INTRODUCTION
Trainer groups are vitally important to trainers as a means of being able to share ideas, keep up to date on training matters, and to benchmark with fellow trainers. Perhaps their most important purpose though is the confidential and supportive setting in which they allow trainers to discuss their training experiences. However, we have increasingly recognised that these discussions have wider implications. Despite the best of intentions and huge experience in our trainer group, we have seen examples of most of the issues (although not the case studies) discussed in this article and we realised that some formal rules were necessary.
Discussions about a trainee’s progress are invaluable for the trainer involved but also for the learning of other group members. These discussions form one of the core functions of the trainer group but do the trainees appreciate that their progress may be discussed in some detail?
Derogatory comments regarding performance may jeopardise future employment prospects in the same manner that an adverse medical history can. A particular concern is that the trainers’ group only ever hears one side of the story. Difficulties often arise due to mismatched expectations between trainee and trainer, potentially leaving the trainer group with the lasting impression of an underperforming individual where in fact there were no such issues.
This situation, described in Box 1, could, in theory, provide a basis for appeals or even litigation (as per the CSA component of the MRCGP1) by trainees, something that could be mitigated against by publishing transparent rules.
Box 1. Legacy of the ‘non-engaging’ trainee
A trainer is having trouble building rapport with his trainee, X. During several trainer group meetings lots of possible causes are considered including some that reflect negatively on the trainee in question.
After a few months the problems are ironed out and X completes training with flying colours. At a job interview some time later, a trainer in the advertising practice remembers some negative comments about X and decides to employ a candidate who has scored marginally less well.
MANAGING CONFIDENTIAL INFORMATION WITHIN THE GROUP
There appear to be no published rules specifically for GP trainer groups. Most of the internet information on ground rules relates to learner sets or therapeutic groups, which are not the same as an educator peer support group. A lack of formal ground rules and a reliance on common sense is a high-risk strategy.
One well known example is ‘the Chatham House Rule’ which states:
‘When a meeting, or part thereof, is held under the Chatham House Rule, participants are free to use the information received, but neither the identity nor the affiliation of the speaker(s), nor that of any other participant, may be revealed.’ 2
Rephrased, this could refer to participants being free to discuss key learning points outside of the meeting providing that anonymity is maintained.
Another example worth considering is the three recognised categories of ‘speaking terms’ (agreements concerning attribution) that cover information conveyed in conversations with journalists.3 In the UK the following conventions are generally accepted:
On-the-record: all that is said can be quoted and attributed.
Unattributable: what is said can be reported but not attributed.
Off-the-record: the information is provided to inform a decision or provide a confidential explanation, not for publication.
Off-the-record conversations are quite rare in clinical practice but do occur when doctors talk to outside agencies (for example, police, social services, and schools) about possible concerns where the patient’s identity is not disclosed. A medical example is an anonymous conversation with social services about a safeguarding issue.
Given that important issues are discussed, recording minutes seems essential, especially for the benefit of absent group members. However, trainees might be entitled to view these (for example, under the Freedom of Information Act 2000). Since some topics will be clearly attributable, even if anonymised, it is likely that certain parts of a meeting should be ‘off minutes’. This reduces the risk of confidentiality breaches but makes it harder to share the learning from meetings. There are also implications for the programme directors in terms of documenting potentially serious issues.
We favour the recording of the themes discussed rather than detailed case studies although even this needs to be risk assessed.
DILEMMAS FACED BY TRAINER GROUPS
It is unrealistic to expect the group to discuss a trainer’s problems without learning something about the specific underlying issues. While it may be possible to generalise it is probably inevitable that some sensitive information will be needed to have a meaningful discussion.
All doctors will recognise the importance of protecting an individual’s medical history, although this can be difficult if behaviour is pathognomonic. Much more uncertainty surrounds the disclosure of a trainee’s professional performance to others not directly involved in their training.
Also important to consider is the manner in which issues relating to a specific trainee are discussed and the language used as this can set the tone for future discussions relating to that individual, which may be difficult to subsequently alter (Box 2).
