Working as a junior doctor is stressful — 25% of interns show signs of “burnout” and 25% are mildly depressed.1-4 Senior doctors, as their teachers and supervisors, are in an ideal position to care for JMOs.5 While a small proportion (3%–7%) of JMOs in training programs are “difficult” or “problem” doctors who require the intervention of someone in authority,1,6,7 a higher proportion of JMOs are simply unable to cope with the stress of the job and exhibit signs of being “in difficulty”, “stressed” or “distressed”.1,2,4,6

Helping the “JMO in difficulty” has important flow-on effects, such as optimising patient safety and care, reducing self-harm of doctors and reducing the number of doctors who drop out of medicine.2 Despite these benefits, consultants (and registrars) often avoid addressing the problems because they:

• Are embarrassed, lack the skills, and fear it may expose their own inadequacies;

• Don’t like upsetting people;

• Believe it will only make matters worse;

• Fear reprisals through legal action against their judgement; and/or

• Feel they have no time to deal with the problem because they are already overstretched.

However, it is incumbent on senior clinical staff to play a major role in managing problems and preventing poor outcomes. Indeed, it is part of their obligation to the profession.

A framework for approaching a JMO who you think may have a problem is to ask yourself the following questions:

• Is there a problem and, if so, what is it?

• What are the underlying causes?

• What is the best way to manage the problem, and what documentation is needed?

Most junior doctors in difficulty are identified either through direct observation (82%), such as poor presentations in the clinical setting, or critical incidents (59%), such as inappropriate prescribing or failure to organise investigations.1,8 The most important first step is to be sure that there really is a problem. Observe and gather information confidentially from all relevant sources: previous supervisors, the Director of Clinical Training, and at some stage, the trainee. Doctors who have significant problems are usually identified through what appears to be insufficient knowledge (48%), poor clinical judgement (44%), inefficient use of time (44%), poor communication (39%) and/or unethical behaviour (15%).1,8 It is important to recognise that there may be self-denial and that stressed doctors who are performing adequately may not admit to problems unless asked in a supportive environment.

When someone is performing poorly, contributing factors (and therefore solutions) are usually multiple (Box). It may be difficult to be sure of the cause(s). As it is essential to ensure the JMO is treated fairly and confidentially, particularly if sharing information may have an impact on assessment, the ideal time to deal with the problem is while the JMO is working with you.

Ask yourself, Am I supporting my trainee? Have I ever given feedback? How is the team working?

The best way to help doctors in difficulty depends on the underlying problem(s). Management may range from support, change of attachment, or time off, to referral to a general practitioner or psychiatrist. It is important to separate the roles of “therapist” and “supervisor” and ensure that appropriate referral occurs. For major problems, the Director of Clinical Training should provide supervisors with support. Early intervention, involving information gathering and discussion with the JMO, is essential. Documentation may be necessary, even if it remains confidential and may only be used if called upon later.