainer who is responsible for overseeing a 

specified trainee’s clinical work for a placement in a clinical environment and 

is appropriately trained to do so. He or she will provide constructive feedback 

during that placement, and inform the decision about whether the trainee 

should progress to the next stage of their training at the end of that placement 

and/or series of placements. 

Named educational supervisor: a trainer who is selected and appropriately 

trained to be responsible for the overall supervision and management of a 

trainee’s trajectory of learning and educational progress during a placement 

and/or series of placements. Every trainee must have a named educational 

supervisor. The educational supervisor’s role is to help the trainee to plan their 

training and achieve agreed learning outcomes. He or she is responsible for 

the educational agreement and for bringing together all relevant evidence 

to form a summative judgement at the end of the placement and/or series of 

placements. 

It is expected that educational supervisors should have all the attributes 

expected of trained clinical supervisors. Being an educational supervisor 

does not necessarily preclude a trainer from having any other educational 

role, and is it desirable for senior educators to be active educational 

supervisors. 

PGMDE definitions of other key supervisors are: 

Academic supervisors are responsible to help the trainee to plan their research 

activity and achieve agreed outcomes. Even if he or she has a clinical contract, 

they should not normally be the trainee’s educational or clinical supervisor. He 

or she is required to provide an annual report on a trainee for the ARCP panel. 

A sessional supervisor is a clinician who supervises a trainee for individual 

sessions, and who may be required to provide formal assessment and feedback 

on the trainee to their clinical, or educational, supervisor. 

6 



The 

The 

table 

table below, 

below, 

adapted 

adapted 

from 

from 

the 

the 

Oxford 


PGMDE 

PGMDE 

Clinical 

Clinical 

Supervisor 

Supervisor 

training workshop and RCPsych Handbook for Trainers, summarises the 

training workshop and RCPsych Handbook for Trainers, summarises the 

differences between clinical and educational supervisors: 

differences between clinical and educational supervisors: 

Clinical supervisor Attribute Educational supervisor 

Operational Vision Strategic 

Clinical Experience Depth and breadth 

Work place based 

assessments 

(Including feedback on 

performance) 

Assessment 

Educational/ 

behavioural (e.g. 

multisource feedback) 

Clinical competence Curriculum All competencies (i.e. 

clinical and 

professional 

behaviours) 

Trainer and apprentice 

(To include equal 

opportunity and diversity 

awareness and 

awareness of ‘trainee in 

difficulty’) 

Skills, knowledge and 

experience 

Specified and defined 

(may include advice on 

suitable courses/ study 

leave) 

Relationship with 

trainee 

Evidence 

Guidance 

Mentor or coach 

(To include equal 

opportunity and diversity 

awareness and 

awareness of ‘trainee in 

difficulty’) 

Portfolio of training 

progress 

Broad and generic (may 

include advice on suitable 

courses/ study leave) 

First edn. Field Guide for Supervisors: Oxford Deanery Jan 2013 7 



Chapter 2 

What are the ‘essential’ responsibilities of Clinical 

Supervisors? 

It is important to make early contact with the trainees allocated to you, ideally 

face to face, but if not, by email to arrange a meeting. A suggested algorithm is 

at the end of this chapter. 

It is important that CSs inform a trainee’s Educational Supervisor of anything 

which is noteworthy, but should include involvement in Serious Incidents, 

complaints from patients and health / probity issues (see Chapter 4) as these 

events are noted at ARCP and inform the revalidation process. 

Your knowledge of the curriculum 

As a clinical supervisor (CS), one is not expected to produce the annual 

assessment report for the ARCP, but a CS should know what skills the trainee 

should develop, or acquire, during the phase of training with you. This should 

be available on your Royal College website. 

CSs do not personally have to sign off every workplace-based assessment, but it 

is good practice for a proportion to be completed by a consultant. Some colleges 

require the final one confirming independent competence for a procedure to be 

signed by a consultant. 

Whilst a clinical supervisor will not be suggesting the likely outcome of the 

ARCP to a trainee (this is the responsibility of the Educational Supervisor), it 

is worth being aware of the possible outcomes and what the trainee needs to 

achieve (See Appendix A for detail on forms and ARCP outcomes). 

The e-portfolio 

All foundation trainees use an electronic portfolio, and increasingly, trainees in 

all specialties are being registered through the Royal Colleges. Each specialty 

has a slightly different set of sections to be completed by trainees and their 

assessors, which is outside the scope of this handbook. However, your local 

College / Specialty Tutor should have a good understanding of your eportfolio 

system, or there may be a member of your School Board who has been charged 

with ensuring consultants know how to navigate the system. Your specialty 

Head of School may organise formal training on eportfolio from time to time. 

8 



Work place based assessments (WPBAs) 

All trainees are required to demonstrate their acquisition of relevant clinical 

skills and behaviours in a structured manner, as described in the relevant 

specialty curriculum. A clinical supervisor is expected to facilitate this process by 

aiding learning using WPBA tools formatively, to give constructive feedback on 

performance and advice on how to improve further, and summatively, when a 

trainee is observed carrying out the procedure or consultation independently. 

There are three steps in the assessment process: 

• Evidence by observation of trainee, e.g. ‘I see evidence of your findings’ 

• Relevance by explanation, e.g. ‘if you don’t record your findings, noone 

else will know what you did’ 

• Competence by evaluation, e.g. ‘these notes do not contain enough 

information’ 

And finally, giving feedback to trainee. 

What sorts of work place based assessments are there and how can 

they be fitted into my job plan? 

Fundamentally, there are three types of activity that trainees undertake where 

a more senior clinician should observe practice, and feedback to the trainee, 

using forms delivered by the Foundation Programme or relevant medical Royal 

College. The forms can be found in the relevant specialty eportfolio and / or 

college website. 

These are: 

• One where the trainee carries out a practical procedure, such as a 

cannulation, insertion of a chest drain or a hysterectomy (DOPs, OSATS 

or other acronyms, dependent upon specialty). 

• Mini clinical examinations, where the trainee is observed for part of a 

consultation with a patient. The focus for assessment may be one of: 

the presentation of the patient’s history, the taking of a history, the 

examination, proposed management and explanation of investigations. 

• Case-based discussions, where the trainee may discuss a real case, or a 

condition which is rare, but of which the specialty curriculum demands 

evidence of at least some supervised discussion (such as a pregnant 

woman with cystic fibrosis). 

The first two activities can usually be easily accommodated ‘on the job’ in 

theatres, on ward rounds, and occasionally in clinic consultations. Casebased 

discussions will need some time setting aside, but it is possible to pool resources 

and invite other trainees and run an interactive and discursive tutorial session. 

These could time tabled for a number of afternoons a year within the teaching 

timetable, with one or two supervisors leading each session. 



A suggested flow chart for clinical supervisors supporting all all 

trainees is shown below: 

At the start of the post 

• Invite trainee to have a conversation about their clinical training to date. 

The meeting should take place within the first two weeks of the trainee 

taking up the post. Invite them to show you their log of work place based 

assessments. 

• Ideally undertake WPBAs electronically uploading to the trainee’s 

eportfolio in real-time. If this is not possible, keep a copy of the paper 

documents in a secure filing cabinet just in case the trainee loses their 

copy. 

• Identify clinical skills training goals. 

• Ensure that the trainee knows what material should be collated for the 

period of training you are supervising. 

• Invite the trainee to make regular, informal contact with you. 

Regularly 

• Share good and positive feedback from colleagues, as well as any issues of 

concern. 

• If there are specific issues or targets to be addressed, write to educational 

supervisor and other colleagues as necessary. Copy the trainee in to this 

letter. This applies to good trainees just as much as those with emerging 

issues. 

Pre ARCP assessment (month 10) 

• Advise trainee to collate all evidence six to eight weeks before ARCP 

scheduled. 

