Trainee in Difficulty
"Because every trainee deserves a fair chance to get back on track — and every trainer deserves to know exactly how to help them."
📅 Last updated: April 2026
📥 Downloads
Handouts, templates, referral forms, and teaching resources — all ready when you need them. Includes the RDMp manual, OH referral letter template, performance review forms, and much more.
path: TID
- rdmp
- bullying - BMA guidance 2006.pdf
- dealing with difficult doctors - king.doc
- doctor in difficulty.ppt
- doctor with problems.doc
- doctors in difficulty - wm deanery.doc
- doctors in difficulty - yh deanery.doc
- doctors in difficulty and SID - share involve document.doc
- doctors in difficulty from NCAS and the CLIMDA model.pdf
- dyslexia and dyspraxia.pdf
- educational performance pathway.docx
- health problems - recognising early triggers - NCAS security plan.doc
- looking after ourselves study guide by Liz Moulton.doc
- occupational health letter referral template for a gp trainee.docx
- performance concerns in gp trainee - referral form to gp school.docx
- performance review on trainee in difficulty - tpd form.docx
- remedial supervision - agreement between trainer and trainee.pdf
- scenarios of difficult trainees.doc
- the problem doctor - flowchart of pathways.pdf
"A hand-picked selection of official guidance and real-world GP training resources. Because the best insights aren't always in the official documents."
Confidential NHS service for doctors and dentists with health concerns. Free and accessible across England.
BMA counselling, peer support, and wellbeing resources for doctors at all stages of training.
The formal route for concerns about a doctor's practice. Understanding when and how this applies.
I-SID framework, RDMp tool, SKIPE model and local escalation pathways.
Dedicated BVTS pages on wellbeing, resilience, and self-care for GP trainees.
Peer support for doctors experiencing mental health difficulties. Run by doctors, for doctors.
GP-specific resource addressing burnout, mental health, and the particular pressures of general practice.
Practical resources on the management and support of GP registrars in difficulty.
Is GP the right career path? A validated tool for trainees (and trainers) exploring career fit.
BVTS pages specifically on financial stress and debt — often an underlying factor in trainee difficulty.
For trainees experiencing domestic or family-related coercion. Confidential support available.
Local deanery support and counselling services for GP trainees in the Y&H region.
🌍 Resources for International Medical Graduates (IMGs)
Specifically for doctors who trained outside the UK. Whether brand new to the NHS or a few months in, these will help you bridge gaps in system knowledge, cultural understanding, and language confidence.
📚 IMG Handbooks
Comprehensive regional resource for IMGs starting GP training in Y&H. Covers induction, support, and practical NHS guidance.
Detailed handbook from the North West deanery covering everything an IMG needs to know about training in the UK. Highly practical and well-structured.
A trusted on-boarding handbook for IMGs. Covers cultural and professional expectations in plain, accessible language.
Essential reading for any IMG relatively new to UK practice. Sets out the ethical and professional standards expected of every doctor practising here. Read this early.
🤝 Support & Career Guidance
Local deanery support for trainees experiencing educational or personal difficulties in the Y&H region.
Confidential counselling services available to GP trainees in the Y&H deanery. Free access for trainees experiencing difficulty.
Helps you work out which specialties best suit your skills and values. BMA membership required. Useful if you are questioning whether GP is the right path for you.
🏥 Understanding the NHS
NHS England's own introduction to how the NHS works — its values, structure, and the role of different services. Clear starting point for anyone new to UK healthcare.
How and why the NHS was created in 1948. Understanding its founding principles helps explain the culture and values of UK healthcare today.
Comprehensive overview of how the NHS has evolved since 1948. Useful for IMGs wanting to understand how the system reached where it is now.
Broad introduction to the NHS — purpose, structure, funding, and workforce. Helps you understand where general practice fits in the bigger picture.
A clear visual and written breakdown of NHS organisation — from NHS England down to individual GP practices and PCNs.
✏️ English Language & Communication
Bradford VTS pages for improving written and spoken English in a UK medical context. Letters, consultation language, and professional communication.
Free guides from the Plain English Campaign. Essential for writing clearly in British English — for ePortfolio entries, referral letters, and clinical correspondence.
Key Principle
Act early. Late intervention leaves no space for effective remediation. The sooner you act, the more options everyone has.
I-SID Mnemonic
Identify the problem early. Share concerns with the trainee. Involve the TPD and deanery. Document everything in the ePortfolio.
Use RDMp
Use the RDMp diagnostic tool to identify what the difficulty is before rushing to fix it. Poor performance is a symptom, not a diagnosis.
ePortfolio Only
Document concerns in the FourteenFish ePortfolio (Educators' Notes) — never in separate records. Separate records may constitute a breach of UK GDPR and the Data Protection Act 2018.
Patient Safety First
If you have serious concerns about patient safety — stop the trainee working immediately and contact the TPD. Then review patients seen.
Compassion Always
Behind nearly every "difficult trainee" is a person in distress. Approach with empathy, not hostility. Adult-to-adult conversations. No hidden agendas.
Don't fret about whether you're making too much fuss — it is always better to raise a concern early than to stay silent. When concerns are passed on late, there is very little space for effective support. The trainee, and the patients they look after, deserve better than that.
🌍 More Common Than You Think
Difficulty in GP training is not rare. Research suggests that between 5–10% of GP trainees will experience a significant problem during their training at some point. Many more will experience milder difficulties that — if not addressed — can escalate.
Every training scheme will have trainees who need extra support. This is normal. It does not reflect badly on the trainee, the trainer, or the scheme — as long as it is handled well.
⏱️ The Timing Problem
GP training is relatively short — 3 years (36 months). There is limited time for course correction. When difficulty is identified early (ST1), there is time to provide meaningful support and remediation. Identified in ST3 — options are significantly narrowed.