Box 2. The ‘unmotivated’ trainee
A trainer is struggling to motivate her current trainee and refers to them as a ‘failing trainee’. This language is subconsciously adopted by the group despite no clear evidence of likely failure. What are the implications?
Common problems
Health issues
Details of any physical or psychological ailment must not be disclosed by the trainer to the wider group unless it is critical to understanding the issues facing the trainer. It should usually be sufficient to speak solely in terms of ‘physical’ or ‘psychological’ problems and not disclose anything further. If the trainer considers that the programme director need know about specific details then it would ideally be with permission from the trainee concerned.
Personal issues
The approach here should be the same as for health issues. While issues such as marital difficulties have a huge impact on trainees it would be inappropriate for them to be aired in a group setting. It is worth noting this separately because it is arguably easier to ‘let slip’ sensitive personal information whereas most doctors are very mindful of health information.
Professionalism issues
It is especially important for trainers to be able to ‘benchmark’ their judgements about trainees’ behaviours and attitudes against their peers’ opinions. However, these issues frequently centre on personality traits and are inherently sensitive. Therefore, trainers must think hard about what information they share and how they frame it.
Clinical competence issues
Again, the ability to benchmark is crucial to trainers. This, perhaps, feels a more comfortable area to be openly discussing just as one might discuss any colleague. However, to maintain trust between trainer and trainee even this sort of information should be thought through before discussion.
SAMPLE GROUND RULES FOR DISCUSSIONS
Readily available published rules relate to learner sets or peer support groups.4,5 Of particular relevance to trainer groups are to:
challenge one another, but do so respectfully;
take responsibility for the quality of the discussion;
consider anything that is said as strictly confidential;
give equal turns and attention to all group participants; and
allow sufficient emotional release to restore thinking.
PROPOSED RULES FOR TRAINER GROUPS
The following guiding principles for combining published generic rules with the specific requirements of trainer groups are proposed.
Mutually supportive environment: the group provides a rare opportunity for participants to air their worries and concerns. Members must feel able to disclose uncomfortable information.
Inclusive: everyone should be encouraged to contribute to discussions and in bringing educational material to meetings. This is especially relevant to newer members who may be less assertive.
Constructive feedback: a framework may be useful to ensure a balance between the negative and the positive. The latter would be especially important if a poorly performing trainee subsequently improves significantly, as it hopefully would serve to reduce the tendency of group members to form a lasting negative impression of the individual concerned.
Educational forum: as well as providing emotional support, the main thrust of meetings is to enhance the educator skills of each member.
Confidentiality: any sensitive information should not be shared with anyone outside the group.
Need-to-know basis: information about trainees should be shared with caution and only when essential to the debate. In particular, information about health and personal issues must be weighed carefully and discussed in the most general terms and anonymised whenever possible.
Non-judgemental: avoid and challenge the use of judgemental statements about trainees’ behaviour or abilities.
Careful minuting: record the themes discussed, not individual stories and accept that some parts of the discussion may be best left unrecorded.
QUESTIONS FOR FURTHER DISCUSSION
To enhance the transparency and robustness of trainer groups the following need to be considered:
Should trainees be asked to give their explicit consent at the start of their training programme for information relating to them to be discussed in the trainer group?
Should trainers be required to sign an agreement regarding rules of the group?
Should the training scheme produce guidelines for producing and storing the minutes of meetings?
Should there be national guidance to ensure consistency between schemes?
CONCLUSION
The trainer group provides a unique forum for the discussion of a multitude of issues that arise during the training process. For this to occur effectively, the group needs to be safe, supportive, and confidential. It is essential that all group members recognise their responsibilities to each other but also to the learners whom they discuss. We believe that the creation of explicit ground rules serve to prepare prospective trainers, remind existing trainers of their responsibilities, reassure trainees about the nature of the groups, and act as a template not only for UK-based GP training schemes but also those internationally.
This article lays down a blueprint for the workings of GP trainer groups, the essence of which could be widely adopted and publicised, so as to cultivate a shared understanding of their function by all those involved in GP training.
Notes
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2015
REFERENCES
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Chatham House Rule, Chatham House. .
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