• Ensure that you have provided written evidence of any outstanding 

practice, or concerns, to the ES. This might include written material from 

patients, complaints, cases reviewed through clinical governance (good or 

bad care / outcomes). 

• Ideally, trainee will have all necessary material for summative assessment 

to be made (sufficient WPBA, mini Cex, CbDs, TO1s) and ‘annual 

assessment review’ to be written by educational supervisor. Trainee 

should submit papers or eportfolio of evidence to programme manager at 

least two weeks before ARCP. 

It is best practice to 

It is (i) best practice Keep copies to of invitations sent to trainee by using 

(i) Keep copies ‘read receipts’ of invitations email sent to trainee by using ‘read 

(ii) receipts’ Sign on all email entries made by yourself into any trainee’s 

eportfolio 

(ii) Sign all entries made by yourself into any trainee’s eportfolio 

10 


10 First edn. Field Guide for Supervisors: Oxford Deanery Jan 2013 


Chapter 3 

Feedback on performance 

What is effective feedback? 

‘Information about a performance or behaviour which leads to action to affirm, 

or develop, that performance or behaviour’. 

Ideally, feedback should be given close in time to the event, and should be in a 

private setting (particularly if behaviour modification is mooted). It should also 

be clear; avoid sandwiching the bit which needs improvement between two 

nuggets of praise as the trainee will miss hearing the awful bit. 

Feedback should increase the trainee’s insight and motivate them to either 

continue (or modify if necessary) their practice or behaviours. It is helpful to 

have a benchmark the level expected of the trainee. However, if the goal is 

perceived to be unrealistic, trainee motivation will drop off. Thus, feedback 

needs to be offered using the Norcini and Burch (2007) headings: 

S specific 

N non-judgemental 

B balanced 

P promotes reflection 

T timely 

For example, you have just observed a consultation between a patient with 

recurrent episodes of cramping abdominal pain and a trainee, where the 

patient mentioned a fear that the pain may be a symptom of cancer, and 

alluded to a relative having been diagnosed with colon cancer a few years 

earlier. The trainee did not pick up on this thread of concern, simply suggesting 

that a colonoscopy would be a useful investigation. As a clinical supervisor, 

you might open the feedback conversation with, ‘What do you think was the 

patient’s greatest concern today?’ 

If you are checking a set of notes where the trainee has failed to record 

important negative findings during an examination, for example there being 

no weakness in the limbs of an elderly patient admitted following a collapse 

at home, the feedback should not be ’these notes are useless’, but something 

along the lines of ‘it is really valuable to state that she did not have any 

weakness on admission, so that the team on duty overnight will be aware of a 

deterioration if this develops’. 

It can also be tricky to give feedback to a trainee who is doing well, but finding 

something to gently challenge them is educational in a way that the report ’well 

you obviously can do that OK’ is not. In these circumstances, open questions 

such as ‘is there anything you would do differently next time?’ or ‘have you 

considered…’ , or ‘what would you like to do to make this even better?’ might 

open a conversation up. 



Other phrases, which could be helpful in a debriefing episode, 

Other phrases, which could be helpful in episode, 

might include: 

might include: 

What was going well? 

What was ELSE going was well? going well? 

Was What there ELSE was anything going you well? found difficult/ what were the difficulties? 

Are Was there anything skills you you found think difficult/ need more what development? 

were the difficulties? 

What Are there were any you skills thinking you think whilst need this more was development? 

all going on? (Might be useful after 

dealing What were with you an thinking emergency whilst situation) this was all going on? (Might be useful after 

What dealing were with you an emergency feeling? situation) 

What were would you be feeling? the best role for you in that situation? 

What would be you the do best next role time? for you in that situation? 

What would else needs you do to next happen? time? 

What else needs to happen? 

The Johari Window (Joe Luft and Harry Ingram, 1955) 

The Johari Window (Joe Luft and Harry Ingram, 1955) 

This tool was initially developed for self help groups, but is commonly 

This used tool for examining was initially personal developed effectiveness. for self The help factors groups, are: but selfdisclosure, 

commonly 

used openness for examining to feedback personal and perceptiveness. 

effectiveness. The factors are: selfdisclosure, 

openness to feedback and perceptiveness. 

And with a shared dialogue the windowpanes change size 

And with a shared dialogue the windowpanes change size 

It may be worth remembering that even experienced supervisors 

can It may find be worth it challenging remembering to give that even positive experienced feedback supervisors to learners. can find 

Frequently, it challenging to there give is positive a mismatch feedback between to learners. teachers’ Frequently, and there learners’ is a 

perceptions mismatch between of the teachers’ adequacy and learners’ and effectiveness perceptions of of the feedback. adequacy and 

(Ramani 

effectiveness 

S and 

of feedback. 

Krakov SK, Twelve tips for giving feedback effectively in 

the 

(Ramani 

clinical 

S and 

environment. 

Krakov SK, Twelve 

Medical 

tips 

Teacher, 

for giving 

2012;34: 

feedback 

787-791) 

effectively in the 

clinical environment. Medical Teacher, 2012;34: 787-791) 


12 



Effective or or ineffective feedback? 

Effective 

Ineffective 

Good 

performance 

Celebratory 

Baffled or puzzled 

Performance 

improvement 

needed 

A hand up 

Dejected 




Chapter 4 

The International Medical Graduate trainee 

International medical graduates constitute 32% of the medical workforce with 

more than one-in-three hospital doctors and one-in-five general practitioners 

having qualified overseas. 

Studies have shown that this group of doctors perceive discrimination, which 

may be subtle, or overt. This can be due to a limited opportunity to train in a 

certain part of the UK, entering the specialty at a more junior level than they 

had worked at before arriving in the UK, and lack of familiarity with assessment 

and career progression in the NHS. (Chen P, Nunez-smith M, Bernheim SM, Berg 

D et al, Professional experiences of International Medical Graduates Practising 

primary care in the United States, 2010; J Gen Intern Med 25 (9): 947-953 ) 

In addition, many of these doctors have become voluntarily separated from 

family and friends in order to gain UK training experience, and may not have a 

geographically local network of contacts from their country of origin. 

Induction programme 

IMGs should attend the Trust run Induction Programme, normally on the first 

day or two days at the start of the new appointments (in the first week of 

August or February). Attendance at this is compulsory, as it will provide all the 

vital local information about working in any particular Trust. 

Support 

The BMA have published a very useful document entitled: “Working and 

Training in the United Kingdom National Health Service - a guide for 

International Medical Graduates (IMGs)”, available through its website. 

The PGMDE Associate Dean for Overseas Doctors (IMGs), Dr Amit Gupta, has 

responsibility for matters specific to doctors who have qualified outside the UK, 

whether in the EEA countries or elsewhere, or whose nationality does not allow 

automatic right of permanent residence in the UK. These include: 

• Guidance regarding visa status 

• Career guidance in relation to overseas status 

• Advice in connection with training and non-training posts 

• Assistance with the Medical Training Initiative Scheme 

• Provision of induction for IMGs 

• Advice to doctors enquiring from overseas about postgraduate training 

• Support for refugee and asylum-seeking doctors in the Oxford area 

14 



Both IMGs and their supervisors can contact Dr. Amit Gupta, the Associate 

Dean for IMGs through the PGMDE for specific advice at 

amit.gupta@thamesvalley.hee.nhs.uk 

The CDU can also help with mentoring and confidential coaching for 

doctors who for whatever reason finds they are in personal or career 

difficulty. The CDU can be contacted on cdu@thamesvalley.hee.nhs.uk. 



Chapter 5 

‘Something isn’t right’ 

Chapter 5 

‘Something isn’t right’ 

Concerns over performance during training 

Concerns over performance during training 

Concerns about a doctor’s performance during training arise more 

Concerns 

commonly 

about 

than 

a doctor’s 

one might 


expect, and 

during 

educators 

training 

are 

arise 

often 

more 

not 

commonly 

sure what 

than 

to do. 

one 

Some 

might 

doctors 

expect, 

will 

and 

have 

educators 

periods 

are 

where 

often not 

their 

sure 


what to do. 

