Workforce, training and education
East Midlands

Supporting Professional Performance during Training

The LETB is committed to providing the highest possible quality of training to optimise trainees chances of successfully completing training and attaining a Certificate of Completion of Training (CCT). This page covers how we support own trainees, whether they are high-flyers or having some difficulties.


We are committed to helping trainees to achieve their potential rather than just ‘coasting’. Our educators are trained to help trainees seek out opportunities for development and to have discussions about future career plans and aspirations. Please look at the downloads on this page regarding attitudes to learning and suggestions about areas that can be explored for those who need more challenge and ‘stretching’..


However we also recognise that in some situations training may not progress as intended. We have therefore developed various inputs to help ensure a successful outcome. These 'inputs' can take place at 5 different stages of training.

Stage 1 – Pre-employment

  • Select the appropriate doctors in the recruitment process – we pride ourselves on having robust recruitment processes and follow the national recruitment office policies and procedures. Indeed the national lead for stage 3 recruitment is Roger Price our Associate Postgraduate Dean.
  • As part of the process of offering maximum and appropriate support to all trainees, we would like to ensure that those with little experience in reflective learning and patient-centred communication are offered an additional module of learning. Sometimes this may be suggested during the selection process but not be sufficient in itself to prevent selection to GP training. We therefore offer a an introductory course based on the RCGP's e-portfolio and Work Place Based Assessments (WPBA). The completion of the e-portfolio and WPBA is a requisite for GP training. The aim of this supportive course is to provide these trainees with a full understanding and ability to successfully complete this aspect of their training at an early stage of their training programme.

We feel it is essential to offer supplementary training to those successful trainees who are less familiar with the NHS and UK clinical practice.

Stage 2 – The unexpected difficulty

Where this occurs, we have a very proactive approach to interventions.

Unexpected difficulties in training can come in many forms and present many different types of difficulties.

We recognise that early and thorough assessment of progress is critical. In addition to WPBA, this should include assessment of videos of consultations, sitting in, joint surgeries as well as triangulation by getting views on trainee performance from other members of the practice team. This will always take the form of regular assessment of and feedback to trainees, which is supported with a documented development plan (in the e-Portfolio). Sometimes a single assessment raises concerns which appear contrary to other information obtained during training. A framework for dealing with this situation is contained in the document Single Assessment Concerns.

Trainers and others involved in supervision will recognise that trainees may be going through an important transitional phase. They will also be explicit about their expectation of trainees and what trainees can expect too.

Where appropriate, for health reasons, referral to Occupational Health will be made.

There are certain patterns of behaviour that we look for, as they are often signs of trainees in difficulty. Paice (2006) identified seven key early warning signs of a trainee in difficulty. She described these in terms of observed behavioural patterns.

The seven key early warning signs:

  1. The disappearing act – lateness, unexplained absence from work, just not being reliable.
  2. Slow work rate – apart from the obvious this relates particularly to trainees who fail to engage with the e-Portfolio, make few log entries, do not complete the minimum number of WPBA etc.
  3. Ward rage – i.e. outbursts of temper.
  4. Rigidity – poor tolerance of ambiguity, inability to compromise.
  5. Bypass syndrome – nurses and others avoid seeking opinions from trainees.
  6. Career problems – difficulty with exams, uncertainty about career choice.
  7. Lack of self-awareness – rejection of constructive criticism, defensiveness, counter-challenge.

When any of these signs are displayed, we will aim to offer support, tailored to individual need. Sometimes, to help facilitate this, we enlist the help of other experts who can assist trainees. That might be another trainer who has not been involved before. We also have our Professional Support and Wellbeing service (PSW). The PSW is a support service for trainees who are experiencing difficulties, which may be adversely affecting performance and progression in training.

Further information about the PSW service can be found here.

Stage 3 – The Routine Assessment Processes

We are fortunate to have very committed and gifted trainers in the East Midlands. All of our GP Trainers have attended a recognised 'New Trainers Course' and a large number have attained a Postgraduate Certificate in Medical Education at master's level. Since January 2011, the certificate has been an essential requirement for new GP Trainers. We have robust quality management processes in place to ensure that our trainers and training practices meet GMC/national standards.

Trainers and training practices are supported by a network of local GP Training Programme Directors and admin teams.

Our hospital posts are also quality managed using nationally approved frameworks to ensure that they provide an appropriate level of education and clinical experience.

We also use the Annual Review of Competence Progression (ARCP) process to assess and review progress and attainment of competencies. Recommendations from the ARCP panel are put into place – again to provide supportive interventions. Further information on ARCP's can be found here.

Stage 4 – The routine support process

Specifically related to the Applied Knowledge Test (AKT) and the Clinical Skills Assessments (CSA)

Firstly, it is important to recognise that the best preparation for these exams is derived from seeing and managing patients and reflecting on the experience of this. For AKT seeing patients and identifying learning needs as a result of those patient interactions is the most effective way of filling gaps in knowledge. For CSA preparation consulting with patients and receiving feedback from GP Supervisors is the most reliable way to prepare. That is in particular relation to:-

  • Developing clinical knowledge
  • Avoiding formulaic behaviour
  • Successfully managing the consultation in terms of:
    1.     Having a structured and organised consultation
    2.     Showing appropriate time management
    3.     Performing appropriate physical examinations competently
    4.     Identifying abnormal findings and results
    5.     Developing a shared management plan and making a diagnosis
    6.     Managing risk and making appropriate arrangements for follow up
    7.     Promoting good health at appropriate times
    8.     Developing rapport, showing sensitivity, exploring the patient's agenda, using verbal and non-verbal clues
    9.     Identifying social and psychological information
    10.  Using language and/or explanations that are relevant

We offer a 2-module CSA course, one during ST2, and one during ST3. Information about these courses can be found here.

In wider terms trainee education and development is supported via programme educational activities. Specific information about what is provided is available on each programmes webpage.

Stage 5 – The extra support process

There are a number of interventions offered when trainees have failed a component of the training programme.

All trainees who have failed CSA are offered a one-to-one session in their own practice. For this a CSA assessor travels to the trainees practice to watch the trainee seeing patients and to provide feedback, based on the CSA assessment methodology to the trainee (and trainer). Please see the downloadable document ‘Trainers and the CSA’ containing useful information for trainers.

We also provide sessions in groups for trainees who have failed CSA. These group sessions look, primarily, at communication skills in the consultation.

For those who have failed AKT,  in addition to specific study strategies derived from clinical exposure we offer a session on evidence interpretation and statistical evaluation.

Work Placed Based Assessment (WPBA)
For those failing on WPBA extra support is offered, most commonly from trainers and Programme Directors.