Secrets of supervision – a trainee's perspective

According to the Royal College of Psychiatrists, all psychiatrists in training should receive weekly supervision from their ‘educational supervisor’ - usually their supervising consultant. College policy dictates that the educational supervisor spends a ‘protected hour per week’ with the trainee (Royal College of Psychiatrists, 1999). Cottrell (1999) has suggested that good supervision should encapsulate the following topics: clinical management, teaching and research, management and pastoral care.

Having recently obtained my Membership and having been a senior house officer (SHO) in psychiatry for almost 3 years, I think that I have finally come to realise the roles and expectations of supervision. Prior to studying medicine, I worked as a clinical research associate in the pharmaceutical industry. The money was good, I had a smart company car and travelled the world managing and coordinating clinical trials. I would talk to my manager informally when the need arose. No formal supervision was given, except for my annual appraisal when there was the opportunity for formal feedback that would later be documented. However, because of the frequent informal chats with my boss, appraisal inevitably went well. I was receiving excellent supervision, but it was not formally timetabled. On reflection, I would talk informally to my manager for at least an hour a week, but this would often be broken down into smaller conversations of 10 minutes or so. Issues fresh in my mind could be dealt with quickly without having to wait for my allocated time.

My first supervision session as a doctor was with a locum consultant working on a busy inner-city acute general adult psychiatric ward. This was my first psychiatric post, having just moved on from a job in general medicine. After 3 days, I had my first session. I remember being asked what I would like from my allocated hour and stating having never experienced supervision before, I would appreciate a little guidance - and that is what I got - a little! At the time, I did not realise that supervision was a relatively new concept and that my consultant was unlikely to be supervised, never mind being trained in giving supervision himself. He did tell me that supervision is somewhat like psychotherapy, but as I was not quite sure what psychotherapy was at the time, I still remained in the dark waiting to be enlightened. I can remember him saying, however, that we would meet at the same time and the same place, and sessions would last for the allocated hour. I cannot remember setting an agenda for my objectives while in the post and how these would be met. Four supervision sessions later, we went out to the pub and that evening all the components of supervision were covered. Outside the hospital one was able to relax and although the alcohol may have caused mild abreaction, the working relationship between my consultant and I was cemented. Thereafter, supervision continued without the same feeling of formality, for me making the whole process more productive and, dare I say it, enjoyable.

One of the major drawbacks of being an SHO is moving to a different job every 6 months. At the start of each new post, one has to form a working relationship with the supervising consultant. For supervision to be effective, mutual trust is required and this takes time. For me this usually takes about 3 months and by the time trust is established and I feel at ease to talk freely in supervision, I leave. Therefore, one needs to break down the formal boundaries as soon as possible.

So what would I recommend to a psychiatric SHO about to embark on their supervision career?

At the initial meeting, take control - supervision is for the benefit of the trainee. The consultant has educational responsibilities towards his/her trainee, but benefits by having a trainee as part of the clinical team. Remember to plan not only for short-term goals (e.g. 3 and 6 months), but also medium (e.g. Part I, 12 months) and long-term goals (e.g. Part II, Specialist Registrar training, 18-24 months). Make the goals ‘SMART’ (specific, manageable, achievable, realistic and time-limited). However, be flexible and your supervision plan can always be revised both at the end and at the beginning of new attachments. Plan setting realistic objectives, how to obtain them and how to measure them. Also write them down, ensuring that your supervising consultant has a copy. Remember, failing to plan is planning to fail.

Short-term objectives could include learning about the speciality. For example, while working in a forensic post, I selected chapters from Seminars in Practical Forensic Psychiatry (Chiswick & Cope, 1995), which both my consultant and I would peruse prior to discussing the educational issues in supervision. For the junior SHO, history-taking, mental state examination, psycho-pathology, prescribing, etc. may be explored. Also explore topics that are explained less well in the textbooks, such as certain aspects of psychopathology (e.g. pseudo-hallucinations) and diagnostic issues (e.g. alcoholic hallucinosis - do they exist?) Other more diverse subjects covered have been how to get the most useful information from pharmaceutical representatives, negotiating with personnel and even how to buy a house.

Medium-term goals could include how best to prepare for the Part I exam, perhaps including practice of multiple choice questions (MCQs) with your consultant. Don't worry about showing your lack of knowledge, as this is usually a learning experience for both individuals. I remember one consultant booting up the hard drive of his PC to get me to try some neuroanatomy MCQs while he looked over my shoulder disagreeing with many of my replies. This was my first supervision session with him, and I remember becoming increasingly anxious as this was my only opportunity to make my ‘first impression’. Fortunately, his neuroanatomy was a little rusty (or at least his temporal lobe was) and often he would disagree and I would press the space bar to find that I had made the right selection. This was certainly a different way to start supervision, but it broke the ice, making supervision an informal and enjoyable experience.

Long-term goals to consider would be tips on passing the Part II exam. Practise presenting clinical cases and also work on patient management problems. Career guidance is another important issue. Don't be afraid to ask your consultant questions such as: ‘What's the secret of your success?’ ‘How do you learn?’ ‘How do you manage your time and/or priorities?’ and even ‘How do you make your money?’ They have managed to pass the hurdle of College exams and to obtain a consultant post - their experience is therefore invaluable.

It is crucial to be on time for your supervision session. The hour is for your own professional development. Your consultant should also be on time and if time keeping is a problem, then time-management skills should be on the supervision agenda. Like good psychotherapy practice, supervision should start and finish on time with a clear agenda at the beginning of each session and an action list for the forthcoming session (Herriott et al, 1994). Supervision is like everything else in life - first build a good foundation, but remember to allow for some flexibility and above all, make it fun.