‘slips’ 

Some 

from 

doctors 

a previous 

will have 

high 

periods 

standard, 

where 

and 

their 

some 


doctors exhibit 

‘slips’ 

challenging 

from a previous high 

standard, behaviours and from some the doctors beginning exhibit of challenging a training behaviours placement. from Factors the beginning both inside 

of and a training outside placement. work may Factors be at play. both inside and outside work may be at play. 

These factors can include: 

These factors can include: 

Situations 

The ‘8 Bs’ mnemonic 

Relationships 

These could be new ones, or 

failing ones, could include 

weddings, or professional 

‘Birds and blokes’ 

‘Bosses’ 

problems (bullying 

/harassment) 

Family pressures Parental expectation 

Fertility issues 

‘Babies’ 

New parenthood 

Financial pressures May be doing locum shifts ‘Broke’ 

Loss or separation Lack of a local supportive 

network 

Lack of cultural reference 

points 

Death of a family member 

Being ' bi-lingual’ 

‘Bereavement’ 

or other close friend 

Exam pressures May impede training 

‘Books’ 

progress 

Substance dependency Prescription drugs, 

especially analgesics, non 

prescription drugs and 

alcohol 

‘Booze’ 

The The symptoms may may manifest manifest as: as: 

• Absenteeism: 

Absenteeism: 

o o Arriving Arriving late late 

o o Leaving Leaving early early 

o o Not Not answering bleep bleep 

• Presenteeism 

o o Arriving Arriving very very early early 

o 

o 

Staying 

Staying 

behind 

behind 

to finish 

to finish 

work 

work 

regularly 

regularly 

o Volunteering for every task and project but not completing them 

o Volunteering for every task and project but not completing 

them 

16 




• Lack of rapport with peers 

• Lack oof rapport Nurseswith peers 

o oNurses 

Colleagues at same level 

o oColleagues Junior or at student same level colleagues 

• Higher o Junior incidence or student of name colleagues appearing in grumbles, formal complaints 

• Higher or case incidence reviews of than name peers appearing in grumbles, formal complaints or 

• case Poor reviews attention than to peers paperwork 

• Poor 

o 

attention 

Reviewing 

to paperwork 

patient’s results and following them up 

o Reviewing patient’s results and following them up 

o Uneven accrual of WPBAs 

o Uneven accrual of WPBAs 

o Failure to register with NHS e-portfolio 

o Failure to register with NHS e-portfolio 

Behaviours 

Behaviours 

It is helpful to characterise behaviours using the seven domains of Good 

Medical It is helpful Practice: to characterise behaviours using the seven domains of Good 

Medical Practice: 

• Good clinical care, 

• Maintaining • Good good clinical medical care, practice, 

• Relationship • Maintaining with patients, good medical practice, 

• Working 

• Relationship 

with colleagues, 

with patients, 

• Working with colleagues, 

• Teaching and training, 

• Teaching and training, 

• Probity, and 

• Probity, and 

• Health. 

• Health. 

A detailed appendix describing incompetence, competence and 

detailed appendix describing incompetence, competence and performance 

performance descriptors (appendix C) is included at the end of this 

descriptors (appendix C) is included at the end of this handbook, and should be 

handbook, and should be referred to regularly. 

referred to regularly. 

Personality as a factor 

Personality as factor 

Human beings do do not not all all perform in in the the same same way, way, nor do nor we do perceive we perceive things 

things similarly. similarly. At times At of times stress, previous of stress, strengths previous may strengths become may overexaggerated 

become overexaggerated 

and metamorphose and metamorphose into weaknesses, into or ‘difficult’ weaknesses, behaviours. or ‘difficult’ behaviours. 

Enthusiastic 

Shrewd 

Careful 

Independent 

Confident 

Focused 

Charming 

Vivacious 

Imaginative 

Diligent 

Dutiful 

Volatile 

Mistrustful 

Cautious 

Detached 

Arrogant 

Passive-aggressive 

Manipulative 

Dramatic 

Eccentric 

Perfectionist 

Dependent 




The Oxford PGMDE policy for supporting trainees about whom there are 

concerns over performance during training can be seen on the deanery’s 

website. 

Although the term “Trainee in Difficulty” has been used commonly as 

shorthand, the deanery recognises that such labelling of individual trainees 

is often unhelpful. The Gold Guide refers to “managing concerns over 

performance during training” (see paragraphs 8.19-8.35, Gold Guide Fourth 

Edition, 2010), and the deanery’s policy has been revised to set out how trainees 

should be supported where there are such concerns. 

NACT (UK) (the National Association of Clinical Tutors) has published a useful 

guide, updated in July 2012, ‘Managing Trainees in Difficulty: Practical Advice 

for Educational and Clinical Supervisors’, which outlines the relationships 

between employers, Deaneries and the GMC in such circumstances. It can be 

downloaded from the NACT website at 

http://www.nact.org.uk/documents. 

Training workshops are hosted by the deanery and are delivered in each Trust 

on an annual basis. Please see the website for details of dates and venues. 

Any supervisor can attend a session at other Trusts; subject to local study leave 

procedures. 

It should be evident that where there are concerns about atrainee’s 

performance in training, or achievement ofcompetencies, there should be more 

frequent reviews of progressthan the ‘minimum’ set out by the medical royal 

colleges. 

Clinical or educational supervisors may need assistance from College Tutors, 

Training Programme Directors or School Board officers. If in any doubt it is 

prudent to seek early confidential advice. The PGMDE Career Development Unit 

(CDU) can provide educators with advice about the appropriate steps to take 

in managing concerns about trainee performance, as well as personal coaching 

and mentoring support for individual trainees. Further information is available 

from the CDU website at www.oxforddeanerycdu.org.uk/index.html. 

Issues that are related to patient safety should be discussed with 

the Director of Medical Education and / or the Medical Director of 

your own Trust. 

Equality and diversity 

It is important for clinical supervisors, educational supervisors, College Tutors, 

Training Programme Directors and School Board officers to treat all trainees 

equally and without discrimination. This is of particular importance when the 

trainee’s problems begin to impact on their performance, as less than equal 

treatment might be alleged through either PGMDE appeals panels or even 

Employment Tribunals. The same standards of communication and support to all 

trainees should be applied from the outset. An electronic file is recommended 

for every trainee with whom you have any dealings, password protected of 

18 



course, and any paper material should be kept securely under lock and key. 

The Oxford PGMDE policy can be viewed on the website. 

Harassment 

Harassment can take various forms and may be directed against males or 

females, ethnic minorities or subgroups, towards people because of their age, 

sexual orientation, physical or mental disability, or some other characteristic. 

It may involve action, behaviour, comment or physical contact which is found 

to be objectionable by the recipient or which causes offence and can result in 

the recipient feeling threatened, humiliated, patronised or isolated. It can also 

create an intimidating work environment. Individual perceptions about certain 

types of behaviour will vary, so what is acceptable for one person, may be 

inappropriate or unacceptable behaviour to another. 

Harassment may be persistent or occur on a single occasion. It may be 

intentional or unintentional on the part of the perpetrator, but it is the impact 

of the behaviour on the recipient, and the deed itself, which constitutes 

harassment. 

As before, this policy can be viewed on the deanery’s website. 

Concerns about health 

If there are any concerns about an individual’s health affecting training, the 

doctor should be encouraged to see their own GP. If there is a possibility that a 

doctor’s health may be affecting their work, then the employer may ask for an 

occupational health assessment. Further information and guidance is available 

from the CDU website and from NCAS at http://www.ncas.nhs.uk/resources/ 

handling-healthconcerns/ 

Dyslexia in relation to Postgraduate Medical and Dental Education 

and Training 

Dyslexia is one of a group of conditions called Specific Learning Difficulties 

in Adults, which also includes Dyspraxia or Development Co-ordination 

Disorder, Dyscalculia, and Attention Deficit Disorder. Further information 

about these is available on the British Dyslexia Association website – see 

http://www.bdadyslexia.org.uk/about-dyslexia. Hereafter in these notes 

the term “dyslexia” will be used to refer to all the Specific Learning 

Difficulties in Adults. 

