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Earlier this year, the General Medical Council (GMC) in the UK published a document setting out standards for training junior doctors.1 As such documents go, it is clear, comprehensive and—as the GMC might say itself—fit for purpose. While no-one would be tempted to set it to music, it's certainly useful to have a standard in writing like the following one: ‘Trainees must be supported to acquire the necessary skills and experience through induction, effective educational and clinical supervision, an appropriate workload, relevant learning opportunities, personal support and time to learn’.
It's also helpful to have such a standard broken down into unambiguous requirements including this: ‘Working patterns and intensity of work by day and by night must be appropriate for learning (neither too light nor too heavy), in accordance with the approved curriculum, add educational value, and be appropriately supervised’.
Three cheers for that. Yet here the document falters, as such official documents so often do. What exactly does it mean to be ‘appropriately supervised’? How are trainees to know if the supervision they are receiving is appropriate or not? Indeed, how should a trainer or supervisor know if what they are offering is appropriate, good, excellent or inadequate? On this, the GMC is, perhaps understandably, silent.
We want to try to answer these questions. Before doing so, however, we need to offer a caution. It's very tempting to follow the same approach as the GMC by breaking down standards into requirements, and then dividing the requirements into competencies, such as the ability to match any teaching to the learner's level. You can then go on to identify the skills needed for each of these competencies, such as asking open questions. After that you can describe the kinds of behaviour that demonstrate these skills and so on, ad infinitum. It is tempting, but in our view it is also wrong. At a certain point, objective definitions like these nearly always fail to capture exactly the thing you are trying to pin down. As the organisational theorist Haridimos Tsoukas has argued, the more light you try to shine on a subject, the less you may see.2 The interactional subtleties of human endeavours get lost in the obsession with trying to seem scientific.
What we want to propose instead is something that may seem fuzzy and idiosyncratic, but—for exactly that reason—may bring us closer to an understanding of what constitutes good supervision. We want to list a number of subjective statements that trainees often say when they recount narratives of positive experiences in their training. We suggest that such statements, while not providing any kind of algorithm or points system, do actually set standards for what we should be looking for when investigating whether or not someone's supervision is appropriate. As it happens, this is also in keeping with research, which shows that ‘the supervision relationship is probably the single most important factor for the effectiveness of supervision’.3 4
Presence and availability
‘They're there when I need them’. For good supervision to happen, supervisors need to be present. Although blindingly obvious, it's also crucial. The supervisor's presence may not be immediate, and may happen over the phone rather than in person. It may also be an impression rather than a mathematical fact: not something you can measure in minutes or hours of proximity, but rather a feeling of reliability. Presence has an emotional as well as a physical dimension to it, so that the most common statement that goes alongside the first one is ‘They're always available for me’. The implication is that good supervision means not being distracted, irritable or dismissive, but present in spirit as well.
‘They take my training seriously’. Probably the biggest factor that impedes supervision is the pressure of clinical service—on both the trainee and the supervisor. The pressure is almost universal, yet trainees are able to distinguish in even the most demanding jobs between teachers who appear to identify teaching as part of their vocation and those who do it merely in passing or by default.
‘They respect me as an equal’. The supervisor–trainee relationship is a complex one. It is bound up with historical ways of being and acting (on both sides) which are difficult to change. Being a partner in training, and treated as a colleague rather than a pupil, makes a difference. It allows a less prescriptive experience, where trainees get a glimpse of what working life will be after training.
Reflection and complexity
‘They strike a balance between getting the paperwork done and time for reflection'. The form-filling involved in training is now so formidable that the time available to reflect on practice can become seriously depleted. Yet reflection—on cases, systems, communication, significant events, critical incidents and everything else—lies at the heart of adult learning. Nothing set down on paper can ever replace it.
‘We discuss wider issues to help me place my work in the bigger picture’. If trainees are ever to see the part they play within the complex system of healthcare, they need to be party to bigger discussions and issues: for example, how a department should be restructured, its aims and objectives for the forthcoming year, and interactions with other departments that need to work together for optimal patient care or population health. They will lead these activities one day, so the earlier they get involved, the better.
‘They treat me as part of the organisation and expect me to act as such.’ Even when trainees provide most of the service, supervisors can still treat them very much as an extra to a department, and don't expect them to get involved in the day-to-day running of the unit. This can foster resentment in ‘employed’ colleagues who feel that trainees have an easier life with better pay. It also handicaps trainees when they reach consultant status, where they may have to head units without any experience of the complications entailed in doing so.
Candour and respect
‘They expect the most from me.’ The best supervision often happens when a supervisor expects trainees to do a good job and shows faith in them. It can lead trainees to raise their game and want to work harder. It can also influence a wider circle of colleagues so they take the same attitude and help the trainee live up to their expectations. The corollary of this is: ‘I don't mind when they criticise me.’ Affirmation is part of good supervision, but so is candour. If trainees hate bullying (as they obviously always do), the majority also appear to appreciate supervisors who don't beat about the bush when a mistake occurs.
‘I trust their judgement.’ When satisfied trainees describe good experiences, they quite often make a distinction between just being covered by someone, and having an implicit trust in the supervisor. Another statement that commonly follows on from this is: ‘I'd be happy for them to treat me or my family.’ Ultimately, it is overall intuitions like these that tell us most about the professional qualities of supervisors.
One could no doubt generate a further list of statements describing good supervision, possibly by interviewing focus groups of trainees, or perhaps through a Delphi process.5 The GMC already carries out and publishes a survey of all trainees every year,6 and some of its questions do approximate to the ones above. Yet they are still framed in abstract concepts, such as ‘competence’ and ‘quality’, or behaviour, such as being forced to cope with clinical problems beyond one's experience. They seem to miss out the one thing that matters the most—the human relationship.
It would be interesting to try out some local surveys, asking if a range of positive statements fit the relationships trainees have with the people supervising them in their current job. Any findings would have to be balanced with other information, including the narratives of trainers, and used as part of a developmental process rather than just as a way of imposing scrutiny or sanctions. But it might provide a fuller picture of whether any supervision being provided in the work place was indeed appropriate.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.