MARION LEIGHTON: Active supervision, and active learning throughout our professional lives, is the key to being the best people we can be for our patients to come to in order to get better, and live the healthiest lives that they can live. We're all in this together.
CAMILLE MERCEP: From the Royal Australasian College of Physicians, welcome to Pomegranate—a podcast for continuing professional development.
Supervision shapes the next generation of physicians—from basic trainees in the PREP Program to advanced trainees transitioning to consultant roles. As a result, supervision also affects the lives and health of patients. Time constraints and large rosters of trainees, however, can challenge even the most motivated of supervisors. What makes "the best," the best?
This month we're joined by three experienced supervisors: Peter Davoren, an endocrinologist and former Director of Physician Education at Gold Coast Hospital; Marion Leighton, a general physician based in Wellington who supervises both for the RACP and for the Medical Council of New Zealand; and Josh Francis, a Darwin-based paediatrician who provides remote supervision for doctors in Timor-Leste. We also spoke to Alexandra Greig, an advanced trainee in public health, to hear the thoughts of a doctor who is currently being supervised.
In this discussion, our guests explore: how the role of the supervisor has changed over time, as well as where the role ends; the skills needed for a good supervisor; and some suggestions on how to deliver constructive criticism. With combined decades of experience, they also share their thoughts on how to improve your own performance as a supervisor—and why they find it worthwhile.
MARION LEIGHTON: My name is Marion Leighton and I'm a general physician working at Wellington Regional Hospital in New Zealand, and I'm Deputy Chair of the New Zealand CPD Committee for the College.
We've changed from just an apprenticeship model where people come to work and hopefully muddle through and come out the other side, to understanding a lot more about how supervision works—especially in a skills-based sort of leadership model that we have in medicine. And as a profession we're starting to apply the evidence and develop the skills we need. And this is being led I suppose by our regulatory bodies, the Medical Councils, and by the public who want us to be seen to be doing supervision. And the trainees who want a more structured and validated learning environment. And as a College our response I think is very positive—to train supervisors in both knowledge and in practice, and to expect consultants to learn and develop those skills.
ALEXANDRA GREIG: My name is Alexandra Greig. I'm an advanced trainee in public health medicine, and I'm currently working as a public health registrar at the Department of Health in Canberra.
We know that all our colleagues have the professional and the technical expertise so it's not really about what they know—it’s about how they interact and behave in a way that you can learn from them, and you can kind of feel like you can pick up their wisdom and their experience. They know a little bit about me and my background and where I'm from and they share a little bit about them and their life outside of medicine. And it means that you have much more than just what you need to do to get through training—you actually have that relationship where you feel like there's somebody who cares about your progress and sees you as a future colleague. To me that's the most valuable thing. You know, I have supervisors who I know I'll have ongoing professional relationships with.
JOSH FRANCIS: My name is Josh Francis—I'm a paediatrician and a paediatric infectious diseases specialist working at Royal Darwin Hospital. And so I supervise general paediatric trainees who rotate through—and I may be their direct supervisor in some situations even just for a week or two before they move on. But then I also have an advanced trainee doing paediatric infectious diseases for a period of 12 months—and I actually find that incredibly rewarding. And it does mean that the role extends beyond the sort of direct involvement in clinical care to being a much closer relationship where we’re working very closely together.
My role in giving input into his development and training isn't limited to the patients that he's dealing with at the time, but also towards planning ahead—both in terms of getting through the 12 months and what that will entail, and what the objectives will be for that training period. But also looking beyond that and trying to invest in a way that will continue to have an impact as he plans the rest of his training and his future work as a consultant as well.
PETER DAVOREN: My name is Peter Davoren; I'm the Director of Diabetes and Endocrinology at the Gold Coast University Hospital. And I'm also an Associate Professor at Griffith University School of Medicine.
Certainly in terms of where the responsibility of the supervisor extends to, the first issue is the complexity of being a representative of the employer, as well as being a supervisor for education. And for many supervisors the two are very closely linked and not always indistinguishable—and so some of the times dealing with the trainee who is underperforming falls within the workplace issues as much as it does with the training.