Specific information about dealing with dyslexia in postgraduate medical and 

dental education and training is hard to find. There is useful information on the 

BMA website produced by the BMA Medical Students Committee – see http:// 

bma.org.uk/developing-your-career/studyingmedicine/common-challengeswhile-studying/studying-with-dyslexia 

but this does not refer to what happens after qualification. 



The GMC website includes references to dyslexia under its Gateways 

guidance – see http://www.gmcuk.org/education/undergraduate/gateways_ 

guidance.asp for general information about this guidance. In summary: 

• GMC Gateways guidance 

• This advisory guidance is aimed primarily at medical schools. It will also 

interest organisations involved in postgraduate medical training and 

many individuals, including disabled doctors, students and potential 

students. 

• It provides practical suggestions to help schools ensure that disabled 

students do not face unnecessary barriers to successful medical careers. 

• The advisory guidance originally resulted from a partnership led by 

the GMC and financially supported by 11 medical schools. Matched 

funding was provided through Gateways to the Professions, set up by 

the Department for Education and Skills (England), as it then was. The 

guidance has been revised to take account of developments including 

the 2009 edition of Tomorrow’s Doctors and the Equality Act 2010. 

• The guidance does not lay down new requirements, quality assurance 

standards or ‘policies’ from the GMC or any of the other organisations 

involved. 

• Section 4.2 of the guidance covers the legal definition of ‘a disabled 

person’ (copied from GMC guidance – the emphasis is added): 

The Equality Act 2010 defines a disabled person as: 

‘A person (P) has a disability if P has a physical or mental impairment which has 

a: 

• Long-term and 

• Substantial adverse effect on P’s ability to carry out normal day-today 

activities.’ 

As this is a legal definition, it is ultimately for a court or tribunal to determine 

to whom it applies. Where there is doubt about whether an individual will be 

covered, it is best practice to assume that they will be and focus on identifying 

reasonable adjustments that will assist them. 

The effect of an impairment is long-term if: 

• It has lasted for at least 12 months 

• It is likely to last for at least 12 months or 

• It is likely to last for the rest of the life of the person affected. 

• A ‘substantial’ adverse effect is defined in the Act as one that is 

‘more than minor or trivial’. 

20 



• Medical schools, postgraduate deaneries and employers should 

use this definition when considering how to assess and support 

disabled applicants, students and employees. They should also 

encourage a greater understanding of who is protected by the 

Act, and seek to protect the rights of disabled people in their use 

of all the services at university and medical school. 

• People with a range of impairments and long-term health 

conditions are included in this definition, such as people who are 

hard of hearing or have mental health issues, multiple sclerosis, 

cancer or HIV. Importantly, others who would not usually describe 

themselves as disabled people, such as those with dyslexia, may 

be protected by the Act if the effects of the impairment are ‘long 

term’ ‘adverse’ and ‘substantial’ on normal day-today activities. 

People with hidden disabilities such as epilepsy are also covered. 

• It is not clear from the above to what extent The Equality Act 2010 

places any obligation on postgraduate deaneries in relation to doctors 

and dentists in training that have diagnosed or suspected dyslexia. 

There are certainly obligations under the Act for the employers of 

doctors and dentists in training. 

• There is most useful and comprehensive guidance for employers on the 

British Dyslexia Association website (see 

http://www.bdadyslexia.org.uk/about-dyslexia/adults-andbusiness. 

html). For example, there is: 

• An Adult Dyslexia Checklist which can be used as a screening tool 

for adult dyslexia – see 

http://www.bdadyslexia.org.uk/files/Adult%20Checklist.pdf This 

test is said to be 90% accurate in predicting dyslexia. 

Some relevant text copied from the BDA guidance follows: 

o There is no legal requirement to disclose a disability. However 

once the employer has been informed of an employee’s dyslexia 

or been given a copy of an assessment report, they are on notice 

that they have a duty under the Equality Act. 

o Disciplinary proceedings around performance issues are frequently 

dyslexia related. Many are off sick with stress as a result. In many 

circumstances they could seek redress under the Equality Act in an 

Employment Tribunal. 

o Assessment. Where an employee has not been previously assessed 

for dyslexic difficulties (post 16 years), the first step would be 

for the employer to arrange for the employee to have a full 

diagnostic assessment: 



• This should by carried out by a Chartered Psychologist 

specialising in adult dyslexia. The cost could be around £500 or 

more. 

• However in the case of a job not involving significant 

paperwork, a screening test such as the one linked to our 

website may be sufficient. This test is 90% accurate in predicting 

dyslexia. 

• Most large employers and those in the public sector would be 

expected to fund a dyslexia assessment for an employee as part 

of their duty under the Equality Act. A small employer may help 

with the cost. For recommendations of appropriate psychologists 

for a diagnostic assessment, contact your nearest Local Dyslexia 

Association. 

Workplace Need Assessment for doctors with dyslexia 

Following the diagnostic assessment, (or where an employee is able to show 

an existing adult assessment report), a workplace needs assessment should 

be arranged with a dyslexia specialist. This will detail the most appropriate 

accommodations and support, (reasonable adjustments) which would be 

successful in mitigating any weak areas and reduce stress. This is not something 

that either the individual or the employer would be able to work out for himself 

or herself. 

Workplace needs assessments can normally be obtained from Access to 

Work, part of the Jobcentre organisation. 

• The application to Access to Work should be made by the employee. 

For information on this process see Dyslexia Support in the Workplace. 

• Independent dyslexia workplace consultants can also be appointed to 

do an assessment. Their report can still be submitted to Access to Work 

for the grant to the individual for items and training recommended. 

Implementing Reasonable Adjustments. 

Reasonable Adjustments should be put in place as soon as possible. 

Failure to implement Reasonable Adjustments would be a breach of the 

Equality Act. Reasonable Adjustments are not a quick overnight remedy. 

Depending on the individual circumstances, it may take 2 or 3 months for 

measures to become embedded and for any associated training and 

learning to become effective. 

22 



External sources of support for trainees 

There are a number of well-regarded external sources of support, and it is 

strongly recommended that supervisors direct trainees to them and do not 

try to act as, for example, marriage guidance counsellors, or ‘doctors’ to 

their trainees. 

The agencies which may be suitable include: 

Medic Support 

The CDU 

‘Doctors for Doctors’ 

Funded by the Oxford PGMDE to provide a free and 

confidential counselling service for doctors and dentists 

in training. See 

http://www.oxforddeanerycdu.org.uk/health/help_for_ 

trainees/medic_support.html 

See the CDU website for more information 

A BMA service for medical students and qualified 

doctors. Contact on 08459 200169 



Appendix A: Forms usually collated by the 

Educational Supervisor and ARCP outcomes 

These are described in detail in ‘The Gold Guide’. Increasingly these forms 

are lodged in the specialty eportfolio. Both trainee and Educational 

Supervisor normally have access to the same site: other assessors may 

be invited by the trainee sending an ‘e ticket’ to login. 

The Educational Agreement (EA) 

Both the trainee and their Educational Supervisor at the start of each year 

of training should sign it. The form looks like this: 

The Trainee’s Personal Development Plan (PDP) 

This should be written by the trainee at the start of the training year, and 

reviewed after each assessment, as a minimum (due at 4, 8 and 11+ 

months) 

The Annual Assessment Review Form (AARF) 

This document forms the summative assessment of a trainee’s progress 

during the preceding year and is an integral part of the evidence required 

for the ARCP panel review. It will include the domains laid out by the 

GMC: 

Good clinical care 

Developing and maintaining good medical practice 

24 




Working with colleagues 

Teaching and training 

Probity 

Health 

and attributes / targets required by the specialty curriculum, including an 

overview of progress and all the work place based assessments. 

