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
Collaborative
teaching
“I saw the
level of his
complete
engagement
with the
patient, how
he turned
from me and
back into the
presence of
the patient”
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



Reflect



Identify initial needs
Establish ground rules
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 metareflection 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 cases
Supervising 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
practice
on the run is a collaborative