CLINICAL SUPERVISION On THE RUN

1. CLINICAL SUPERVISION On THE RUN Christine Phillips

3. 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.

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

5. Is clinical supervision on the run always bad? 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 Educational principles Androgogy – adults learn best on the job and solving immediate problems

6. Clinical teaching is an educationally sound approach, all too frequently undermined by problems of implementation. BMJ  2003;326:591.

7. 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

8. Connect

9. 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

10. “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.

11. 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

12. Reflect

13. 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 Boudand 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

14. 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.

15. Becoming reflective • Meta-reflection Reflections on the ways I think and perform overall • Reflection in action How I consider as I undertake a course of action, or make a decision between courses of action. The most effective reflection that can emerge from supervision is meta-reflection

16. 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.

17. 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.

18. 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

19. Respect

20. Ethical concerns • Don’t humiliate the learner • Respect confidentiality • Patient autonomy • Patient confidentiality • The ethical imperative of service • Business ethics

21. 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

22. Special cases Supervising groups on the run

23. 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

24. Supervision on the run… • Is feasibleand educationally desirable • Prepare: • Learner self-assessment + ground rules • Reflect: • Reflection in action + meta-reflection • Respect: • Supervising on the run is a collaborative practice