Confirmation that an audit has been completed, evidence of reflective 

learning and, from 2013, reporting of the trainee’s involvement in 

complaints or critical incidents are usually required fields on these forms. 

An example of such a form is shown below (note TO2 is the abbreviation 

for multisource feedback used by the example specialty) 

First First edn. edn. Field Guide for Supervisors: Oxford Deanery PGMDE Jan Apr 2013 2013 25 25 


Action Plans / Improvement Plans 

These are formulated to address any concerns about the trainee’s 

performance, should be agreed and documented between the educational 

supervisor and trainee. This is effectively what we call a Professional 

Improvement Plan (PIP) in the PGMDE ‘Supporting the Trainee Protocol’. 

ARCP outcomes 

Outcome 1 

Outcome 2 

Outcome 3 

Outcome 4 

Outcome 5 

Outcome 6 

Outcome 7 

Outcome 8 

The trainee has achieved all the required technical and 

educational targets set for the period of training under 

review 

The trainee has almost achieved the targets set, and 

does not need to have the CCT date delayed. This may 

be a small shortfall in WPBA numbers. Exam failure may 

be such a target, unless the trainee is at a point in 

training where continued progress demands exam 

success. 

This trainee has not achieved the training targets set for 

the period of training and will need more time in 

programme to achieve these targets. 

This trainee is leaving the programme, either with the 

required targets having been achieved, or without. Some 

trainees choose to leave the specialty because it was the 

‘wrong’ choice for them, others leave because their 

training time has already been prolonged by the 

maximum of two additional years, but has still not 

achieved the educational targets required to progress 

further. 

This trainee has not submitted the required evidence of 

training to the ARCP panel and a decision on their 

progress cannot be made. This trainee is expected to 

produce the necessary evidence within two weeks of the 

date of the ARCP. 

This trainee has completed the entire specialty training 

programme and can apply for the CCT 

This prefix is used for trainees in LAT or FTSTA posts. 

The suffix is .1, .2, .3 as above. 

This trainee is currently ‘out of programme’. This may be 

for research, specific clinical experience elsewhere, or as 

a career break. 

26 




Appendix B: Expectations of generation Y 

This has been taken from the Medical Careers pages of the NHS Medical 

Careers website. 

People born between 1946 and 1964 are often described as ‘baby 

boomers’, those between 1965 and 1981 as ‘generation X’ and those after 

1981 as ‘generation Y’. Whilst these terms are American, the expectations 

and experiences of the groups are transferable to the UK. The 

demographic groups have different expectations and values when 

compared to each other. 

There have been several recent studies that have looked into the 

differences in attitude between generations and how this relates 

to the working environment. These studies do not relate strictly to 

medicine; however they are relevant as they are valid in any 

working environment. This article focuses on the attitudes of 

Generation Y as today the majority of medical trainees fall into 

this category. 

One recent study is the ‘Gen Up’ report, published in September 2008, 

which is a joint survey report commissioned by the CIPD and Penna. This 

study surveyed over 5,500 employees across 6 Western European 

countries. 

The ‘Gen Up’ report compares attitudes between the above four 

generations under the following headings: 

• Retention and loyalty 

According the report ‘Gen X and Y may ‘demand’ more flexible hours and 

are less likely to take a long term career view with the organisation’. 

However, ‘nearly half of Gen Y intend to be with their current employer in 

five years time and one in four expects to change jobs every two to three 

years.... So the commonly held belief that Gen Y is easy to recruit, hard to 

retain may not be strictly true.’ 

• Driving Customer Service 

‘Gen Y is more positive about service being recognised than other 

generations’, although ‘16% of Gen Y are not at all interested in customer 

service being part of their role.’ 

• Performance Management 

‘Gen Y is much less tolerant of under-performance. Nearly one in five Gen 

Ys believe that the best solution for under-performance is for someone to 

be fired’. 

• Mobile and Flexible Working 

‘As a generation, Gen Y are the first to truly adopt technology to manage 

their life/work balance as the boundaries of office and personal life 

become blurred.’ 




• Internal communication 

‘Gen Y is actually the most positive generation about communication. 

They may be expected to be more demanding of internal communication 

given the fact that they are used to ‘information at their fingertips’. 

• Leadership and Management 

‘Gen Y may find that older generations demonstrate less trust for senior 

management. Gen Y are also more likely to rate senior mangers well 

including the fact that they make work priorities clear.’ The report also 

finds that ‘Gen Y is the most trusting of the organisation as they have not 

been exposed to significant downsizing or economic uncertainty.’ This 

characteristic may now be subject to change, however, with the effects of 

the current recession. 

• Career development 

‘Gen Y may find some generational conflict in terms of career 

development’. 

’Gen Y may find development conversations with other Gen Y much easier 

to manage – conversations are likely to stretch beyond the current 

organisation’. The Baby Boomer may be surprised at the ‘self- sufficiency’ 

of Gen Y as they expect to manage their own career development’. 

28 




Appendix C: Good Medical Practice: Indicators for 

assessors 

1 Good Clinical Care 

Incompetent 

History Taking 

Incomplete, inaccurate and 

confusing history taking from, 

and communication with, 

patients (carers). 

Fails to take into account the 

patients (carers) concerns, 

expectation or understanding. 

May repeatedly upset patients 

(carers). 

Examination 

Regularly fails to elicit physical 

signs of common clinical 

problems. Poor technique 

Frequently takes inappropriate 

short cuts when examining. 

Routinely fails to adequately 

explain procedures for intimate 

examinations. 

Cannot get patient co-operation 

for examination. 

Investigations 

Regularly fails to order 

appropriate basic investigations 

Orders inappropriate, random 

unnecessary investigations, no 

thought given. 

Often fails to perform 

investigations requested 

Fails to recognise normal and 

abnormal results of common 

investigations. 

Fails to ask for help or take 

appropriate action thereon. 

Competent 


Clear history taking and 

communication with patients (carers). 

Uses open & closed questions 

appropriately 

Knowledge of ‘alarm’ symptoms 

Appreciates the importance of 

clinical, psychological and social 

factors. 

Attempts to incorporate the patients 

(carers) concerns, expectations and 

understanding. 

Ability to take specialised histories: 

mental health, sexual health, from 

children / parents. 

Examination 

Explains the examination procedure 

and minimises patient discomfort. 

Uses chaperones appropriately 

Can elicit individual clinical signs but 

may lack co-ordinated approach and 

sometimes fails to target detailed 

examination as suggested from the 

patient’s symptoms. 

Able to use instruments appropriately. 


Requests common investigations 

appropriately for patients’ needs. 

Ensures investigations requested by 

team are completed. 

Discusses risks, possible outcomes 

and later results with patients (carers) 

appropriate to level of expertise. 

Recognises normal and abnormal 

results. 

Prioritises importance of results and 

asks for help appropriately. 

Understands local systems and asks 

for help appropriately from the 

relevant individuals. 



Accomplished, concise and 

focused (targeted) history 

taking and communication, 

including difficult 

circumstances (when 

English not the patients first 

language; confused patients 

or other psychiatric / 

psychological problem or 

special educational needs; 

deaf patients; child abuse / 

neglect. 

Examination 

Elicits signs appropriately 

and with attention to patient 

dignity. Skilled 

examination technique 

Teaches examination 

techniques. 

Able to examine children of 

all ages 


Arranges, completes & acts 

on investigations 

intelligently, economically 

& diligently. 

Teaches F1 trainees about 

requests for, interpretation 

of and action on normal and 

abnormal results, for 

common investigations. 




1 Good Clinical Care (2) 

Incompetent 

Making a diagnosis / 

management plan 

Decisions frequently 

questionable. 

Unable to make decisions or 

even make a working diagnosis 

Seeks help all the time. 