Early identification and early intervention are not just "nice to have" — they are essential for good training outcomes.
📊 Differential Attainment
Research consistently shows that IMGs and trainees from ethnic minority backgrounds are over-represented in formal performance processes. This is a systemic issue — not a reflection of these trainees' abilities or potential.
Trainers and TPDs need to be aware of this and ensure that cultural and contextual factors are actively considered when assessing difficulty.
🔄 Performance vs The Person
Poor performance is rarely just about clinical knowledge. Research (NCAS) has shown that behavioural factors are present in the majority of cases referred for formal assessment.
Problems with communication, insight, interpersonal skills, and emotional wellbeing underlie most significant cases — not simply "didn't know the right answer."
Analysis of cases referred to NCAS found that 47 out of 50 cases referred for full formal assessment had a significant behavioural element — not primarily a knowledge deficit. This is why the RDMp tool (see below) approaches performance diagnosis holistically, not just focusing on clinical knowledge.
"The insights on this page come from aggregated patterns seen repeatedly across GP trainee communities, research interviews, and peer discussions — translated into professional teaching points."
All insights have been verified against RCGP, GMC, and NHS guidance. Nothing here contradicts official advice.
📊 The Scale of the Problem
How widespread are difficulties among UK GP trainees? The numbers are striking — and they matter for how trainers and TPDs calibrate their expectations and vigilance.
GP Trainee Wellbeing — Key Statistics (BMA GP Training Survey & Research)
Sources: BMA GP Training Survey 2021 (652 trainees); GMC National Training Survey 2023. These are UK-specific figures.
⚠️ High-Risk Groups for Burnout — Research Findings
Research shows that informally considered "high flyers" — especially young, female, UK-trained trainees — are at surprisingly high risk. Perfectionism and pressure to maintain high standards become liabilities under sustained stress.
Burnout risk spikes at specific points: post/rotation changes, approaching exams, and year transitions. These predictable stress peaks are when trainers should be most vigilant — and most proactive.
Trainees consistently cite ePortfolio workload as a major stressor — particularly in ST3. The administrative burden of evidence collection, on top of clinical work and exams, is frequently underestimated.
Unique cumulative pressures: cultural adjustment, language nuance, NHS system unfamiliarity, family separation, sometimes financial strain — all on top of clinical training demands. This context must inform how we interpret performance.
✅ What Actually Helped — From Trainees Who Came Through It
These patterns come from trainees who experienced difficulty and successfully completed training — what they consistently say made the difference.
Speaking Up Early Changed Everything
Trainees who disclosed difficulties early — even when terrified to do so — consistently described it as the single best decision they made. The conversations they dreaded were almost never as bad as they imagined. Trainers were "not what I expected — actually really supportive."
Peer Support Was Underrated
Finding out that colleagues were also struggling — through HDR group discussions, informal chats, or online communities — provided profound relief. Social normalisation of difficulty is genuinely protective. HDR is not just teaching: it is a peer support network. Use it.
Getting a Label Was a Relief, Not a Threat
For trainees found to have dyslexia, ADHD, or other learning differences during training: the moment of diagnosis was frequently described as a relief — finally understanding why they were struggling. "It wasn't that I was thick. It was that nobody had assessed me." Getting assessed is worth it.
Seeing Their Own GP Made a Difference
Many trainees in difficulty had not registered with a GP — or had never made an appointment for themselves. Seeing a GP separate from their training practice, getting proper assessment, and in some cases starting treatment for anxiety or depression, made a significant difference to their capacity to train.
Understanding What Kind of Difficulty It Was
Trainees found it easier to work on difficulty once it was clearly named and categorised. Vague feedback like "you need to improve your consulting" was demoralising. Specific, RDMp-informed feedback — "your diagnostics are sound, but your relationship domain is what's affecting you" — gave them something concrete to work on.
Less Than Full Time Training
Trainees who were drowning at full time often thrived at 60–80%. This is not failure — it is using the system well. The LTFT option exists precisely for situations where health, caring responsibilities, or wellbeing require a more sustainable pace. Ask your TPD.
⚖️ Trainer Relationship — The Single Biggest Factor
Research consistently identifies the quality of the trainer-trainee relationship as the most important factor in whether a struggling trainee succeeds or fails. More important than knowledge, resources, or formal interventions.
✅ What Trainees Say Helped Most
- A trainer they could tell anything to, without fear of judgement
- Regular, informal check-ins — not just formal reviews
- Specific, observable feedback (not vague "you need to improve")
- A trainer who noticed something was wrong before the trainee said anything
- Being treated as an intelligent adult going through a hard time — not as a problem
- A trainer who held them to account and showed they cared about the person
- Feeling that their trainer believed they could succeed
❌ What Made Things Worse
- An "absent or non-existent" relationship with their trainer
- Feedback only at formal reviews — too late, too little
- Feeling they were a burden to their trainer
- Sensing that their trainer had already given up on them
- Being compared unfavourably to previous trainees
- A trainer who documented concerns without having spoken to the trainee first
- A training environment where asking for help felt unsafe
💎 What Nobody Tells You — Insights From Those Who've Been There
Trainees describe being so exhausted they couldn't eat lunch, couldn't switch off after work, couldn't focus on days off — and being told this was "just what general practice is like." When a whole cohort normalises burnout, individual trainees lose the signal that something is wrong. If you can't eat lunch, something is wrong.
Many trainees — particularly IMGs and those from didactic educational backgrounds — found the self-directed, reflective, patient-centred model of GP training genuinely unfamiliar. It is not "easier" than lectures and exams. It requires a completely different kind of engagement. Trainers who acknowledge this transition explicitly, and teach the model as a skill, report much better outcomes.
