Susan Wearne, Rural Clinical School, Flinders University, PO Box 2681, Alice Springs, Northern Territory 0870, Australia. Tel: 00 61 8 8952 6553; Fax: 00 61 8 8952 6553; E-mail: firstname.lastname@example.org
Medical Education 2012: 46: 1161–1173
Context General practice supervisors are said to serve as the cornerstones of general practice postgraduate education and therefore it is important to clearly define their roles and what makes them effective. The commonly used definition of a supervisor is not primarily based on general practice and does not cover aspects predicted to be important according to work-based learning theory.
Methods We searched for papers published between 1991 and 2011 inclusive, categorised them according to whether they provided empirical evidence, descriptions or recommendations, open-coded the empirical evidence, and used the resulting coding scheme as an analytic framework within which to present a narrative summary of findings.
Results Recommendations and descriptions far outweighed empirical evidence, which showed how supervisors intertwined clinical and educational activities and formed educational alliances with resident doctors that provided a foundation for learning. Residents needed a balance of challenge, usually provided by patients, and support, provided by supervisors. Supervisors established learning environments, assessed residents' learning needs, facilitated learning, monitored the content and process of learning and the well-being of residents, and summarised learning in ways that turned ‘know that’ into ‘know how’.
Conclusions General practice must be expert in ensuring patients are well cared for ‘by proxy’ and in giving residents just the right amount of support they need to face the challenges posed by those patients. As general practice responds to contemporary clinical demands and rising numbers of undergraduate medical students, it is essential that the ability of general practice supervisors to develop and sustain supportive supervisory relationships with residents is preserved.
Doctors learn how to be general practitioners (GPs) by working in training practices under the supervision of accredited GP supervisors.1–6 Vocational training has been shown to improve learners’ skills,7,8 but supervisors’ exact contribution remains unclear9 and often unseen.10 Three general practice (GP) colleges1,3,6 (organisations which oversee specialty education nationally) use the following definition:
‘Supervision involves providing monitoring, guidance and feedback on matters of personal, professional and educational development in the context of the doctor’s care of patients. This would include the ability to anticipate a doctor’s strengths and weaknesses in particular clinical situations, in order to maximise patient safety.’11
We question whether this definition is relevant to GP training because it came from a literature review that cited just one source of postgraduate GP empirical data.12 In addition, the definition’s emphasis on monitoring, guidance and feedback seems unidirectional and insufficient in the context of the multiple, dynamic, inter-related processes that affect clinical learning.13 Learning is situated in work and in meaningful participation in communities of practice.14,15 How learners engage with workplaces affects the learning affordances the latter provide.16 Learners require supervised professional development rather than didactic input17 as they progress to independent practice.18
Education in general practice is changing. Traditionally, it was based on a resident–supervisor apprenticeship model, which facilitated educational and clinical continuity. Now, GP clinical supervisors are responsible for more student and junior doctor GP placements,19 following evidence that community-based medical education can effectively complement education in hospitals.20,21 More doctors work part-time,22 and some resident doctors (residents) are supervised at a geographical distance, supported by information and communication technology.23–25 The need to oversee multiple learners at different educational levels may have unintended negative effects on GP supervisors.26
If GP supervisors are to function effectively as the cornerstone of GP training,27 evidence on what their role is, how this links with contemporary learning theory, and how the role can be maintained is required.
Research team, literature search and terminology
The researchers on this study included SW, an GP academic, 25 years post-graduation, who completed her Masters thesis at the Cochrane Centre for General Practice. TD and PWT are medically qualified academics with expertise in work-based learning, and TS is a health psychologist and director of a rural clinical school. SW conducted the initial searches and coding. The interpretation of the resulting codes, categorisation and settling of disagreements were undertaken collaboratively by the research team.