Fails to involve patients in 

decision making. 

Therapeutics 

Prescribing regularly shows lack 

of clarity. 

Repeatedly fails to take account 

of drug history. 

Frequently fails to prescribe 

according to standard BNF 

recommendations, including 

potentially harmful interactions. 

Record Keeping 

Keeps inaccurate or illegible 

notes with key information 

missing. 

Fails to sign entries. 

Clinical Risk Management 

Lacks knowledge or 

understanding of common 

complications/side effects of 

treatments / procedures. 

Fails to identify signs that might 

indicate acute illness. 

Does not seek help 

appropriately. 

Consistently fails to hand over. 

Competent 



Decisions generally 

satisfactory, though occasional 

inadequacies when under work 

pressure. 

Can make a sound diagnosis & 

produce safe, appropriate 

management plans. 

Involves patients (& other 

professionals where 

appropriate – aware of own 

skill & competency) 

Therapeutics 

Takes an accurate drug 

history. 

Uses the BNF and other 

sources to access information. 

Prescribes drugs (including 

oxygen, fluids and blood 

products) clearly and 

unambiguously. Understands 

the implications of religious 

beliefs. 

Describes common drug 

interactions and allergic 

reactions. 


Routinely records accurate, 

logical legible history which is 

timed, dated and clearly 

attributable. Medico – legally 

sound. 

Routinely records patients’ 

progress including 

management plans and 

discussion with relatives and 

other health care professionals. 

Utilises information systems 

effectively. Adapts style to 

multidisciplinary case record 

where appropriate. 


Describes common 

complications and side effects 

of treatments/procedures. 

Identifies and responds 

appropriately to patients with 

abnormal signs. 

Recognises personal 

limitations and seeks help at 

an early stage. 

Communicates effectively to 

ensure continuity of care. 




Decision making satisfactory even 

when under pressure. 

Shows intelligent interpretation of 

available data to form an effective 

hypothesis, understands the 

importance of probability in 

diagnosis. 

Teaches F1 trainees on taking drug 

history, obtaining prescribing 

information and unambiguous 

prescribing. 

Describes the implications of 

pregnancy for safe use of 

commonly used drugs. 

Therapeutics 

Teaches on common drug 

interactions and management of 

allergic reactions. 

Ability to manage adverse drug 

reactions 


Teaches record keeping and 

intra/internet access skills to F1 

trainees. 

Timely sending out of letters, 

discharge summaries. 

Structures letters to communicate 

findings and outcome of episodes 

clearly. 


Appropriately discusses potential 

advantages and disadvantages of 

treatments/procedures with patients 

(carers). 

Teaches F1 trainees the appropriate 

response to patients with abnormal 

signs. 

Sets example by calling for help 

from appropriate health care 

professionals in timely fashion. 

Demonstrates good handover to 

ensure continuity of care. 

Involvement in critical incident 

analysis. 

30 




Management of Acutely Ill patients (1) 

(i) Promptly assesses airway, breathing, circulation in the collapsed patient 

Incompetent 

Fails to respond promptly to 

calls for help 

Slow, incomplete or 

unstructured initial 

assessment 

Competent 

Completes initial assessment within 2- 

3 minutes 

Supports and clears airway 

Observes respiratory pattern and rate, 

identifies inadequate ventilation 

Assesses pulse rate, rhythm, volume 

Measures blood pressure using 

automated methods or 

sphygmomanometer 


As preceding, plus… 

Makes a clinical assessment of 

adequacy of cardiac output & 

oxygen delivery 

Capable of leading multidisciplinary 

team 

Helps others stay calm 

(ii) Identifies & responds to acutely abnormal physiology 

Incompetent 

Fails to focus on correcting 

abnormal physiology as a 

priority 

Lacks understanding of 

clinical relevance of 

abnormal vital signs 

Uses oxygen or intravenous 

fluids in a potentially unsafe 

manner 

Fails to monitor effect of 

interventions 

Competent 

Administers oxygen safely, monitors 

efficacy 

Identifies and attempts to correct 

hypotension appropriately 

Identifies oliguria, checks for common 

causes, intervenes appropriately 


Interprets abnormal vital signs 

correctly in context 

Anticipates and prevents 

deterioration in vital signs 

Recognises patients at risk 

Investigates causes for 

abnormal vital signs 

(iii) Where appropriate, delivers a fluid challenge safely to an acutely ill patient 

Incompetent 

Regularly fails to identify 

need for a fluid challenge 

Unable to distinguish 

between different fluids 

Competent 

Selects an appropriate fluid for 

intravenous resuscitation 

Sets up fluid administration giving set 

correctly 

Administers fluid bolus(es), observes 

response, ensures continued 

administration with monitoring of 

effect to desired endpoints 

Identifies hypokalaemia and chooses a 

safe & effective method of potassium 

supplementation 


Reviews impact of fluid 

administration on organ system 

function 

Considers additional electrolyte 

replacement requirements 





(iv) Reassesses acutely ill patients promptly following initiation of treatment 

Incompetent 

Is unreliable in performing 

regular review of acutely ill 

or unstable patients 

Does not pass on information 

to other members of the 

health care team to ensure 

continued review 

Competent 

Implements a system of regular 

checking of unstable patients 

Calls for help if patient does not 

respond to initial measures 

Makes patient safety a priority 


Provides clear guidance to 

colleagues about monitoring 

Supports nursing staff in 

designing and implementing 

monitoring or calling criteria 

(v) Requests senior or more experienced help when appropriate 

Incompetent 

Permits problems to remain 

unresolved without seeking 

help 

Does not make decisions 

Seeks help all the time 

Over-confident 

No insight into own 

limitations 

Competent 

Analyses clinical problems, considers 

possible causes & solutions. 

Calls for help or advice appropriately 


Prioritises problems 

Puts the patient first 

Seniors are confident in his/her 

judgement 

(vi) Undertakes a secondary survey to establish a differential diagnosis 

Incompetent 

Fails to consider underlying 

cause for deterioration 

Inaccurate examination 

technique, mistakes or 

overlooks important clinical 

signs 

Competent 

Recognises the importance of iterative 

review 

Competent history taking and clinical 

examination 

Arranges basic laboratory tests 


Focused further history taking 

in difficult circumstances 

and/or when patient unable to 

co-operate (see 1.A) 

Rapidly identifies clinical signs, 

links them to the history to 

form a differential diagnosis 

Plans appropriate investigations 

to confirm or refute a diagnosis 

32 





(vii) Obtains an arterial blood gas sample safely, interprets results correctly 

Incompetent 

Fails to understand the need 

for arterial blood gas 

sampling and often omits or 

delays taking the sample 

Does not know the main 

indications and 

contraindications for 

sampling 

Fails to attend to patient 

comfort during the procedure 

Competent 

Takes an arterial sample safely using a 

heparinised syringe 

Describes common causes of abnormal 

values. 

