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Recognising signs and symptoms

Paice (2006) identifies seven key early warning signs of a trainee in difficulty, characterised in terms of observed behavioural patterns. These patterns may relate to behavioural problems per se, or reflect underlying educational or personal difficulties.

Seven key early warning signs

  • The ‘disappearing act’: not answering bleeps; disappearing between clinic and ward; lateness; frequent sick leave.
  • Low work rate: slowness in doing procedures, clerking patients, dictating letters, making decisions; arriving early, leaving late and still not achieving a reasonable workload.
  • ‘Ward rage’: bursts of temper; shouting matches; real or imagined slights.
  • Rigidity: poor tolerance of ambiguity; inability to compromise; difficulty prioritising; inappropriate ‘whistle blowing’.
  • ‘Bypass syndrome’: junior colleagues or nurses find ways to avoid seeking the doctor’s opinion or help.
  • Career problems: difficulty with exams; uncertainty about career choice; disillusionment with medicine.
  • Insight failure: rejection of constructive criticism; defensiveness; counter-challenge.


If you notice any of these warning signs in your own trainee, the first step is to identify an opportunity to share your concerns with the trainee, being careful to focus on observable behaviours rather than personal characteristics or traits. There are parallels with feedback and supervision, so see the modules on How to give feedback and Supervision for more information and ideas on how to do this effectively.

An early conversation of this nature may rapidly identify the possible cause(s) of the trainee’s difficulty, which can then be dealt with immediately. Some trainees may readily disclose information to a supervisor who clearly indicates their willingness to listen and support. Others may have concerns about revealing information to those who they perceive to have power to influence their progression. You may wish to encourage those who are not immediately forthcoming to seek help elsewhere by labelling your concerns and suggesting they may wish to speak to others within the organisation, guiding them towards the appropriate personnel. In the next section, however, we focus on the ways in which supervisors themselves can support the trainee in difficulty.

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