It is pertinent that all possible steps are taken to identify and act on early signs, triggers and symptoms of performance issues. In most cases performance issues are detectable and early identification prevents an issue from escalating to a more serious situation.

Doctors' performance may be affected by a variety of issues:

• Predisposing factors e.g. previous ill health, personal issues
• Precipitating factors e.g. acute events, social isolation
• Perpetuating factors e.g. chronic ill health, organisational issues

Early identification will reduce the potential risks to the trainee, to the colleagues, the patients and also the organisation. The evidence on prevention of performance issues suggests that good induction properly constituted teams, together with effective educational supervision reduces stress and potential difficulties.

Successful remediation or support for doctors in difficulty requires an accurate understanding of the underlying reasons for the difficulty. This increases the likelihood of being able to tailor subsequent intervention to the individual's circumstances, personality, abilities or learning style (e.g. McManus et al, 2004).

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