We use the term ‘general practitioner’ synonymously with that of family doctor and the term ‘supervisor’ to denote a GP supervisor or tainer. The search strategy and selection process are shown in Fig. 1. The search produced three types of paper describing, respectively:
• empirical evidence of GP supervision in action;
• descriptions of the role of the supervisor by residents, supervisors or educators, and
• recommendations about what GP supervisors should do.
Empirical evidence of supervision in action was used as the main data source because it reflects authentic rather than espoused supervision practice. Empirical evidence was analysed, open-coded and grouped into themes to establish a structure that best reflected the activity of GP supervisors.28 The resulting framework was critiqued by all authors, modified as needed, and then used to analyse remaining publications. We will first cite the sources of evidence and types of recommendations. We will then use our analytical framework to structure a narrative account of empirical evidence, descriptions of the role of clinical supervisor, and factors considered to influence its effectiveness.
Table 1 shows the scheme used to code data sources. In the subsequent text, these codes are used to define the data source. Table 2 shows that empirical evidence was obtained by directly observing supervision in routine practice,29–34 recording tutorials,35–37 writing notes in diaries38,39 and noting the content of corridor conversations.40 Descriptions of the role of supervisors came from group discussions,41–45 Delphi exercises,46,47 interviews,44,48–59 supervisor meetings,60 written feedback on placement evaluation forms,61 case reports62 and questionnaires55,63–78 (Table 3). There were many published recommendations about teaching methods.79–93 There were also recommendations based on the application of educational theory11,94–105 and derived from personal experience or consensus.10,81,106–113
Table 1. Coding scheme for data sources
In the text, codes are preceded with ‘e’ for empirical evidence, ‘d’ for descriptions and ‘r’ for recommendations. Thus, for example, ‘dCA’ means a description based on content analysis of transcripts
The evidence reviewed showed supervisors’ educational activities to include establishing learning environments, assessing residents’ learning needs, facilitating learning, monitoring learning, monitoring learning processes, attending to residents’ well-being, and summarising learning. These dynamically inter-related educational processes are represented in Fig. 2.
Balancing competing priorities
Supervisors recognised that although residents valued carrying out clinical work (dQ63) and performing procedures (dCA61), the care of vulnerable, sick people must not be jeopardised by residents’ learning. Most supervisory interactions focused on assuring the delivery of safe patient care (eDO33) and therefore supervisors needed to be expert, up-to-date clinicians (eWD,39 dDM,46,47 dQ,65,71,77 dCA,61 dIN50,53). Supervisors’ supposedly protected teaching time was so often interrupted by clinical requests that they spent about half of it (eDO29,33) on non-teaching activities. Residents found that interruptions, the inaccessibility of supervisors (dIN59) and abrupt closure of teaching sessions detracted from the quality of their education (eDO33).
Providing relational and personal supervision
Supervisors’ personal qualities (dDM,46,47 dIN,44 dQ71), communication skills (dDM,34,47 dQ42,77) and relationships with their residents (dDM,41,46,47 dIN,53,56–58) contributed to their effectiveness. One-to-one relationships were vital (dQ67) because they influenced the quality of training (dQ69). Effective teaching behaviours included being able to correct mistakes without belittling residents, being pleasant and helpful when called after hours (dQ65), and being encouraging (dIN57). Likewise, ready availability (dNGT + FG,47 dIN,54 dQ74), approachability (dIN57) and the provision of ongoing pastoral and personal support were key issues (dIN,53 dCA61).
Vulnerable residents and ‘breakdown’
In-depth interviews and diaries showed that residents felt vulnerable because they wanted to prove their competence to patients and other doctors in their practices, but were learning at the same time (dIN,44 eWD39). They learned from the challenges posed by clinical work (eDO,30 dIN30,44,57), particularly when breakdowns in care resulted from their inability or inexperience (eDO30), provided they felt supported by their supervisors (dIN,44,102 dQ101). Insensitive communication could destroy residents’ desires and capacities to learn and work (dIN44).