For many trainees — especially those who are already struggling — the ePortfolio becomes an overwhelming second job. Falling behind on it generates anxiety, which makes performance worse, which makes the ePortfolio harder to write about authentically. Early, thorough training in using the FourteenFish ePortfolio well (including what actually needs to go in each box) significantly reduces this burden. Trainers who invest in this in the first weeks of training save everyone time and stress later.
IMGs often have technically good English — but British English is full of understatement, implication, and colloquial norms that are genuinely hard to read. A patient who says "I'm a bit worried" may be expressing significant distress. A patient who says "I don't want to bother you" may be very unwell. Understanding British patient behaviour — not just clinical knowledge — is a skill that needs explicit teaching, and many IMGs benefit enormously from being told directly what to watch for.
GP training doesn't pay as well as many trainees expected, especially for those with family commitments, student debt, or who moved for training. Financial stress in the background is a real driver of difficulty — affecting sleep, concentration, and motivation. Most trainees would never mention it unless directly asked. Bradford VTS has a dedicated section on financial wellbeing (see Web Resources). It is worth signposting proactively.
Trainees who think being a "good trainee" means accepting every opportunity, never saying no, always staying late — frequently hit a wall. The ability to set appropriate limits on your workload is explicitly part of the RCGP curriculum (Fitness to Practise capability). Trainers who model this behaviour, and who explicitly give permission to set limits, help protect their trainees. The precautionary principle applies to energy as well as clinical risk.
🛠️ Practical Tips — What Works in Real Life
Accumulated practical wisdom from UK GP training communities — strategies that trainees and trainers describe as making a real difference day-to-day.
Plan Study & Leave Early
Arrange annual and study leave at the start of each rotation — before the rota gets locked. Knowing a break is coming genuinely sustains you through difficult periods.
Use Your HDR Group as a Support Network
HDR is not just teaching — it is your built-in peer network. Talking informally with colleagues outside formal sessions helps enormously. Find out who is struggling. You are almost certainly not alone.
Register With a GP — Before You Need One
Register with a personal GP outside your training practice at the start of each new post. You do not want to be filling in new patient forms when you are unwell and need urgent help. GPs need GPs too.
Protect Your Physical Basics
Experienced clinicians are clear: eat lunch, drink water, take breaks. Cognitive errors increase with fatigue. Protecting your physical capacity is not self-indulgence — it is a Fitness to Practise issue and explicitly part of the curriculum.
Learn to Write a Good Log Entry Early
Ask your trainer to teach you specifically how to write a good FourteenFish log entry in your first weeks. Many trainees describe spending hours on entries that demonstrate very little. A good model, shown once, saves weeks of wasted effort.
Get to Know Practice Admin Staff
Admin staff, receptionists, and practice managers see the trainees day in, day out. They often notice things before the trainer does. They are part of your support system — treat them as colleagues. And they will often go out of their way to help you if you've invested in the relationship.
A short-term swap to a different training practice — even for a week — gives both the trainee and the trainer a fresh perspective. Other trainers may spot patterns or strengths that the original trainer has become too familiar with to see clearly. It also gives the trainee a reset and the chance to demonstrate capability in a new environment. This is particularly valuable when the trainer-trainee relationship has become strained, or when a trainer genuinely wants a second opinion on their assessment.
Some trainees are statistically more likely to experience difficulty. This is not a judgment — it is a fact that enables better, more proactive support.
International Medical Graduates
Different educational backgrounds, unfamiliar NHS systems, cultural adjustments, language nuance, family separation, financial pressures.
Career Changers
Trainees moving from hospital specialties may struggle with the generalist model, patient autonomy, and managing uncertainty.
GP Post Transition
Trainees transitioning from hospital posts to GP placements often find the autonomous, generalist environment unexpectedly challenging.
Health & Wellbeing Issues
Mental health, burnout, physical illness, or substance misuse — any of which may not be visible until performance deteriorates.
Personal Circumstances
Relationship breakdowns, bereavement, financial difficulties, family pressures, childcare demands — life does not pause for training.
High Achievers Under Pressure
Sometimes the highest achievers — especially those with perfectionist tendencies — struggle most with the inevitable uncertainty of general practice.
If your trainee is an IMG, it is worth actively exploring whether difficulties relate to NHS system unfamiliarity, communication in a second language, or cultural differences in the doctor-patient relationship — before drawing conclusions about clinical capability. These are addressable. NHS England funds additional support for IMGs across many regions. Ask your deanery.
The earlier you spot a problem, the more can be done. Adapted from Paice et al. and NCAS guidance — these are the signals most commonly seen in trainees before a formal problem is recognised.
🟢 Watch & Monitor
- Occasional lateness or missed tutorials
- ePortfolio entries becoming sparse
- Less engaged in tutorials than before
- Slight dip in consultation feedback
- Occasional unexplained absence
- Appears quieter or withdrawn
🟡 Actively Address
- "The disappearing act" — not answering calls, late, frequent sick leave
- Slow work rate — taking far longer than peers
- "Bypass syndrome" — colleagues avoiding asking for their help
- Lack of insight — rejecting constructive feedback
- Failure to arrange WPBAs or reviews
- Repeated unexplained HDR absence
- Defensiveness in clinical discussions
- Inconsistent or unprofessional communication
🔴 Escalate Urgently
- Patient safety incident or near-miss
- Complaint from patient or staff
- Dangerous prescribing patterns
- Failure to act on abnormal results
- Signs of acute mental health crisis
- Unexplained prolonged absence
- Criminal investigation or arrest
- Conduct issues (dishonesty, boundary violations)
The most commonly missed early warning sign is the trainee who goes quiet. They attend, they complete just enough, they don't cause trouble — but they've disengaged. Nobody worries because nothing is obviously wrong. By the time problems become visible, months of opportunity for early support have passed. The quiet withdrawal is often the earliest sign of all.