Interprets results in context 

Documents results clearly in the case 

record 


Communicates significance of 

acid base disturbances to others 

in the team 

Directs corrective measures 

(viii) Manages patients with impaired consciousness including fits 

Incompetent 

Omits major supportive 

measures 

Unaware of complications of 

anticonvulsant therapy 

Fails to provide a safe 

environment for the patient, 

including seeking senior 

assistance 

Competent 

Appreciates urgency 

Administers oxygen, protects airway in 

unconscious patient 

Places unconscious patient in recovery 

position 

Calls for help if fitting does not 

respond to immediate measures 

Follows local protocols 


Seeks and corrects 

abnormalities of physiological 

signs, particularly hypoxaemia, 

hypotension, hypoglycaemia 

and electrolyte disturbances 

Questions and discusses 

scientific content of protocols 

in use 

Capable of leading 

multidisciplinary team 

(ix) Safely uses common analgesic drugs 

Incompetent 

Does not routinely seek 

information about patient 

comfort 

Fails to review patient’s 

comfort in a timely manner 

Lacks knowledge of side 

effects of commonly used 

analgesic drugs 

Prescribes analgesics 

unsafely 

Fails to consider interactions 

between patient’s condition 

and side effects of commonly 

used analgesics 

Competent 

Evaluates the patient in pain 

Prescribes opioid and non-opioid 

analgesic drugs safely 

Re-evaluates the efficacy of analgesia 

in a timely manner 

Monitors patients for common side 

effects of analgesic drugs 

Safely uses anti-emetic drugs to treat or 

prevent nausea & vomiting 


Considers the effect of hepatic 

and renal dysfunction on 

analgesic pharmacology 

Makes patient comfort a 

priority 





(x) Explains the principles of managing a patient following self-harm 

Incompetent 

Fails to consider 

possibility of self harm as 

cause for patient’s 

presentation 

Omits appropriate 

investigations in patients 

who present after selfpoisoning 

Does not identify main 

monitoring goals 

Competent 

Focussed history taking, including 

psychosocial causes requiring social 

services or police intervention 

Can access Toxbase 

Recognises need for involvement of 

Mental Health or more experienced 

personnel 

Demonstrates tolerance & understanding 


Protects and supports 

colleagues faced with an 

abusive patient 

Anticipates necessary steps to 

minimise risks to patient 

Can perform a mental state 

assessment 

(xi) Describes the management of a patient with an acute psychosis 

Incompetent 

Fails to recognize features 

of psychosis 

Unaware of provisions of 

Mental Health Act 

Competent 

Recognizes diagnostic features of psychosis 

Summons experienced help promptly 

Can discuss safe administration of antipsychotic 

drugs 

Can discuss provisions of Mental Health 

Act 


Protects patient and 

colleagues from harm 

Can safely administer antipsychotic 

drugs 

Can initiate requirements of 

the Mental Health Act 

Considers underlying causes 

of psychosis 

(xii) Resuscitation training 

Incompetent 

No certification or 

indication of not reaching 

the required standard 

Competent 

Trained to Intermediate Life Support (ILS) 

standard 


Trained to Advanced Life 

Support (ALS) standard 

(xiii) Discusses Do Not Attempt Resuscitation (DNAR) orders/advance directives appropriately. 

Incompetent 

Does not understand the 

importance of timely 

DNAR decisions and their 

discussion with patients, 

relations and/or colleagues. 

Ignores advance directives. 

May cause unnecessary 

upset 

Competent 

Understands the criteria for issuing orders 

and level of experience required to issue 

them 

Can discuss with colleagues including 

nurses and also relatives. 

Facilitates the regular review of DNAR 

decisions and understands actions required 

if decision challenged 


Discusses the DNAR criteria 

and their legal framework 

with colleagues including 

nurses and also relatives 

Encourages regular review of 

this order and takes 

appropriate action if 

challenged 

34 




Practical procedures 

Incompetent 

High failure rate for 

simple procedures 

Hurts patients 

Ignores patients 

feeling and wishes 

Unsafe, prepares 

badly 

Unclear and worrying 

consent 

Muddled records 

Competent 

For each procedure consider the following: 

1. Knowledge of indications & 

contraindications 

2. Explanation to the patient 

3. Skill in gaining informed consent 

4. Preparation of equipment 

5. Preparation of the skin where 

appropriate 

6. Positioning of the patient 

7. Trainees hygiene where appropriate 

8. Sharing of information and aftercare 

arrangements 

9. Monitoring of the patient 

10. Disposal of equipment 

11. Documentation of procedure 

12. Recording complications 


A model performer, seen as 

the example to follow. 

Contributes to the 

improvement of this aspect 

of the service 

Procedures 

• Venepuncture, cannulation and venesection 

• Central venous access 

• Blood cultures from peripheral and central sites 

• Intravenous infusions including the prescription of fluids, blood and blood products 

• Performing an ECG 

• Arterial blood sampling 

• Injection- subcutaneous, intradermal, intramuscular, intravenous 

• Urethral catheterisation, male and female 

• Airway care, oxygen, nebulisers 

• Respiratory function tests – spirometry, peak flow rate 

• Nasogastric tube insertion 

• Urinalysis 

• Proctoscopy 

• Pleural aspiration 

• Lumbar puncture diagnostic and therapeutic 

• Skin suturing 




2 Maintaining good medical practice 

Incompetent 

Learning 

Lazy 

Never turns up to timetabled 

teaching sessions 

Never voluntarily addresses 

gaps in their knowledge. 

When assessed for a second 

time on core knowledge has 

made no progress. 

Does not learn from mistakes 

No use of IT 

No personal learning plan 

No engagement with the e 

portfolio 

Inadequate number of 

SLEs/WPBAs 

Clustering of SLEs, over 

reliance on other trainees and 

allied health professionals 

Evidence / audit / guidelines 

Fails to show any knowledge 

or understanding of the 

evidence base in medical care. 

Avoids discussions with 

colleagues and patients 

(carers) in this area. 

Ignores or unaware of local 

guidelines/protocols 

Has no knowledge of the audit 

cycle, or any recognition of its 

relevance to the assessment 

and improvement of clinical 

standards 

Competent 

Learning 

Hard working 

Regular and active contribution at 

organised teaching sessions. (>50% 

attendance) 

Uses sensible methods to build up their 

knowledge and skills. 

When assessed for a second time on 

core knowledge has a well-formulated 

answer. 

Awareness of & can access electronic 

learning resources, databases, library 

Personal learning plan (reflective 

learner) 

Contemporaneous engagement with the 

e portfolio 

Prescribed number of SLEs/WPBAs 

Regular SLEs, mainly by consultants 

Evidence / audit / guidelines 

Demonstrates a clear ability to 

critically appraise evidence base of 

medical care 

Willing to discuss with colleagues and 

seeks to inform patients (carers) 

appropriately 

Applies local guidelines/protocols. 

Understands the audit cycle and 

recognises how it relates to the 

improvement of clinical standards 


Learning 

Exemplary 

Sets standards (>75% 

attendance at teaching 

sessions) 

Always has a well 

researched and organised 

approach to medical practice 

Reports own errors 

unhesitatingly & shows 

ability to learn from the 

experience 

Actively evolving personal 

learning plan (reflective 

self-directed learner) 

E portfolio exemplary 

organisation 

More than enough SLEs: 

with evidence that the 

curriculum is being 

systematically covered 

Evidence / audit / 

guidelines 

Implements the available 

evidence base in most areas 

of clinical care 

Seeks out opportunities to 

discuss with colleagues. 

Supports patients (carers) in 

making sense of the 

evidence base in terms of 

their personal circumstances 

Seeks to refine local 

guidelines/protocols 

Has been actively involved 

in undertaking a clinical 

audit, and recognises how it 

relates to the improvement 

of clinical standards and 

addresses the clinical 

governance agenda 

36 




3a 

Relationship with Patients 

Incompetent 

A: patient centredness 

Discourteous, inconsiderate of 

patients’ views, preferences, 

cultural norms, dignity & 

privacy 

Discusses one patient in front 

of another 

Unable to reassure, subject of 

repeated complaints. 

Discriminates against patients 

with disabilities 

Exploits relationships with 

patients to own advantage 

Has inappropriate financial or 

personal relationships with 

patients 

B: Communication Skills 

Consistently ignores, 

interrupts or contradicts 

patients 

Competent 


Respects the autonomy, dignity, 

confidentiality & privacy of the 

patient. 