Establishing learning environments
Supervisors were responsible for constructing positive learning environments (dDM,46 dCA,61 dQ65). Positive, safe and blame-free environments had lasting value according to experienced general practitioners (dIN56) and residents (dFG45). Supervisors were brokers (dQ,72,74 dIN,44 dFG45) who could either facilitate or obstruct access to the educational and clinical networks within a practice and its community. Learning from practice was threatened when residents were used solely as a workforce and therefore an important role of supervisors was to manage residents’ workload (dIN,54 dFG45). Residents wanted supervisors to grant them autonomy to the levels permitted by patients’ needs and their own confidence and competence (dFG,45 dIN58). Residents’ responsibilities were required to match their authority (eDO30) for optimum learning. Figure 3 illustrates how a balance of challenge and support facilitates learning.
Assessing learning needs
Supervisors were expected to ensure the provision of regular, structured teaching related to the learning objectives of their programmes (dQ53), but over 90% of 949 observed resident–supervisor encounters were initiated by residents who were uncertain of what to do (eDO31). Residents also identified learning needs during their work as doctors and sought to address these in tutorials (eAR37). Discussing cases (eVR35) and asking questions (eAR37) in tutorials and on wards (eDO31) showed supervisors their residents’ had learning needs or were confused about a topic. Supervisors’ questions, however, were more often at the level of knowledge recall (eDO33,34) than about understanding, analysis, evaluation or synthesis. One of the roles of supervisors was to negotiate and agree learning agendas with residents (eVR35); learning was inhibited if supervisors did not prioritise learning agendas or sacrificed the fulfilment of learning needs for the comfort of easy topics (eVR36).
Promoting reflection by acting as a mirror
Supervisors promoted reflective learning (dFG,43 dIN53) by helping residents to become aware of their own attitudes (eVR35). Residents could find it challenging to be observed by supervisors as ‘it created performance anxiety, forcing them into self-examination and allowing others to see them as they really were’ (dIN52), although that reaction was not universal (dQ64). Portfolios promoted reflection, were valued more by supervisors than by residents, and were most effective when both parties were involved (dQ55,73) and when the portfolio was used for formative rather than summative assessment (dQ49,73). Supervisors promoted personal and professional development by encouraging residents to examine and reflect on the parts of their portfolios in which emotions, values and beliefs predominated (dIN49).
Residents rated the quality of teaching encounters more highly when supervisors were prepared and brought along medical content (dQ66,74), such as guidelines and patient records (eWD38), although ethnographic observation showed that such resources must match identified learning needs (eDO30). Most questions answered in corridors were about clinical care: 50% referred to diagnosis, 40% to treatment and 10% to how to perform procedures. Skin conditions were the most common reasons for such conversations (eCC40). Supervisors were valued for their experience of ‘the real world’ and as a source of advice on how to apply knowledge to specific contexts (dCA60); this represented the key difference between ‘knowing that’ and ‘knowing how’ (dQ67).
Residents wanted regular, honest (dFG43,45), supportive (dQ74) feedback ‘characterised by a large number of reflective remarks’ (dQ75). Feedback based on direct observation of clinical practice was a powerful influence on learning (eWD,38 dIN52). As a result, supervisors needed to possess the courage and ability to give feedback that might be uncomfortable (dDM47). Learning was assisted by supervisors’ provision of constructive criticism (eVR,35,36 dDM,46 dIN56), whereas their avoidance of being critical had a negative impact on learning (eDO36). Verbal praise, however, was recorded in only 3% of observed encounters in one study (eDO31) and in 16% of interactions in another (eDO28).
Residents learned from listening to informal meetings and conversations in their practices (eAR37) and from watching clinicians interacting with patients (dIN,50,51 dQ63,65,71). Supervisors showed how to manage clinical uncertainty by discussing their own difficult cases and solving problems jointly with residents (eAR37). Effective, supportive relationships with supervisors who were role-models showed residents how to support their current and future patients (dQ67).
