Henry Goldstein. Supervision, Don't Forget the Bubbles, 2017. Available at:
I’ve been lucky enough to be one of the few paediatric registrars allocated to an Adolescent Inpatient Mental Health ward for a 6 month rotation. Although I’d worked in (adult) Psych wards before, I had few well formed ideas about psychiatric theory or practice past how to “do a takedown”. In Shem’s House of God, the future psychiatrist repeatedly states that “Good medicine as doing as much nothing as possible”. Until this term, I wasn’t entirely sure what that was, and knew even less about what to expect when it came to the care of young people.
As this opportunity is becoming rarer by the year and the rarefied air of Inpatient Adolescent Psychiatry is far removed from most paediatric practice; this is the second post in a series aiming to help understand the work (and underpinning theories) seen on the inpatient unit.
Several months in advance of my rotation through Adolescent Psychiatry, there was much made of term supervisor allocation. I was pleasantly surprised on arrival into psych that the approach to mentoring and clinical supervision is quite different from that in paediatric training.
It’s worth pausing to reflect on the origins of medical training; until Osler introduced the intern/resident medical officer – style system we use today, much of medicine was a 1 on 1 apprenticeship. Some, including Dornan, have argued in favour of a “new apprenticeship model”; but for most trainees, as we change rotations, roles or hospitals on a regular basis, a longstanding, whole-of-training supervisor might feel like a pipe-dream. In this respect, psychiatry was not particularly different to paediatrics, but, in general, the approach to supervision was quite apart from what I’d previously experienced.
Each member of the team, from case manager to consultant psychiatrist is allocated a senior supervisor. The pair is scheduled one hour of protected one-on-one time on a weekly basis. This is enshrined in the RANZCP program, which stipulates “Of [the 4 hrs/wk clinical supervision], a minimum of 1 hour per week must be individual supervision of a trainee’s current clinical work.” I can’t think of any other clinical job I’ve done where there is this kind of opportunity, let alone mandatory requirement!
What is this mean?
This tremendously augmented my education and overall experience from what could easily have been a paediatrics trainee “just muddling through” to being a functional member of the team, able to work independently in clinically challenging situations. Although I’m speaking of my experience, the general principles that this kind of supervision fosters, include establishing and maintaining an active/mentoring role, frequent contact, open dialogue, identifying opportunities for learning and discussion about multiple domains of practice.
A good mentor and active supervisor means much more than reducing the likelihood of the awkward end-of-term assessment most of us have endured in our junior years. By it’s nature, my experience of supervision in psychiatry was more immediate and active. The supervisor and trainee would see several patients together each week and discuss the clinical interaction.
I believe it possible to parallel this in medical specialities, as it is a key part of a consultant ward round. It is, however, something that must be actively held in mind by the supervisor, in addition to patient care. Interestingly, in 2004, a Danish group published a validated checklist assessing ward round performance in internal medicine. Although this kind of tool, along with other standardised forms, undoubtedly have their place for objectively measuring skill attainment and improvement, the many aspects of medicine that are learned from mentoring are often numerically elusive.
Frequent contact leads to both the supervisor having a better handle on how the trainee is going, and running counter to this, the trainee establishing a greater chance of understanding the supervisor’s philosophies of practice, and hopefully the opportunity to humbly question and challenge them!
This increased overall fidelity (rather than one tired afternoon as a chore), enables the opportunity to discuss not only clinical work but also system issues, learning points and more grand theories of practice and professionalism.
Much has been written in recent weeks about physician well-being, and I’d speculate regular meetings might also enable a supervisor to become both aware and active at an earlier stage for a doctor struggling with burnout or overwork, rather than picking up the pieces of an upset, overburdened registrar mid-term, or much worse. Supervision is a key part of a culture of care.
With some months of hindsight, I perceive the main barriers for this kind of supervision in paediatric training are threefold:-
Firstly, and most profoundly, the culture of making time, and the will to include this as paid work. Many departments battle to have protected teaching time, reasonable hours and a safe clinical workload. Non-clinical time is at a premium for everyone in a service and, in this context, supervision might strike many as an inefficient, unproductive use of time to have both a trainee and a consultant unavailable for an hour each week. There is strong argument to the contrary; as Bradfield observes “[t]here is overwhelming evidence that closer clinical supervision of junior doctors results in better patient outcomes, in the same way that double-checking reduces medication errors in a nursing context.”
Secondly, the immediacy of supervision may be heavily diluted. I’ve alluded to check-box supervision above, but additionally, one or two sessions in a three-month rota often equates to a global impression that is simply too diluted to utilise pragmatically. I imagine it quite frustrating to know an observed ward round is more likely to terminate with the consultant dashing off to clinic, rather than a thoughtful, timely discussion about the morning’s caseload.
Thirdly, the goodness of fit between the supervisor and trainee probably plays a role. It’s understandable that not everyone gets on with everyone. Not all physicians are, by their nature, extroverts, teachers or energised by their work; qualities which may be more or less helpful for mentoring. This isn’t something to modify aggressively, but more an observation of personality, culture and the world, and bears consideration as a barrier to close supervision.
This topic isn’t a new one, having been more comprehensively reviewed in Bradfield’s take on the 2008 Garling Report into the provision and governance of Acute Care Services in New South Wales Public Hospitals.
What about senior staff?
Everyone benefits from senior supervision, irrespective of experience. The consultants in the Adolescent Unit also had supervision on a weekly basis. As a junior observing, this seemed to evolve with a clinician’s experience; from the outside, depending on the experience differential, this appeared as either a grandparent-parent interaction, and, as the age and experience of the pair narrowed, two older professional siblings discussing their work thoughtfully and with joy.
The further I extend this metaphor, the more supervision strikes me as being about communication between generations of clinicians. That is, interns (consciously or subconsciously) model their thinking and behaviour on their immediate peers and seniors, often those whom they have the most contact.
Within this framework, registrars are the adolescents of the medical world; they have developed sufficiently as clinicians to think and act, and are often looking for guidance about the transition to (clinical) adulthood.
Having senior peers effectively in the role of parents and grandparents are indispensable in guiding, modelling and nurturing the “adolescent” clinician through these tricky years. Further, the parallel key roles of the consultant and the parent; to be bigger, wiser, stronger and kind, are equally applicable in mentoring. Like parenting, the most important thing to have someone who is willing and able to supervise and hold the younger in mind.
References and Further Reading:
Garling P . Final report of the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals. Sydney: NSW Government, 27 November 2008. https://www.dpc.nsw.gov.au/?a=34194 Accessed June 2017.
Pelling, N., Barletta, J. and Armstrong, P. The practice of clinical supervision. Bowen Hills, Qld. : Australian Academic Press, 2009.