Difficulty with MRCGP exams (repeated AKT or SCA failures), disillusionment with medicine, or persistent uncertainty about career choice may sometimes be an early warning sign of deeper difficulty — not just exam underperformance. The SCI59 questionnaire (see Web Resources) can help explore career fit in a structured, supportive way.
A significant proportion of trainees in difficulty have an unrecognised learning difference — dyslexia, ADHD, dyspraxia, autism spectrum condition, or dyscalculia. This is often only identified during training, sometimes only when formal difficulty is flagged.
The Journey — From Difficulty to Identification to Support
- Consistently slow with written tasks despite apparent intelligence
- Disorganised notes, records, prescriptions despite trying hard
- Significant discrepancy between verbal reasoning and written output
- Difficulty processing complex written information quickly (e.g. BNF entries)
- Poor time-keeping despite visible effort to improve
- Difficulty with sequencing tasks or maintaining working memory under pressure
- Reports having "always struggled" with reading, writing, or organisation
- Ask directly and sensitively: "Have you ever been assessed for any learning differences?"
- Refer to the PSU (Professional Support Unit) at your deanery — they have specialist assessment capability
- Check whether RCGP examination adjustments may be applicable (extra time, etc.)
- Adapt your teaching style — more verbal explanation, less reliance on written summaries
- Document your observations and concerns in the FourteenFish ePortfolio (Educators' Notes)
- A download on dyslexia and dyspraxia is available in the Downloads section above
Please talk to someone early. Your GP Trainer, Hospital Consultant, Educational Supervisor, or Training Programme Director are all people who genuinely want to help you. The earlier you speak up, the more options are available to everyone — including you.
We know that talking about difficulty is hard. You might feel embarrassed, guilty, or worried about what people will think. You might be afraid of letting people down. These feelings are completely understandable — and very common.
Who to speak to
- Your GP Trainer or Clinical Supervisor
- Your Educational Supervisor
- Your nominated Training Programme Director
- Another TPD if the issue involves the above
- The scheme administrator if you're unsure who to contact
What to know before you speak
- Your trainers and TPDs are supportive people — not enforcers
- Their job is to help you get back on track, not punish you
- You are not the first trainee to have difficulty
- Talking early gives you the most options
- The Deanery's performance team also exists to help, not to scare you
Health Concerns?
Register with a GP who is not based at your training practice. Make an appointment now — don't wait.
Unfit to Work?
Contact your local Occupational Health Department (usually at the main hospital). Your TPD can help arrange a referral.
Need to Talk Now?
Practitioner Health is a free, confidential NHS service for doctors. Available 24/7 for urgent needs. (practitionerhealth.nhs.uk)
Doctors are among the least likely healthcare professionals to seek help for themselves — despite being trained to encourage patients to do exactly that. If you are struggling, reaching out is not weakness. It takes courage, self-awareness, and exactly the kind of professional insight your trainers want to see in you.
Bradford Occupational Health: Employee Health & Wellbeing Manager, Lynfield Mount Hospital, Daisy Hill House, Heights Lane, Bradford, BD9 6DP. Tel: 01274 228570 / Mobile: 07432 721813. Your TPD can refer via the template in the Downloads section above.
You do not have to face difficulties alone. These services are here for you — several are specifically for doctors, and most are free and confidential.
NHS mental health service specifically for doctors and dentists. Free, confidential, accessible. One of the most important resources on this page.
BMA counselling helpline, peer support, and practical wellbeing resources. Available 24/7 for BMA members. Helpline: 0330 123 1245.
Peer support network for doctors with mental health concerns. Run by doctors who have been there.
Burnout, stress, and mental health support specifically designed for GPs and GP trainees.
Local deanery support and counselling services for GP trainees in the Yorkshire & Humber region.
A validated psychometric tool for exploring whether GP is the right career. Useful for trainees and trainers who have career concerns.
Financial stress is a significant but under-recognised driver of trainee difficulty. Bradford VTS has dedicated pages on debt and financial wellbeing.
For trainees experiencing coercion or control within family or domestic situations. Confidential government support service.
Different types of difficulty require different responses. Understanding the nature of the problem is the first step to managing it well.
1. Personality Clashes
Interpersonal conflict between trainee and trainer/team.
2. Health Problems
Physical or mental health affecting performance or safety.
3. Academic / Exam Failure
Repeated AKT/SCA failures, poor WPBA engagement.
4. Unexplained Absence
Uncontacted absences from clinical work.
5. HDR Absence
Missing half-day release without agreed arrangement.
6. Criminal Act
Alleged or confirmed involvement in criminal behaviour.
🤝 1. Personality Clashes
Interpersonal difficulties between a trainee and their trainer, practice team, or colleagues should be faced sooner rather than later. These situations do not resolve themselves with time — they typically escalate.
What to do
- Start with a direct, respectful conversation with the trainee. Seek to understand their perspective.
- Seek advice from fellow GP Trainers (maintaining confidentiality) or your TPD.
- A TPD should involve themselves at an early stage to help clarify issues and arbitrate if needed.
- If required, the trainee may be moved to another practice — this should not be seen as failure by either party.
- Consider doing an RDMp assessment to understand whether the "clash" has deeper underlying roots.
- Document all concerns in the trainee's FourteenFish ePortfolio (Educators' Notes). Keep the trainee informed of what you write.
- Do not keep these concerns to yourself, hoping they resolve.
- Do not consider "sacking" the trainee as a solution.
- Do not assume the Deanery will sort this out "sometime" — escalate promptly.
- Do not keep separate records outside the ePortfolio.
Most personality clashes have two sides. Before concluding the trainee is the problem, honestly consider whether there are factors within the practice environment contributing to the tension — workload, communication styles, unclear expectations, or cultural mismatches.