Being committed and skilled teachers
Residents learned from teachers who were committed and enthusiastic (dDM,46,47 dCA,61 eDO,30 dFG,45 dQ,71,77 dIN57), open to criticism (dDM47) and able to individualise their teaching styles (dQ,65 dIN52).
Monitoring resident learning
Supervisors monitored residents’ progress, narrowing or widening the focus of discussions to extend from specific to broader situations (eVR35). At times, supervisors used a ‘quick fix response’ (eAR37) or taught didactically (eDO31) to match the task in hand (eDO30), but this impacted negatively on learning when used too often (eVR36).
Monitoring learning processes
Supervisors monitored the process of teaching sessions (dQ69). They or other residents present interjected to release tension or to stop one person from dominating group sessions (eDO34). Learning was most effective when residents did most of the talking (eVR35) and supervisors listened intently (eVR36).
Attending to residents’ well-being
Supervisors monitored the well-being of residents (eWD,39 dQ,66 dIN44) as they learned through stimulating (dQ77) but stressful (dFG43) work. Supervisors allocated time according to need, observing residents in their first year of training more than those in subsequent years (eDO29,32).
Good conclusions to learning interactions consolidated learning (eDO31) and residents scored interactions as being of higher quality when their content was summarised at the end of the interaction and follow-up activities were planned (eWD38).
The educational and clinical roles of supervisors were intertwined even when teaching time was supposedly protected. Supervisors were responsible for ensuring the provision of safe patient care and had, therefore, to be clinically expert. They oversaw an educational process in which residents’ learning needs were met if they matched patients’ needs. Supervisors’ personal characteristics, particularly their ability to form nurturing, ongoing relationships and balance the level of support they gave against the challenges of residents’ work, provided a foundation for residents’ learning. Residents, likewise, saw their supervisors’ main asset as their ability to give flexible, personal support, rather than just their possession of technical, clinical or educational skills. Supervisors scored the ability and courage to give feedback highly; thus it was important for supervisors to be critical as well as supportive. This suggests that, although residents crave reassurance, supervisors must understand registrars’ strengths and weaknesses well enough to nurture growth and development. This ongoing supportive relationship taught residents, in turn, how to form ongoing supportive relationships with their patients.
The negative impact on resident learning of interruptions to teaching reinforces the value of protected clinical teaching time,114 but how supervisors balance the competing tensions between patient and resident needs is not documented. Supervisors’ provision of ‘just-in-time’ answers to residents’ clinical questions suggests that higher-order thinking, such as in analysis or synthesis, should be the focus of non-clinical teaching time.
The supervisor’s role in the summative assessment of residents was not mentioned in the empirical evidence and in relatively few description papers.49,53,60,67,73,78 Supervisors report uncertainty on how to manage poor performance53 and supervisors working at a distance were found to enjoy freedom from a gatekeeper role (dIN60). The role of GP supervisors in summative assessment may cause a background tension that they suppress by focusing on residents’ development.
Strengths and limitations of this research
The strengths of this review are that it has brought together a larger body of research on the role of GP supervisors in postgraduate training than the most commonly quoted previous review11 and draws on this synthesis to describe the role of the GP supervisor. As in any such review, there was an element of subjectivity in how the synthesis was carried out.
We judged the trustworthiness of each paper according to its ability115 to answer our research question and took the results at face value, giving more weight to empirical research evidence than to descriptions of supervision or recommendations. We did not include texts from the grey literature. The scope of the evidence available to us also imposed some limitations. We found no empirical research on the effect of supervision on clinical encounters or patient care outcomes and therefore the picture is incomplete. A review of teaching about specific clinical topics, rather than supervisory practice, might have yielded different results.