MARION LEIGHTON: Trainees have often moved cities recently—it might be the first time they're in a new place. They've got no close friends nearby and so it's hard for them to be able to find other people to talk to about both difficult work issues and personal issues. So I think the supervisor is an important first point of contact to help them out. Where our responsibility to the trainee ends is a mutually negotiated process—some trainees may not want to share personal details or things with us. On the other hand, if issues in their personal life are impacting on the job then it's really important that we do ask those questions and say: “Why is it? It looks like you're not looking too good today?” or, “I've been worried about you for a few weeks now—is there anything else going on in your life that you're struggling with?”
And it can be everything from just getting completely worn out revising for the exam to, you know, trainees who are ill, trainees who have got family problems. And it's often good to ask them, “Do you want to talk to me about it? Or would you like to find someone else?” “Who do you have that you can talk to?”
JOSH FRANCIS: If I was to give one example of a truly great supervisor, it was a wonderful paediatrician in Queensland—Dr Michael O’Callaghan. I clearly remember preparing for the RACP exam, and it's very easy in that context to become completely focused on thinking about what it is that you need to do to get the marks to get through to never have to do this terrible exam ever again. I know that he was interested in me as a person, and I know that he cared about whether or not we would get through the exam, and I know he wanted to give us feedback that would help us. But he would start asking questions, probing questions, about this child that I'd seen with their parents, about where things were up to for them, and how they were experiencing what they were going through, and what difference could be made in their management that would have an impact on their life. And that—even in the context of preparation for a high stakes exam—to me was a really wonderful investment that he had in me and in my development in terms of understanding that wherever you're up to in your career, this is a vocation that sees us investing in the lives of our patients and their families.
And that has to be primary—that has to be key—and it's something that I thank him for. And again I really hope is something that comes through in the way that I work and certainly in the way that I supervise my trainees as well.
MARION LEIGHTON: Often the challenge looks the same, and yet when I've sat down and tried to work out what the problem is, it’s been a huge different range of problems. I've had two trainees who've been very depressed—and one of them it was just a very difficult run. And you know in the end I plucked up the courage really to sit down with her and say, “You know, I'm really struggling with this relationship, and I'm finding it hard to guide you—because every time I talk about things, you have reasons why you can't do what I'm asking you to do.” And it was as that conversation unfolded that it turned out that she was really struggling at home and was very depressed. And we were able to find her help through the Employee Assistance Program and Occupational Health with the hospital. And within six months she'd turned around into a different doctor. She was a joy to work with.
PETER DAVOREN: When it comes to the other side of things—people who are struggling because of external factors—then I suppose the important thing there is to firstly recognise that they occur, secondly recognise how much and what impact it’s having on the trainee and their performance. And if it's going to the point where it makes the care of patients dangerous you have to deal with that. If it's a temporary thing for which the trainee will get over, it's reasonable to accept that if their work performance is adequate.
But for some people it often comes down to suggesting that they seek the right assistance to sort that out. Because obviously the supervisor is not going to be able to sort out people's marital problems or their substance abuse problems necessarily quite easily. And in reality having an independent third person interacting with the trainee is probably a very good idea anyway.
I mean certainly it's not necessarily within our remit or even our ability to deal with a lot of those problems which are common to any person in any walk of life, and not particular to their training as a physician. Making sure the trainee goes to a general practitioner if that's the appropriate course of action—or many hospitals have staff counsellors that may be the correct place to go. Some of the times the trainee listens, and sometimes they don’t.
MARION LEIGHTON: If I don’t deal with an issue within a week I let it pass. I might collect it up as, “I'll pay more attention to what that trainee is doing, and make sure I pick up on the next problem.” But I don’t think it's really fair on trainees, nor appropriate, to meet them at the end of six months and sit down and say, “Well, actually that was all a bit rubbish”—but not have allowed them the opportunity to improve and change things as they went along.
The other thing I do as a supervisor is have my ear to the ground in terms of the gossip, particularly amongst the junior doctors, because some things I don’t think we're ever going to be told. I think being curious about our trainees and curious about our working environment is what keeps it both interesting and enables us to be proactive and nip problems in the bud.