💊 2. Health Problems
Health difficulties — physical or mental — are among the most common underlying factors in trainee difficulty. The key principle is that you share your concern with both the trainee and the TPDs.
What to do
- Encourage your trainee to have a personal GP who is not based at the training practice.
- Document concerns in the trainee's FourteenFish ePortfolio (Educators' Notes).
- Refer them for an Occupational Health assessment (discuss with TPD first) if you are concerned about their ability to work safely.
- Allow sick leave where needed — extended training provisions exist if training time is missed due to illness.
- If there are serious doubts about the trainee's safety to practise, escalate urgently to the TPD and Deputy Director at the Deanery.
- Do not take on the role of being the trainee's personal GP.
- Do not take over responsibility for their healthcare.
- Maintain appropriate professional distance — you are their trainer, not their clinician.
If the health problem raises doubt about the safety of the doctor to practise, escalate urgently to the TPD and then the Deanery. The Deanery has clear mechanisms for referral to the GMC. You will need to have documented your concerns thoroughly.
📚 3. Failing Academically or in Exams
Academic difficulty — whether with MRCGP exams, WPBA, or clinical performance standards — requires the SID (or I-SID) approach to be applied from the first sign of concern.
SHARE your concerns with the trainee at the earliest possible time. INVOLVE the TPD. DOCUMENT in the FourteenFish ePortfolio.
What to do
- Share concerns with the trainee immediately — never sit on a concern waiting for the next scheduled review.
- Document all concerns in the ePortfolio (Educators' Notes) contemporaneously.
- Involve the TPD early — they may need to involve the Deanery's performance team.
- If you are uncertain whether you can sign off the ESR or CSR — share that concern with your TPD early.
- Consider an RDMp assessment to identify the root cause of underperformance (knowledge? reasoning? professionalism? personal factors?).
DO NOT FALL INTO THE TRAP of signing the ESR or CSR in the hope that the trainee will definitely improve in future posts. This is one of the most common and most serious errors trainers make. If in doubt, talk to your TPD first.
❓ 4. Unexplained Absence from Work
Any unexplained absence from work should trigger an immediate attempt to make contact with the trainee. Do not assume it is simple carelessness.
Unexplained absence is almost always a sign of an underlying problem — often a significant one. Case experience suggests that something has overwhelmed the trainee to the point where they feel unable to function or communicate. Approach this situation with care and compassion, not frustration.
What to do
- Attempt to contact the trainee — phone, email, via next of kin if needed.
- If unable to make contact, communicate with your TPD immediately.
- If contact is made, be supportive — avoid immediately demanding an explanation.
- TPDs may involve the Deanery if the trainee cannot be reached or if a serious problem is uncovered.
Do not dismiss a GP trainee without first discussing with your TPD. Employment law applies. The problem may be a serious health crisis — treat it accordingly until you know otherwise.
📅 5. Absence from Half-Day Release (HDR)
GP trainees are paid to attend half-day release. Absence from HDR without an agreed alternative arrangement is not acceptable — and in some cases constitutes a serious breach of their employment contract.
Important clarifications
- If a trainee has identified a more effective personal method of learning, this must be agreed in advance with both you and the TPD.
- Absence simply because they "don't feel like attending" is not acceptable.
- If a trainee is absent from HDR but not working in the surgery, they are being paid for time they are not using for educational purposes — this constitutes a contractual issue.
Absence from HDR may be one of the first visible signs of a deeper problem. Before considering it a disciplinary matter, explore whether something else is going on. A pattern of missed HDR is always worth a supportive conversation.
⚖️ 6. The Trainee Who May Have Committed a Criminal Act
This is the most complex and legally sensitive category. As an employer, you must follow employment law.
What to do
- Ensure your trainee's contract contains sections relating to discipline, in line with current employment law. Advice is available from the BMA.
- Share your concerns with the TPDs and Deanery at the earliest possible moment.
- It may be necessary to suspend the trainee on full pay whilst investigation is taking place.
- The Deanery will advise on whether the GMC needs to be notified.
- Do not attempt to handle this alone — involve TPDs and Deanery immediately.
- Do not dismiss the trainee without following due process.
- Do not discuss the situation with other trainers or staff beyond those who need to know.
- Document everything in the ePortfolio — you may need it for a written report.
I-SID stands for Identify, Share, Involve, Document. This is the framework recommended by NHS England (Yorkshire & Humber) — formerly HEE and forms the basis of good practice for all trainers managing trainees in difficulty. (The original SID mnemonic has been updated to I-SID to emphasise the critical importance of identifying the problem first.)
🔍 IDENTIFY — Recognise the Problem Early
Early identification is the single most important factor in successful outcomes. All the support in the world counts for little if a problem is not noticed until it is advanced.
Practical steps
- Maintain regular, meaningful contact with your trainee — not just formal reviews.
- Watch for the early warning signs listed in the section above.
- Trust your instincts — if something feels "off," explore it.
- Consider using the RDMp screening tool (see next section) to help structure your diagnostic thinking.
- Look beyond the obvious: a trainee struggling with clinical knowledge may actually have an underlying health, confidence, or life circumstance issue.
Don't wait for the ESR to find out there's a problem. Regular informal conversations — a brief check-in, a chat over coffee — often reveal concerns long before any formal assessment would.
🗣️ SHARE — Talk to the Trainee First
The first conversation is often the most important — and the one trainers are most tempted to delay. Share your concern with the trainee as early as possible, directly, honestly, and compassionately.
How to approach the first conversation
- Invite — don't summon. The phrasing matters: "I'd like to have a chat with you about something I'm concerned about" lands very differently from "I need to see you in my office."