Knowledge of limits to 

confidentiality 

Elicits the patients hopes, fears & 

expectations 

Relates to patients as equal 

partners, encourages questions 

Knowledge of children’s rights 

B: Communication Skills 

Courteous, polite, communicates 

well with patients 

Demonstrates active listening & 

an ability to establish trust & 

rapport 

Able to break bad news to 

patients sensitively, & avoid 

conveying unrealistic optimism 

& undue pessimism 

Able to handle difficult patient 

interactions – reassurance of the 

‘worried well’, self discharge, 

complaints, do not resuscitate 

decisions 

Avoids jargon 

Telephone skills 



Able to anticipate patients emotional 

& physical needs & plans to meet 

them 

Recognises & responds to their health 

beliefs 

B: Communication skills 

Explains clearly & checks 

understanding 

Able to apply models of the 

consultation appropriately 

Able to use language (and 

interpreters) appropriately; including 

communicating with patients with a 

disability e.g. deafness, visual 

impairment 

Respond to a patients understanding 

when breaking bad news or in 

discussion of life threatening or 

terminal illness 

Able to handle difficult patient 

interactions –advance directives / 

living wills, organ donation, 

reporting patients to DVLA, 

compulsory detention under a section 

of the Mental Health Act 




3b 

Relationship with Patients 

Incompetent 

C: Patient 

Involvement: 

Ignores the patients best 

interests when deciding 

about treatment or 

referral 

Fails to obtain patients 

consent to treatment 

Competent 

C: Patient Involvement: 

Explain the concept of risk to a 

patient 

Knowledge of legal framework of 

consent 

Apply the rules of consent – gain 

consent for a variety of procedures 

Able to provide patients with 

understandable information 

Appropriate use of leaflets & 

written information 

D: Patient in Context 

Understanding of the impact of the 

patient as a person in a family 

E: Relationship with patients 

relatives / carers 

Can gain consent for a postmortem 

Able to break bad news to relatives 

sensitively 

Able to share decision making with 

relatives 

F: Health Promotion 

Give simple health promotion 

advice 


C: Patient Involvement: 

Respond to a patients understanding & 

attitude towards risk 

Ensure patients are able to make 

informed choices in health care 

decisions 

Respects the rights of patients to refuse 

treatments or tests 

Share an understanding of printed or 

internet information to enhance the 

patients concordance with management 

plans & prescriptions 

D: Patient in Context 

Gain understanding of physical, 

psychological, social & cultural 

dimensions of problems presented 

E: Relationship with patients 

relatives / carers 

Able to deal with patients who cannot 

give informed consent 

F: Health Promotion 

Assess an individual’s risk factors & 

tailor make health promotion advice 

38 




4 Working with Colleagues – Team working 

Incompetent 

a. Communication 

Unable / refuses to communicate 

with colleagues 

Intolerant of other professional 

viewpoint 

b. Team Working 

Does not know the members of 

the team in which they work 

Does not partake in team 

meetings 

Does not know what skills other 

team members have 

Delegates tasks to other 

members of the team for which 

they don’t have the appropriate 

skills 

Bullies or harasses her 

colleagues 

Can’t work to a common goal – 

selfish, inflexible 

c. Referral and handover 

Doesn’t pass on information to 

colleagues about at-risk patients 

Dismisses patients requests for a 

second opinion 

Refers patients for care which 

they should be able to provide 

Does not provide information in 

a referral that enables the second 

opinion to give appropriate 

advice 

Competent 


Listens to colleagues, accepts 

the views of others 

Able to communicate 

effectively with other 

members of the team & interprofessional 

communication 

(nursing staff / social services / 

coroner) 


effectively with other teams 

(hand over) 


effectively with GP colleagues 

-(telephone referrals ‘on take’) 

-written communication 

(discharges) 

Able to present a case clearly 

b. Team working 

Attends & contributes to team 

meetings 

Knows how to contact team 

outside meetings 

Ensures satisfactory 

completion of reasonable tasks 

by the end of the day / shift 

Arranges cover for duties with 

colleagues 

Flexible – ability to change in 

the face of a valid argument 

a. Referral and handover 

Knowledge of roles & 

responsibilities of team 

members & other 

professionals in patient care, 

able to involve them in care 

appropriately 

Accompanies referrals with 

the information needed by the 

second opinion to make an 

appropriate and efficient 

evaluation of the patients 

problem 



Able to bring together views for a 

common goal 

b. Team Working 

Anticipates problems for next shift 

& takes pre-emptive action 

Able to lead and facilitate team 

meetings 

Able to facilitate change 

Team goal is put before personal 

agenda 

Able to facilitate the development 

of colleagues 

c. Referral and handover 

Where appropriate feeds back to 

specialists views on the quality of 

their care 

Uses handovers systematically for 

training other doctors and nurses. 




5 Teaching and Training 

Incompetent 

Teaching 

No interest in teaching, 

mentoring and/or supervising 

more junior doctors / medical 

students 

Few teaching skills 

Presentations 

Absent themselves at the last 

minute, poor preparation and 

structure 

Competent 

Teaching 

Beginning to develop teaching 

skills, supervising more junior 

doctors & medical students 

Presentations 

Gives presentations to small 

groups e.g. journal club 


Teaching 

Actively involved in teaching, 

enthusiastic, able to motivate 

Clear demonstration of teaching 

skills 

Presentations 

Confident, embraces new 

technology 

Able to present material using 

different media 

40 




6 Probity / professional behaviour: 

Trustworthiness, honesty, confidentiality, ethics, dress code, manners, punctuality, time 

management 

Incompetent 

Poor attitude / approach in 

above areas, possible concerns... 

Fails to make care of patient first 

concern 

Own beliefs prejudice care 

Abuses position as doctor 

Seeks inappropriate personal 

gain in pursuit of practice 

Carelessly attaches her name to 

certificates or documents 

Provides false information on 

such documents 

Persistently failing to cope with 

own work, despite advice, 

support and extra clinical help 

Fails to involve patients in 

decision making 

Competent 

Reasonable approach / 

attitudes in above areas… 

Recognises own limitations – 

seeks advice if unsure 

Accepts professional 

regulation 

Punctual 

Attends to detail 

Respects living wills & 

advance directives 

Knowledge of legal 

responsibilities & ability to 

complete death certificates 

Only shares clinical 

information, whether spoken 

or written, with appropriate 

individuals or groups 

Needs occasional help with 

organisation and prioritisation 

of tasks 

Mostly re-prioritises 

appropriately and usually calls 

for help when falling behind. 


Excellent attitude / approach in 

above areas, a credit to the 

profession. Coaches F1 trainees in 

these attitudes 

Patient care a priority 

Seeks constructive criticism & 

changes performance as a result 

Fosters trust amongst others & 

promotes sensitivity to others 

feelings & needs 

Prioritises and re-prioritises 

appropriately 

Delegates or calls for help in a 

timely fashion when he/she is 

falling behind 




7 Health: 

This section should be used if there are any health issues which have influenced 

the doctor’s progress in the foundation programme 

Concerns 

Often off sick 

No explanation 

Often coincides with duty 

Genuine health issues used to justify 

underperformance 

No concerns 

Rarely sick 

Always explains and apologises 

Genuine health issues never used to justify 

underperformance 

42 




Appendix D: Checklist for Adult Dyslexia 




Appendix E: 

Role of educational supervisor in the revalidation of trainees 

As ES your role is to support the revalidation of trainees by: 

• ensuring the ES report for ARCP is sufficiently comprehensive and clear to be 

used in triangulation about fitness to practise 

• including a statement in the ES report for ARCP about your knowledge of 

their involvement in conduct, capability, serious untoward incidents, 

significant event investigation or complaints as a named individual 

• helping trainees to understand the PGMDE process for revalidation and what 

is required of them (http://www.oxforddeanery.nhs.uk/revalidation.aspx) 

• Role model of good appraisal 

• Encouraging trainees to document their reflection 

• Communicating concerns any concerns about fitness to practise in a timely 

manner and to the appropriate people 

44 




Notes 



Notes 

46 





Postgraduate Medical & Dental Education 

The Triangle, Roosevelt Drive, 

Headington 


OX3 7XP 

Tel: 01865 740601 

www.thamesvalley.hee.nhs.uk 

www.oxforddeanery.nhs.uk

Field Guide for Supervisors of Medical and Dental ... - Oxford Deanery

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