JOSH FRANCIS: Working with a trainee or a medical student who is underperforming is without a doubt the hardest part of being a supervisor I think. And it can be very tempting I think to "let it ride" and leave it as someone else's problem. But we're all very much aware that that isn't a good solution—it certainly isn't a good solution for the patients. It's not a good outcome even for the trainees who actually genuinely benefit from having the extra effort applied in terms of addressing the issues that are there.
So I won't pretend that it's something that I find easy, but I do think that it's a really important part of being a supervisor. It's one of the things that you sign up to and it takes a little bit of courage and patience at times but it's crucial.
PETER DAVOREN: Over the years I've seen a number of trainees who have been lacking in some form of skills that they required for their work, and there were various reasons for that. Those same people often have other skills and qualities that make them good trainees—but that's only in one particular area that they're letting themselves down. And so I suppose being able to point out that in these areas you're performing quite well but you need to improve is helpful, and having concrete examples of that is always helpful. I think having the same message coming from more than one consultant is often a helpful factor as well, so that it's not coming from just a single reference point. Often times we do it individually—but for specifics of telling trainees that they're needing to improve, that would be something that we would do with more than one person with the trainee, so that they are getting the message from more than one person.
ALEXANDRA GREIG: One of the experiences I've had is that people are differently skilled in providing constructive criticism. There are some people who, in my experience, have been able to do that really well, and to say, “Look, this is what you did, and I don’t think it worked for these reasons, and this is a way that I think next time you could approach it differently, and that that would maybe help to overcome some of the challenges you had.”
That compares to sometimes people who might be able to say, “Well, you know, I didn’t like this, you did it this way,” or, “I didn’t think that was the right way to do it.” But who don’t offer you any tool or any approach that you could do it differently or better. So to me that's a real skill, and if you can learn to do that and to offer people criticism that's constructive, and that gives them a different approach, or something to test out the next time, or something to try to do it differently, then that is so much more effective to learn from.
JOSH FRANCIS: The role of the supervisor does change between working in a metropolitan setting compared to working in a rural or remote setting. The different nature of the work really can result in significantly increased expectations for trainees. And so I think that the roles and responsibilities of the supervisors have to be flexible given that. And so if you have a trainee who is going to be relatively autonomous in their decision making because of the limited resources in a rural or remote setting, then the supervisor has to have themselves in a position to provide adequate support, but also adequate rope if you like to be able to give the trainee enough rein to be able to make those decisions, to be able to develop in the way that a rural or remote setting can result in.
I also supervise doctors who are working in Timor-Leste and that provides a whole different context to supervision when you're at a complete distance talking over the phone—in a way like I am now for this interview. To not have that direct face-to-face interaction, but to be able to still provide support and advice, and sometimes just an ear to listen to the stories for somebody who is working in a very difficult situation with a huge amount of responsibility laid on them. It probably just requires a little bit more patience because the lines of communication can be challenging. But also perhaps a little more persistence so that you're not tempted just to forget about them and leave it go and assume that they're ok. You really do have to make sure that you stay on the case in terms of making direct contact with them. So it's really important for me to be not only willing but also actively involved in seeking them out, checking on how they're going and making sure things are going OK.
ALEXANDRA GREIG: You spend too much time at work to not enjoy what you’re doing, and you work really closely with your supervisor, you want to feel like when you come in to work each day that they're going to be another friendly face, and that interacting with them is going to be a good part of your day. Because you’re just here too much, you invest too much time and years of your life doing this to not have that kind of relationship.
And I think it's valuable for them as well, I think when you have that personal relationship that's part of being able to trust each other, and to be able to rely on another person, you know, is to have that relationship where you see each other as good colleagues.
JOSH FRANCIS: I was talking to my trainee who was about to go off and do some work and I asked him what I should say if I was asked if I'm an excellent supervisor, and he threw his head back and laughed. So I didn’t really know how to take that one—but it definitely is really important to me to get a sense of how I'm going as a supervisor. And I think in any capacity that we're working in, if we genuinely care about the work we're doing we want to know how we're going, and getting feedback is a really important part of that. Supervisors should feel comfortable and willing to ask and to ask in a very frank sort of way, “How am I as a supervisor? Are you getting the sort of feedback that you need? Are you getting the support that you need? Are there ways that I could improve the work that I'm doing?”