Comparisons with existing literature
The importance of supervisory relationships identified in this review mirrors a finding in a meta-analysis in the field of psychology, which showed that the formation of a therapeutic alliance between a therapist and his or her client is the strongest predictor of a positive outcome: ‘a collaborative and affective bond between therapist and patient’ is more consistently effective than any particular style or method of psychological intervention.116 If they do not feel supported, it may be difficult for residents to be open enough to acknowledge their clinical, educational and personal weaknesses and to address them. There are similarities between the role of supervisors in calibrating the mix of support and challenge experienced by residents in terms of their creation of cognitive dissonance within a relationship founded on ‘unconditional positive regard’117 and practitioners' role when helping patients modify behaviour by means of motivational interviewing.118 Experiencing such a relationship may teach residents about their role in forming ongoing supportive relationships that help patients be vulnerable and make difficult changes. The process follows Egan’s skilled helper model in addressing a current scenario (the story, blind spots, creating leverage), the preferred scenario (possibilities, change agenda, commitment) and strategies for action.119,120
Although group learning within practice might seem a more efficient use of supervisors’ time and some residents report benefits from learning from their peers (dIN57), there is risk involved in changing from one-to-one educational relationships. Unless supervisors are skilled in group facilitation, residents and students might vie to show their strengths rather than weaknesses. The role assumed by supervisors in overseeing patient care and enabling residents to learn by doing fits with contemporary theories of work-based learning.16 The supervisory role of helping residents learn as participants in GP communities aligns with socio-cultural theory of practice-based learning.14,15 The promotion of reflection and the provision of feedback based on direct observation provide the conditions residents need to develop expertise through ‘deliberate practice’.121
The previous definition of clinical supervision cites one12 of 192 papers with empirical data relevant to postgraduate GP training11 (and that paper’s focus was finance). We included seven empirical articles published prior to the earlier review11 that the previous reviewers did not include29,31–34,36,37 and five articles published later.30,35,38–40 We think it would be useful to specify the attributes of an effective supervisor and propose the following definition from our integration of the literature:
‘A GP supervisor is a general practitioner who establishes and maintains an educational alliance that supports the clinical, educational and personal development of a resident.’
Key components of the GP supervisor’s role are to oversee patient care and broker the relationship between the resident and the community of practice in which the resident is learning through work. Effective GP supervisors balance the level of support they give against the challenges confronted by the resident. They promote reflection and give feedback based on direct observation to facilitate clinical deliberate practice. GP supervisors attend to the resident’s well-being and make it safe for the resident to reveal and address weaknesses in his or her knowledge, skills and emotional responses to practice.
Areas for further research
This review has highlighted areas for future research. Studies of patient care by residents might alter our perceptions of the importance of supervisory relationships. Observation of residents’ clinical practice and the subsequent teaching relating to that practice would enable exploration of how topics for discussion are agreed and at what level of thinking, how supervisors decide when to focus on residents and when on clinical practice, and whether this differs between more and less effective supervisors. Evidence that research and recommendations make any difference to what supervisors do and how their residents learn is also needed. The impact of the increasing role of supervisors in assessment27,122 requires consideration, particularly given how little this was mentioned, despite supervisors’ traditional role in judging when residents can advance through training. This will test the majority view of residents and supervisors that their one-to-one relationships will assist the supervisor’s assessment task.67
In summary, the relationship between a resident and his or her supervisor is important. This educational alliance provides a platform for all other aspects of learning. Residents learn by immersion in the challenges of clinical practice and the supervisor’s role is to provide a zone of safety and support for clinical, educational and professional development. As general practice responds to contemporary clinical and educational demands, it is essential that the ability of GP supervisors to develop and sustain supportive supervisory relationships with GP residents is preserved.
Contributors: SW, TD and TS discussed the scope and design of the research. SW conducted the searches and discussed the strategy used with TD and TS. PWT and TD proposed and oversaw methods of analysis. SW led the writing of the paper and each author contributed significantly to multiple subsequent revisions. All authors approved the final version of the manuscript submitted.
Acknowledgements: the authors thank Peter Cantillon, Penny Cooper and Louise Stone for their critique of earlier drafts.
Conflicts of interest: SW is a PhD candidate and GP supervisor, researching the role of the distance GP supervisors.