- Choose a private, comfortable setting, free from disturbance. Not in the corridor between consultations.
- Have all the relevant information ready before the conversation.
- Suggest the trainee may bring a friend or support person if they wish.
- Make the conversation as close in time to the triggering concern as possible — stale concerns lose impact and context.
- Listen as much as you talk. There are always two sides.
Gathering wider information sensitively
- It may help to speak sensitively to others — admin staff, nurses, other doctors — to gather a more rounded picture.
- Maintain confidentiality throughout.
- Consider doing an RDMp assessment to determine the nature of the problem and its causal factors.
If your trainee is being defensive, it is often because they are scared. Defensiveness is a normal human response to threat — not evidence of dishonesty or bad character. An adult-to-adult conversation, not a parent-to-child interrogation, is what produces the best outcomes. No hostility. No assumptions.
📞 INVOLVE — Bring in the Right People
The two key people to involve are: 1. The Training Programme Director (TPD) and 2. The Deanery's Performance Lead — depending on the severity of the situation.
👩💼 The Training Programme Director
Your first point of contact for most concerns. At Bradford VTS, each of the 5 TPDs is the nominated advisor for approximately 20 trainees — for both pastoral and educational difficulties. If unsure, contact the scheme administrator.
🏥 Deanery Performance Team
Involve if there are health concerns, serious performance issues, or patient safety concerns. They carry the burden of difficult decisions and provide expert guidance. You do not need to manage complex situations alone.
Advising the trainee on additional support
- Own GP — if health concerns are present
- Counselling service — if emotional or psychological support needed
- Occupational Health — if fit-to-work questions arise (via TPD referral)
- BMA Industrial Relations Officer — for contractual or employment concerns (free, confidential)
- Medical Defence Organisation — if a Serious Untoward Incident (SUI) is involved
- NHS England Responsible Officer — contact via TPD/Deanery if required (0300 311 22 33)
- Review the Support Services section below for a full list of available organisations
- Stop the trainee from working (arrange sick leave) immediately
- Review patients seen so far to ensure no harm has occurred
- Contact the TPD as a priority
- Do not short-circuit the ladder — natural escalation: Trainer → TPD → Deanery
📝 DOCUMENT — Record in the ePortfolio
No Separate Records
Do NOT keep separate records about a trainee. This may constitute a breach of UK GDPR and the Data Protection Act 2018. A trainee has the right to request access to personal data held about them — including emails — under a Subject Access Request.
Keep the Trainee in the Loop
Share all concerns with the trainee. Consider documenting concerns together, so both parties are on the same wavelength. No surprises.
No Hostility
Aim for adult-to-adult dialogue. Be open, honest, caring, and compassionate. Your goal is to get the trainee back on track — not to build a case against them.
ePortfolio: Educators' Notes
All meeting notes go in the FourteenFish ePortfolio, under "Educators' Notes." This section is visible to all who have ePortfolio access — including the trainee. If writing something potentially upsetting, consider writing it together with the trainee present.
Good Educators' Notes are factual, compassionate, and forward-looking. They describe what was observed, what was discussed, and what was agreed — not personal judgements or characterisations. "Trainee described feeling overwhelmed by admin demands and agreed to discuss workload management at next meeting" is good documentation. "Trainee is clearly not coping" is not.
Developed by Dr Ramesh Mehay (Bradford VTS), the RDMp model is a structured way to diagnose the nature of a trainee's difficulty before trying to fix it. Poor performance is a symptom, not a diagnosis. This tool helps you identify what is actually going wrong.
When a trainee underperforms, the temptation is to jump straight to knowledge-building: send them on a course, give them more reading, increase supervision. But this only works if knowledge is the actual problem. If the real issue is poor insight, an unrecognised health condition, or a personality-environment mismatch, knowledge-building will achieve nothing. RDMp helps you avoid this trap.
Relationships
How the trainee manages their relationships — with patients, colleagues, admin staff, supervisors. Includes communication style, empathy, and professional boundaries.
Diagnostics
The process of making decisions — clinical diagnoses, but also decisions for patients, colleagues, the practice, or oneself. Where does the trainee's reasoning fail?
Management
How the trainee acts on decisions and manages clinical situations, systems, and themselves. Organising care, following through, managing complexity.
professionalism
The underlying platform that enables R, D, and M. Includes values, ethics, insight, reliability, fitness to practise, and attitude to learning. Note the lowercase "p" — it underpins everything.
🧩 The SKIPE Causal Framework
Once you've identified which of the RDMp domains is affected, use SKIPE to explore why — what factors are causing or maintaining the difficulty.
Skills
Clinical, communication, consultation, procedural
Knowledge
Clinical knowledge gaps, breadth, depth
Internal
Personality, attitudes, health, insight, culture
Past
Previous training, upbringing, educational experience, prior medical culture
External
Current stressors: family, finances, commute, work environment
- Gather evidence (e.g. from MSF, WPBA, direct observation).
- Score the evidence against the four RDMp domains (R, D, M, p).
- Explore the SKIPE causal factors with the trainee directly.
- Use findings to develop insight — together with the trainee, not as a verdict delivered to them.
- Once the "diagnosis" is made, move to targeted problem-solving and an agreed remediation plan.
📥 The full RDMp manual is available in the Downloads section above.
When a trainee is in difficulty, the question of who to involve and in what order matters. This is the recommended hierarchy. Do not short-circuit it — but do not delay each step either.
Always the first step. Share your concern directly, compassionately, and promptly. Document the conversation in the FourteenFish ePortfolio.
Gather a rounded picture sensitively. Maintain confidentiality. Avoid creating a hostile atmosphere in the practice around the trainee.
Use the RDMp tool to identify the nature of the problem and its causal/maintaining factors. See the section above. The full manual is in the Downloads section.
