THE DIALOGUE
What are the ingredients for a safe training climate? And how do you guarantee a safe training climate when there is a training dispute? Suzanne Geerlings, internist-infectiologist and chair of the Central Training Committee (COC) of the Amsterdam UMC and Madelon Minneboo, cardiology resident and chair of the Amsterdam UMC physician assistant council, entered into a discussion.
Memoryboo: ‘An environment where there is room to learn – where you are allowed to make mistakes and dare to ask questions without being judged. That is what I understand by a safe training climate. A committed trainer is extremely important in this respect.’
Gerlings: ‘For me it is related to the discussion about vitality. You can work very hard, as long as you do it in a group where you feel at home and comfortable, so that you are in your element at work. But I also think that you should be given the space to learn, and that things don’t always have to go well. In fact, that doesn’t stop when you’re done with the training. Watching a medical specialist who is on guard for the very first time is incredibly exciting. And even with years of experience you will still be faced with surprises, as an infectiologist I had never seen monkeypox. So I see it as a continuum: throughout your career it’s important to be vulnerable and to acknowledge when things go wrong. Educators and medical specialists also have an exemplary role in this. When they show that you can be vulnerable, residents in turn are much more likely to do so.’
Memoryboo: ‘What I also find important is that the bigger picture is looked at during an assessment. Of course the work must be done properly, but sometimes other things come into play. A sick family member, a move, a pregnancy… you perform differently than someone who has everything in order. That context is important and, in my opinion, contributes to a safe training climate. It ensures that you lose sight of each other less quickly or run into a dispute.’
Gerlings: ‘As chairman of the physician assistant council, do you ever have to deal with training disputes between residents and trainers?’
Memoryboo: ‘I have the impression that disputes with us are not so much about content, but about broader themes. Think of the number of working hours, leave and education. For example, the latter regularly takes place in the evening, while more and more residents see those evening hours as private time. And recently someone wanted care leave: you used to take vacation days for that, but that’s different nowadays. Residents are starting to stand up for themselves much more and I notice that educators are a bit hesitant about how to deal with this – although I don’t know if you can really call that a dispute. The fact is that these matters are also important for residents when it comes to a safe training climate, that they can discuss this with their trainer. How do you view this as COC chairman?’
Gerlings: ‘Such questions sometimes end up with the COC, but these are not – yet – disputes. If you look at the disputes that the COC has to deal with, it usually concerns the functioning of a resident. So that a trainer thinks a resident is not suitable for the training, while the resident thinks otherwise.’
Memoryboo: ‘How do you guarantee a safe training climate if there is such a dispute?’
Gerlings: ‘ Hearing both sides is extremely important, so we talk to both the trainer and the residents. In addition, we check whether everything has been laid down procedurally and whether it is, for example, not a personal feud, or whether the resident may thrive better in another hospital. After all, you can also function differently if you feel unsafe – because you may have had an unpleasant interaction with a staff member and you can no longer perform your work properly as a result. Of course there is a possibility that the resident is really not suitable, we have to be honest about that. But in the first instance I always plead for a new chance in another hospital.’
Memoryboo: ‘It is very difficult to show that you have changed. Sometimes weeks or sometimes months or years precede a dispute and there may already be a stamp on someone of dysfunction. I do indeed believe that in such a case a different hospital can be a good solution, so that you can start with a clean slate. The open-mindedness is very important in such a new place. That a trainer in the new training institution has an open mind and is sufficiently available, so that a resident can start the conversation in time.’
Gerlings: ‘Plus that the new trainer also schedules open conversations himself to ask how things are going, and not wait for the resident to arrive.’
Memoryboo: ‘When we talk about a safe training climate, I think that steps can also be taken in the communication between trainer and resident and the application of soft skills. Okay, someone is not functioning, but how do you make that negotiable? This is often perceived as difficult. The result is that undercurrents get bigger and bigger and at a certain point the bomb bursts – while it shouldn’t have come to this if you had stayed in conversation with each other. So it’s about how you bring it. Personally, I think that someone who is unfit becomes unhappy in the long run. If you approach it that way as a trainer and help the residents to choose the right direction, then that is a completely different approach than just slamming the door.’
Gerlings: ‘It’s quite complicated sometimes. As a teacher you have a kind of double role. On the one hand, you act as a coach, especially if a resident puts himself in a vulnerable position. On the other hand, you are judgemental: if someone is still unable to do something after a few months, an internship should at least be extended and, in the worst case, that person is not suitable. I can imagine that it is quite difficult for a resident to put himself in a vulnerable position. When things run smoothly in these kinds of situations, you can still solve it by calling in a mentor. But in the end, the trainer conducts the progress interviews. And that’s fun when it goes well, but more challenging when it doesn’t.’
Memoryboo: ‘What would you like to say to residents about this?’
Gerlings: ‘As COC chairman I often see the end of a process and I sometimes think: how did it come to this? I find it very sad that people have struggled with something for so long. That is why I still want to mention the importance of prevention and advise residents and trainers to try to start the conversation earlier. They often think that a problem will go away on its own, but usually it just gets bigger. So don’t run away from it, but talk it out. And what would your advice be to the COC, from the resident’s perspective?’
Memoryboo: ‘I do believe in the Teach the Teacher programme, in which trainers further develop conversational techniques and their soft skills. And I think it is good that the COC continues to emphasize how important the open conversation between trainer and resident is. After all, the sooner you can talk to each other, the more limited the dispute will be – and it may not even come to a dispute. In addition, I think it also contributes to communication after a dispute – that you can continue on good terms with each other once a problem has been resolved. I really think you’ll come out better that way.’
Gerlings: ‘Such a dispute can of course have two outcomes. At one extreme, the conflict is unfortunately not mediable. Then it goes through to the RGS and our role ends. But it is of course fantastic if a mediation by the COC does succeed. For example, my secretary and I received a present from a resident last Christmas after something had ended in a good way. Such a good outcome, that’s what you do it for, of course.’