I think that that is actually really important. And for me it’s part of being honest with myself about how I'm going—being willing to hear what others will say as well.
PETER DAVOREN: Some trainees are happy to give positive feedback when they're moving on to a new job or a new position and that's always welcome. You sometimes get positive feedback by second- and third-hand routes, and probably for most of the time the negative feedback of trainees doesn’t come directly—and maybe as supervisors who need to get some negative feedback that wouldn’t hurt as well.
If it's practical and helpful and constructive feedback then it does allow supervisors to see where they might be able to do better because we can always improve in the work that we do. And certainly in my department we have a system of anonymous feedback where all the trainees can report on the performance of the consultants, and that seems to be a quite helpful task which we undertake once a year.
MARION LEIGHTON: A more formal way to do it is to get a 360 review from the trainees you’ve supervised—maybe not at the time you're supervising them because there is that power imbalance at that point, but perhaps a year later. And also feedback from your peers; as I say that's something that we discuss at my peer group as to what do we do and how do we do it, and what things have we tried, especially when we’re working with someone trying to get them to do a new area of practice. And getting each other's ideas has been really good for working out, “ooh, I never do that—maybe I should.”
The College now has these three excellent supervision workshops looking at how to supervise on the ward, how to supervise in the sort of things we've been talking about here in terms of being an educational supervisor, and how to give more difficult feedback and interact with trainees in difficulty. The College is also developing a Trainee in Difficulty Pathway and that will help to hone, you know, the supervisory skills around that area. And the Medical Council of New Zealand and I’m sure in Australia as well, also has intern supervisor workshops and programs.
PETER DAVOREN: My motivation for becoming a supervisor started from the fact that I recognised the benefits I got from the people who taught me when I was a trainee, and it was an expected role of the consultants of the time—although I suspect for myself it's the extra interest that adds to the day to day work which makes it most interesting. A large number of the consultants in my hospital now have been advanced trainees of mine at one place or another—and I suspect they add up to quite a number now. So it's pleasing to see that they've all been able to attain employment in a place where they’ve worked. And certainly for some of them they came here from somewhere else and decided they would like to stay here. So that's a very pleasing factor.
MARION LEIGHTON: It's really good fun to be involved in postgraduate teaching—it's quite different to teaching medical students. You’re honing in on the areas that both of you want to learn more about, and areas that people are willing to learn about and willing to try out new things and be creative. You also stay really up to date; junior doctors will often ask you the challenging questions, "Why exactly are you doing this?" So that makes us reflect and allows us to improve as a team.
I think it's really good practice for the house surgeons and the more junior RMOs to see us nutting out a really tricky problem around a patient and see that things aren't always certain—I think that's very good role modelling. It also develops the profession. Supervision ensures that the next generation are hopefully even better than those of us currently in the role.
CAMILLE MERCEP: The College’s Supervisor Professional Development Program offers online learning, peer-to-peer coaching in supervision, and three face-to-face workshops: Practical Skills for Supervisors, Teaching and Learning in Health Care Settings, and Workplace-Based Learning and Assessment. The Pomegranate website—www.racp.edu.au/pomcast—has links to the program and related topics, including the College’s pathway to help supervisors support trainees in difficulty.
Many thanks to Peter Davoren, Josh Francis, Marion Leighton and Alexandra Greig for appearing on this episode. The views expressed are their own and may not represent those of the Royal Australasian College of Physicians.
Pomegranate comes to you from the College's Learning Support Unit. The program is presented by Camille Mercep, and this episode was produced by Alastair Wilson with editing assistance from Anne Fredrickson. You can explore past programs on our website, in iTunes, or wherever podcasts are distributed. On the next episode of Pomegranate we'll be discussing adult and childhood obesity—what should clinicians be thinking about in 2016?
We hope you can join us.