Your nominated TPD is the natural first escalation point. Do this early — they can advise on next steps and share the burden of decision-making.
For performance or health concerns, the Deanery's performance team will need to be involved. This is not a failure — it is appropriate escalation that protects you, the trainee, and patients.
Refer to (a) own GP, (b) Counselling service, (c) Occupational Health. Consider whether NHS England or the GMC need to be informed — your TPD and Deanery will advise.
Contact the BMA Industrial Relations Officer (free, confidential advice) and involve the TPDs and Deanery Deputy Director.
Involve the Deanery and the trainee's Medical Defence Organisation immediately. Advise the trainee to contact their MDO directly. Do not delay.
If you are ever worried about a trainee seeing patients — apply the precautionary principle. Put measures in place to stop them seeing patients independently until further assessments have taken place and appropriate supervision and safeguards are in position. Then contact the TPDs immediately. Patient safety is non-negotiable.
Occupational Health (OH) is a vital resource for managing trainees with health concerns. Knowing how and when to use it — and how to use it well — is an important skill for trainers and TPDs.
📋 Key Points for the Referral
- The more detailed the referral letter, the more useful the response. Vague letters produce vague reports.
- Tell OH about the nature of the trainee's rotation and what their expected clinical duties involve.
- Use the Occupational Health Referral Letter Template available in the Downloads section — it covers everything OH needs to provide a useful assessment.
👤 Who Should Make the Referral?
The best person to make the referral is the person who knows the trainee best — this may be the GP trainer, the hospital consultant, or the TPD.
However, whoever writes the referral should collaborate with others who need to contribute to the picture.
Currently, referrals are made either by the employer (GP practice or hospital trust) or by the scheme — depending on who has the most relevant concern and knowledge.
📄 Sharing of OH Reports
Who receives the report?
- The report is prepared for the referrer and shared by OH with both the referrer and the trainee.
- Trainees are encouraged to upload the OH report to their FourteenFish ePortfolio.
- However, as it contains personal health information, trainees may reasonably edit what goes into the open-access ePortfolio. Some editing is appropriate.
⚠️ Consent Requirements
- Consent is required before the OH report is shared with anyone beyond the referrer.
- Relevant people (HR, scheme, future employers) should be informed a referral has been made — but the report itself can only be shared with the trainee's consent.
- The DID (Doctor in Difficulty) tutor at the Deanery has a role in ensuring OH reports are not lost and are followed up.
- If consent to share is withheld, you can share awareness that a report exists — but not its contents.
Do NOT Keep Separate Records
Do not maintain separate files, documents, or email threads specifically about a trainee's concerns. This violates the Data Protection Act and could result in a fine. A trainee has the legal right to see everything written about them — including emails. If you want to write about the trainee, write it in their FourteenFish ePortfolio and share it with them in advance.
Keep the Trainee in the Loop at All Times
Share all your concerns with the trainee. Consider documenting concerns together, so that both of you are on the same wavelength. There should be no surprises — no trainee should log into their ePortfolio and discover a comment they were unaware of. If you are going to write something that may be emotionally difficult for the trainee, consider writing it together with them present (having signposted it first).
No Hostility in Written Records
There is absolutely no need for hostility in documentation. Aim for an adult-to-adult tone throughout. If your trainee is being defensive, remember that this often reflects fear, not obstruction. Written concerns should be factual, compassionate, and focused on specific observable behaviours — not characterisations of the person.
Meeting Notes Go in the FourteenFish ePortfolio — Educators' Notes Section
All notes from meetings, conversations, and significant events relating to the trainee's difficulty should be recorded in the FourteenFish ePortfolio under "Educators' Notes." This section is visible to all who have access to the ePortfolio — including the trainee. It forms the official record. This protects everyone involved.
These insights are drawn from years of trainer and TPD experience. They are the things that experienced trainers wish someone had told them earlier.
Waiting. Hoping it will improve by itself. Telling themselves it's "probably just a settling-in issue." Signing the ESR anyway. The single most common and consequential mistake in managing trainees in difficulty is acting too late. If you've noticed something concerning, the time to act is now — not at the next scheduled review.
The first instinct is often to prescribe more learning — more reading, more courses, more cases. But in the majority of formally referred cases, the primary problem is not knowledge. It is insight, communication, professionalism, or wellbeing. Use RDMp to find out what's actually going on before you intervene.
When a trainee pushes back, argues, or seems defensive in the face of feedback — it can feel obstructive. It rarely is. In most cases, it reflects fear: fear of failure, fear of the consequences, fear of being judged. Lower the temperature. Create a safer space. Curiosity works better than confrontation every time.
Some trainees are working hard and competently but struggling because of unfamiliarity with UK cultural norms, NHS systems, or the expected style of communication between doctors and patients here. This can look like poor clinical performance or unprofessionalism but is neither. It is addressable with targeted support. Ask your deanery what IMG support programmes are available — NHS England funds specific provision.
Occasionally, a trainee who is struggling clinically has a suspiciously polished ePortfolio — reflections that are too abstract, learning points that are generic, assessments that don't quite ring true. The ePortfolio should reflect real practice. If it doesn't feel authentic, explore further in supervisory conversations.
Every training scheme, every year, has trainees who experience difficulty. Many go on to qualify and become excellent GPs. The trainee who acknowledges their difficulty early, engages with support, and shows genuine reflection often makes far more progress than expected. The conversation you're dreading is rarely as bad as you imagine. And the alternative — suffering in silence — is always worse.
This section is specifically for GP educators. It addresses how to teach this topic, what to watch for, and how to have the most difficult conversations well.
