There are many reasons why the term “trainee in difficulty”, or perhaps even worse “problem doctor”, strikes fear into the hearts of consultant trainers. It may be because of issues around patient safety or how to manage the on-call rota, but Richard Smith, former Editor of the British Medical Journal, would have us believe that, at least in part, it is because all doctors are “problem doctors”, or at least have the potential to become so.1 In September 2005, the Medical Defence Union (MDU) and the National Patient Safety Agency (NPSA) produced a document entitled “Medical error” in which 14 distinguished senior doctors admitted to making significant clinical errors in an attempt to encourage openness as part of organisational risk management.2 In his foreword,3 the Chief Medical Officer promotes the “new (Foundation) curriculum” for Modernising Medical Careers (MMC) as an opportunity for doctors in training to learn from their mistakes which mostly happen “because systems are not working as they should” rather than because doctors are careless. This view is supported by Wu and colleagues,4 whose anonymous survey of junior doctors identified a large number of errors, many of which were attributable to inexperience and lack of supervision as well as trainee exhaustion. On re-publication in 2003, the accompanying commentary5 suggested that new methods of working and changes in organisational culture were needed rather than the NHS “blame culture” which often led to individuals being inappropriately sacrificed as the organisational scapegoat.

However, it is rarely a single error of judgement that identifies a doctor who is “failing”. In the National Clinical Assessment Service (NCAS) review of the first 50 cases referred to their service,6 over half had a history of concerns stretching back more than 2 years before referral. It is sadly often …