CLINICAL SUPERVISION On THE RUN Christine Phillips

Learning through interrupting vs formal supervision

When I started working in primary care, I was terrified of what I didn’t know. I had gaps where I didn’t even know I had gaps. For the most trivial things, I’d go next door and bang on the door of the clinician.

You couldn’t function as a mental health professional if you didn’t have a formal system of supervision. Every fortnight at 4 pm.

Why on the run? Most of us are clinically busy Junior clinicians need answers Problems are best solved early Patient safety demands rapid response

Is clinical supervision on the run always bad? Educational principles

Androgogy – adults learn best on the job and solving immediate problems

Professional modelling

“I saw the level of his complete engagement with the patient, how he turned from me and back into the presence of the patient”

Collaborative teaching

Opportunistic engagement: with patients as teachers – exposes them (and models respect for) patient expertise

Clinical teaching is an educationally sound approach, all too frequently undermined by problems of implementation.

BMJ  2003;326:591.

Principles of supervising on the run Connect

Identify initial needs Establish ground rules

Reflect Reflection in action Meta-reflection

Respect Be ethical Be responsive

Supervising on the run is a collaborative activity

Connect

Learning needs Known unknowns and unknown

unknowns Beware the learner bias to stick with

known areas Teachers should identify areas of

learning emphasised in the setting Be prepared to re-assess learning needs

as learners move further up the learning taxonomy

“I want to work with MSF…”Because of her view that people who work in global aid agencies must know a lot about infectious diseases, the learner had spent a great deal of time studying infectious diseases. She identified this as her big learning gap.

In fact her real need was to develop personal resilience and to recognise and manage psychological illnesses.

Ground rules Plan for interruption How to interrupt What kind of questions can be asked on

the run, and what kind can’t Where the supervision will be held Role of the patient Back-up arrangements

Reflect

Reflection is the means through which people develop relationships between what they know and value and the learning in which they currently engage

Thorpe 2000

Reflection should enable learners to express doubt, uncertainty and awareness of contradictions

Boud and Walker 1985

Reflection is a means of monitoring our own learning, both what we know, how we know it, and the process through which we learn Thorpe 2000

Being able to reflect on oneself and one’s learning is a fundamental skill for any professional

Self-awareness has never been the strong suit of those who choose to become doctors. When so much fuel is readily available for stroking the fires of ego, there is a little inclination to apply it in raising the candlepower of the searching light that might illumine the inner man or woman.

Sherwin B Nuland, 1998.

The uncertain art: the whole law of medicine. The American Scholar Summer 1998, vol. 67, no. 3, pp. 125-9.

Becoming reflective

Reflection in action

How I consider as I undertake a course of action, or make a decision between courses of action.

Meta-reflection

Reflections on the ways I think and perform overall

The most effective reflection that can emerge from supervision is meta-reflection

We needed all our equipment to be replaced, so I developed a strategic management plan. We replaced it all, and then I developed a way to manage the distribution of free medications from our cupboard.

I learned that I become distressed when patients are angry and react to them. I think I am thrown when people are not grateful for how hard I try. I also realised that I have always tended to dismiss “social and emotional work” as not real clinical work.

We needed all our equipment to be replaced, so I developed a strategic management plan. We replaced it all, and then I developed a way to manage the distribution of free medications from our cupboard.

I learned that I become distressed when patients are angry and react to them. I think I am thrown when people are not grateful for how hard I try. I also realised that I have always tended to dismiss “social and emotional work” as not real clinical work.

Meta-reflection on the run Be gentle, and socratic. Don’t personalise or blame or be overly

intrusive…it’s all about self-knowledge Often the best opportunities for meta-

reflection are “heartsink” patients The inventory of irritating characteristics

can be useful for those who struggle with meta-reflection

Respect

Ethical concerns Don’t humiliate the learner Respect confidentiality

Patient autonomy Patient confidentiality

The ethical imperative of service Business ethics

Being responsive Recognise that clinical practice is always

a process of discovering new gaps in our knowledge and capacity which we can reassess.

Daily three sentence reflection. Recognise when learners are need concrete strategies

Special casesSupervising groups on the run

Can you supervise more than one on the run? Yes, if they have a shared project or

enterprise Yes, if you are all closely co-located Same principles of preparation apply Possibilities for meta-reflection are

reduced in the on-the-run mode (reflection in action may improve)

The supervisor will need to scale back their own clinical work

Supervision on the run… Is feasible and educationally desirable Prepare:

Learner self-assessment + ground rules Reflect:

Reflection in action + meta-reflection Respect:

Supervising on the run is a collaborative practice