- Believing that difficulty = failure (it doesn't — it's normal and manageable)
- Focusing only on knowledge gaps when the real issue is insight or professionalism
- Not recognising the emotional dimension of the conversation they need to have
- Signing off reviews in the hope things improve — a known and serious trap
- Keeping notes separately (violates DPA) or, worse, keeping mental notes only
- Case discussion: "You've noticed your trainee has been late 3 times this week and missed a tutorial. What do you do?" — Walk through the I-SID steps.
- Role-play: the first supportive conversation with a trainee in difficulty. Practice tone, framing, listening.
- RDMp exercise: Take a described case and work through the RDMp domains to identify the likely problem.
- Discuss: "What would stop you raising a concern about a trainee?" — Explore barriers.
- When you have a gut feeling something is wrong — how long do you usually wait before acting on it?
- What would make it harder for you to raise a concern about a trainee? What gets in the way?
- How do you ensure your documentation is compassionate and fair, not just protective of yourself?
- What support do you need when managing a trainee in difficulty? Who is in your support network?
- How does your own cultural background influence how you interpret a trainee's behaviour?
📚 Useful Distinctions to Test Understanding
| Term | What it means in practice |
|---|---|
| Trainee in Difficulty (TID) | A trainee who is struggling to progress — for any reason. Early identification and support is key. This is a broad term. |
| Doctor in Difficulty (DID) | Typically used for more significant concerns — performance, health, or conduct — that may require formal deanery involvement. |
| Remediation | A structured, time-limited programme of additional support designed to address specific identified concerns. |
| Supervised Practice | A formal arrangement increasing the level of clinical oversight — typically arranged by the deanery for patient safety reasons. |
| ARCP Outcome 2 | Development needs identified — requires an additional plan. The most common outcome for trainees with concerns. Not a failure. |
| ARCP Outcome 3 | Insufficient evidence — usually a paperwork/WPBA issue. Addressable relatively quickly. |
| ARCP Outcome 4 | Insufficient progress — this is the more serious outcome, often triggering extended training or formal performance processes. |
When should I formally contact the Deanery about a trainee?
The natural escalation route is: Trainer → TPD → Deanery. Your TPD is your first call. They will advise you on whether the Deanery's performance team needs to be involved. Generally, Deanery involvement is appropriate when: there are patient safety concerns; the trainee has a health problem affecting their ability to work; performance has not improved despite local support; formal remediation is being considered; or there are conduct concerns.
When in doubt, call your TPD. That's what they're there for.
Can I sign off an ESR/CSR even if I have doubts?
No. This is one of the most critical points on this page. Do not sign off an ESR or CSR if you have significant doubts about the trainee's progress, in the hope that they will improve in the next post. If you are unsure whether you can sign off a report, discuss this with your TPD immediately — before the report is due, not at the last minute. Signing off prematurely has consequences for patient safety and for the training programme.
What do I do if I'm worried about patient safety right now?
Apply the precautionary principle immediately: stop the trainee from seeing patients independently. Arrange sick leave or supervised practice as a temporary measure. Review recent patients seen by the trainee to ensure no harm has occurred. Then contact your TPD as a matter of urgency. This is not an overreaction — patient safety always comes first.
What if the problem is between the trainee and me personally?
This is harder to navigate, but the principle remains the same: raise it early, be honest, and involve the TPD. In a personality clash situation, a third-party perspective is especially valuable. A TPD or senior colleague can help mediate, identify whether there are systemic issues contributing, and — if necessary — arrange for the trainee to move to another placement. This is not failure. It is sound management.
What if I think my trainee might be struggling with burnout?
Burnout in GP trainees is real and increasingly recognised. Signs include emotional exhaustion, detachment, reduced personal accomplishment, and cynicism about medicine. If you suspect burnout, the conversation starts with compassion — not performance management. Explore what's been happening, what support they have, and what they need. Refer to Practitioner Health for professional support. Consider whether workload or rota factors in the practice are contributing — and what can be changed.
What about confidentiality — can I discuss the trainee with anyone?
You can — and should — discuss concerns with the trainee themselves, the TPD, and relevant members of the educational oversight team. Beyond that, maintain strict confidentiality. Do not discuss the trainee's situation with colleagues who are not directly involved in their training. Do not include identifying information in emails to large groups. Be mindful of the small-world nature of GP training in many areas.
What support is available for me as the trainer?
Managing a trainee in difficulty is emotionally demanding. Trainers also need support. Sources include: your fellow GP trainers (Trainers' Workshops are excellent for this, maintaining anonymity); your TPD; the Deanery's educational team; and in some regions, dedicated trainer wellbeing support. The BMA also offers counselling that extends to trainers. You are not expected to manage complex situations alone — asking for help is professional, not weak.
Act Early
Late intervention leaves no space. The moment you sense something is wrong — start the conversation. Waiting rarely helps and often harms.
I-SID Always
Identify. Share. Involve. Document. Follow this sequence — in this order — every time.
Diagnose First
Use RDMp before prescribing remediation. Poor performance is a symptom. Find the cause first.
ePortfolio Only
FourteenFish ePortfolio, Educators' Notes. Separate records are a DPA violation. No exceptions.
Patients First
If patient safety is in question, stop the trainee from clinical work immediately. Then call your TPD.
Compassion Always
Behind nearly every "difficult trainee" is a person in distress. Adult-to-adult. No hostility. No assumptions.
Most trainees who experience difficulty and receive appropriate, timely support go on to qualify and become good GPs. The trainee who reaches out early, engages with the process honestly, and shows genuine reflection often makes remarkable progress. The goal of every trainer, TPD, and deanery is the same: help the trainee succeed. When everyone works together, that is usually possible.
This page is part of the Bradford VTS Teaching & Learning resource suite. Created and maintained by Dr Ramesh Mehay, Programme Director, Bradford VTS.
Content for educational purposes only. Always refer to your local deanery guidance and RCGP/GMC official guidance for formal decisions.