Healthcare organisations are a fertile breeding ground for interpersonal conflict and the development of dysfunctional relationships. The supervisory relationship between trainer and trainee is a particular area of concern for junior doctors. Aside from a problem trainee, such conflict can arise from a difficult supervisor, poor communication, personality clashes and power inequalities. This article will come from a trainee’s perspective in emphasising how these factors relate to the difficult supervisor. Recommendations are made for organisations and individuals on how the causes and consequences of this problem can be addressed.

The nature of working relationships

“Like a successful personal relationship, both sides must be able to acknowledge their goals, the obstacles they perceive in achieving their goals, and must be willing to compromise …” 1

Working relationships, like personal relationships, are embedded in a complex and diverse world with people of different   personalities, backgrounds, motives   and desires. Getting on with our fellow humans is a fundamental part of living and a challenge in our working lives. Garelick and Fagin (2004) have explored this area and have identified what facilitates a good working relationship (figure 1):

Dysfunctional Working Relationships

“Differences of perspectives … lead to interpersonal conflict that spirals into dysfunctional relationships” 3

Interpersonal conflict is a “dynamic process that occurs between interdependent parties as they experience negative emotional reactions to perceived disagreement and interference with the attainment of their goals” 4. Interpersonal work conflict can impact in terms of satisfaction, well-being, work disability, and mental health outcomes such as psychiatric morbidity, depression, fatigue and psychological distress 4. Factors that can play a role in conflict include perceived disagreements about tasks, ambiguities in role definition, or if the responsibilities are unclear 4.

One of the central issues inherent in workplace disputes is irrational behaviour on the part of one (or both) of the employees when the facts get confused with their highly charged feelings 5. In an attempt to avoid conflict the other individual may be uncomfortable about raising the issue, feel intimidated by someone with greater authority or power, or suspect a personal agenda, but does not want to sound argumentative. This can result in an emotionally charged situation with layer upon layer of faulty assumptions building up to a proverbial house of cards and the development of entrenched beliefs 3. Therefore, what started as a misunderstanding can led to a dysfunctional relationship 3, which can result in multiple problems impacting on the organization and the individuals involved. Specific consequences include complaints of bullying and racism against the trainer, labelling of the trainee as a doctor in difficulty, or the trainer developing a reputation as a “difficult supervisor”.

Causes of trainer-trainee conflict in medicine

In the field of medicine, particularly given the hierarchical structure of the profession, the potential for conflict is accentuated. Trainees tend to rotate around jobs, and educational supervisors, every 6-12 months. Trainees and trainers are expected to adapt to working with each other with differences in personality, styles of working, and expectations. It is therefore inevitable that difficulties will develop.The fundamental causes of the conflict between trainer and trainee in healthcare are:

1.The problem trainee

The problem junior doctor is a well-established area of concern6.This type of doctor may be inflexible, clinically incompetent, arrogant, have poor time keeping or organisational skills, refuse to do what is asked, exhibit poor communication skills, lack enthusiasm, lack educational objectives, or have a difficult personality. Despite the “doctor in difficulty” being regarded as a “problem trainee” the dysfunctional relationship between trainer and trainee in medicine is usually a product of both parties.

2.The difficult supervisor

The most important factor in determining trainee satisfaction has been shown to be the quality of supervision provided by the consultant trainer 7. However, the difficult supervisor, often a consultant, is an issue that is underreported. The problem consultant comes in various guises shown in figure 2:

Generally, a problem consultant would have, over the years, established a reputation as a difficult person to work with, usually confirmed by their peers and trainees. Unfortunately, this aspect of their personality is ignored when they complain about a new trainee. Therefore, the consultant is never identified as a difficult supervisor. Knowledge of what constitutes a bad supervisor should be accompanied by what is a good supervisor. In the field of psychology, the notion of a good supervisor applies to any supervisory relationship (figure 3).

A supervisor should possess good communication skills in the form of: active listening, demonstrating understanding, using open questions, building areas of agreement and being open. As a good communicator the supervisor should refrain from stating unreasonable expectations, views, or opinions. They should avoid offering incentives / warning of consequences or revealing feelings. In the workplace, in times of pressure, dysfunctional communication is instrumental in trainer-trainee conflict.

These communication problems are prominent in the area of feedback 9. Feedback is a key role of the supervisor 10. Feedback should be honest, relevant, objective, specific, timely, and planned 9. It should be based on accurate information rather than hearsay and focused on behaviour and performance rather than personality and attitude. It should be constructive, conducted in private, descriptive rather than evaluative, and designed to avoid personalizing and blaming 9. Feedback should not be given on things the trainee cannot change e.g. personality.

Should the trainee feel offended by feedback at any point then it may be that the supervisor has a hidden agenda or is a bully. A delay in feedback impedes efficient working so the giving and receiving of feedback should also be a balanced ongoing process in order to boost morale and motivation, leading to greater effectiveness and job satisfaction 9. If the supervisor has a good relationship with the trainee, then constant feedback should be given about his/her performance: the final report should never be a surprise 11.

4.Personality clashes

Conflict may also reveal itself in personality differences between trainee and trainer. Personality characteristics of the latter that can significantly affect an otherwise healthy relationship include a trainer who is preoccupied with details, order, organisation and schedule. Such trainers may be seen as perfectionist, pedantic, rigid and stubborn, and often insist that others submit to their way of doing things, according to their own self- proclaimed high standards. Personality clashes may arise from poor communication or underlying factors including racism, sexism, religion, or jealousy and envy interfering with the relationship on both sides 12. The crucial question to ask is whether the trainer-trainee conflict is a result of a difficult trainee, or whether it arises when a trainee does not fit the supervisor’s scheme of things.11

5.Power differential

The trainer/supervisor also has an evaluative function in relation to the trainee and therefore the potential for abuse and trainee vulnerability in respect of the supervisor, is clear 8. The dependence of trainees on trainers for references creates a “potential power imbalance and in some cases may lead to intentional or unintentional harm to the trainee” 13. This harm may be identified in the trainer’s assessment of the trainee when completing the end-of-post evaluation. The trainer taking a proactive approach in writing complaints and sending emails to sabotage a trainees’ career may also demonstrate abuse of power.

Equally an overpowering consultant may, consciously or unconsciously, take advantage of the situation by going on a fault-finding mission. This can become part of a self-fulfilling prophecy. If the trainee is perceived to be poorly performing the supervisor may feel under more pressure and become hostile towards the trainee, without addressing the main problem 12. The result is that the supervisor engages in “continuous criticism and academic humiliation” 12 which causes the trainee to feel more useless and helpless. This can lead to the trainee becoming a scapegoat in an already dysfunctional team12.

Another consequence of the power imbalance is that it causes a state of confusion for trainees who want things to change but will often tolerate the problem and endure it to avoid jeopardising their career prospects. The trainee may feel powerless and fearful about addressing the current problem and choose to be silent on the matter, rather than risk an unpleasant situation 12. Unfortunately, such passive behaviour may result in the problem escalating and the trainer may, unconsciously and unwittingly, bully the trainee 8.

How to deal with trainer-trainee conflict?

“Conflicts are really a house of cards ... you can bring them down by getting to the bottom and getting to the facts” 3.Dealing with trainer-trainee conflict involves good emotional intelligence, self-awareness (being self-aware and taking an honest look at oneself), self-regulation (ability to control emotions), empathy (ability to identify and understand the wants, needs and viewpoints of others), being well-motivated, and having good social skills 14. In other words, successful conflict resolution relies on first understanding ourselves, being aware of our personality, our prejudices, why we like some people and not others, and recognising that certain things will annoy us and not others 11.

From a trainee’s perspective conflict with the supervisor should be addressed at an early stage to prevent escalation of the problem 12. This should include self-appraisal, thinking about the root of the problem in a factual and non-personal way, and informal discussion with a discreet colleague to gain another perspective. Trainees should find out how their predecessor got on in the post. Finally, problems should be freely discussed with the supervisor. However, there may be supervisors with whom it is difficult to have a discussion; therefore, the trainee must involve others to deal with the issues which escalate or remain unresolved. If the supervisor is considered the source of the problems there are steps to take to ensure the power of the supervisor is not misused against trainees (figure 4):

Trainees may be reluctant to take the steps described in figure

4. The power differential between trainer and trainee, as well as acting as an antecedent to the conflict, is a perpetuating factor that ensures nothing is done about it. The difficult supervisor may be underreported for the same reasons seen with workplace bullying, namely, fear of making matters worse, belief that nothing will be done, concerns regarding confidentiality, fear of victimisation, and concerns about being labelled as a troublemaker 15. Ultimately it is the fear of the consequences that deters trainees from speaking out, though it is worth remembering that Franklin D Roosevelt stated in his first inaugural speech, “the only thing we have to fear is fear itself”.

What can healthcare organisations do about supervisory conflict?

Organisations must be proactive in identifying and dealing with problems between trainers and trainees, who in turn ought to be aware of their responsibilities. Organisations may be tempted to sweep problems under the carpet but there are recommendations on how they can address the causes of trainer- trainee conflict (figure 5).

Paice (2002) describes an excellent mentor as someone who “will always inspire, teach by example, and excite admiration and emulation” 16. Mentoring can be beneficial in facilitating the development of the trainee but “faculty mentoring should be avoided’’ 17. In other words, mentoring of doctors should not be carried out by the trainee’s educational supervisor or line manager, nor should they be involved in their assessment or appraisal, to avoid blurring the distinction between the roles

17. A good mentor should:

Motivate Empower and encourage Nurture self-confidence Teach by example Offer wise counsel

Raise the performance bar

However, the authors argue that these are the qualities that should be part of being a good supervisor 17.

“Differences in references, places power and status, and dependence on juniors in invidious positions when they bexperience problems in their relationships with trainers” 2

The relationship between trainer and trainee should reflect the same warmth and nurturing as in a parent-child relationship. There is a parallel with both types of relationship in that there is an imbalance of power that interacts with poor communication and personality conflicts. In medicine although the problem junior doctor is frequently highlighted it must be remembered that the trainer-trainee conflict may reflect a difficult supervisor. The supervisor needs to achieve a healthy relationship that is sensitive to the needs of the trainee, void of any of their preconceived beliefs and prejudices, and act as a role model in making a good doctor and achieving their full potential 16. Interpersonal conflict can nevertheless develop and escalate to the extent that the trainee may suffer in silence. Healthcare organisations can be more proactive in penetrating the causes of the dysfunctional working relationship. Trainees should be fearless in turning to existing support in face of a difficult supervisor.

Competing Interests: None Declared

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