Janet Grant

AMEE guide no. 27: effective educational and clinical supervision.

Background: This guide reviews what is known about educational and clinical supervision practice through a literature review and a questionnaire survey. It identifies the need for a definition and for explicit guidelines on supervision. There is strong evidence that, whilst supervision is considered to be both important and effective, practice is highly variable. In some cases, there is inadequate coverage and frequency of supervision activities. There is particular concern about lack of supervision for emergency and ‘out of hours work’, failure to formally address under-performance, lack of commitment to supervision and finding sufficient time for supervision. There is a need for an effective system to address both poor performance and inadequate supervision. Supervision is defined, in this guide as: ‘The provision of guidance and feedback on matters of personal, professional and educational development in the context of a trainees experience of providing safe and appropriate patient care.’ A framework for effective supervision is provided: (1) Effective supervision should be offered in context; supervisors must be aware of local postgraduate training bodies’ and institutions’ requirements; (2) Direct supervision with trainee and supervisor working together and observing each other positively affects patient outcome and trainee development; (3) Constructive feedback is essential and should be frequent; (4) Supervision should be structured and there should be regular timetabled meetings. The content of supervision meetings should be agreed and learning objectives determined at the beginning of the supervisory relationship. Supervision contracts can be useful tools and should include detail regarding frequency, duration and content of supervision; appraisal and assessment; learning objectives and any specific requirements; (5) Supervision should include clinical management; teaching and research; management and administration; pastoral care; interpersonal skills; personal development; reflection; (6) The quality of the supervisory relationship strongly affects the effectiveness of supervision. Specific aspects include continuity over time in the supervisory relationship, that the supervisees control the product of supervision (there is some suggestion that supervision is only effective when this is the case) and that there is some reflection by both participants. The relationship is partly influenced by the supervisors commitment to teaching as well as both the attitudes and commitment of supervisor and trainee; (7) Training for supervisors needs to include some of the following: understanding teaching; assessment; counselling skills; appraisal; feedback; careers advice; interpersonal skills. Supervisors (and trainees) need to understand that: (1) helpful supervisory behaviours include giving direct guidance on clinical work, linking theory and practice, engaging in joint problem-solving and offering feedback, reassurance and providing role models; (2) ineffective supervisory behaviours include rigidity; low empathy; failure to offer support; failure to follow supervisees’ concerns; not teaching; being indirect and intolerant and emphasizing evaluation and negative aspects; (3) in addition to supervisory skills, effective supervisors need to have good interpersonal skills, good teaching skills and be clinically competent and knowledgeable.

Learning needs assessment: assessing the need

Learning needs assessment is a crucial stage in the educational process that leads to changes in practice, and has become part of government policy for continuing professional development. Learning needs assessment can be undertaken for many reasons, so its purpose should be defined and should determine the method used and the use made of findings. Exclusive reliance on formal needs assessment could render education an instrumental and narrow process rather than a creative, professional one. Different learning methods tend to suit different doctors and different identified learning needs. Doctors already use a wide range of formal and informal ways of identifying their own learning needs as part of their ordinary practice. These should be the starting point in designing formalised educational systems for professional improvement.

BEME Guide No. 1: Best Evidence Medical Education

There is a need to move from opinion-based education to evidence-based education. Best evidence medical education (BEME) is the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. It involves a professional judgement by the teacher about his/her teaching taking into account a number of factors-the QUESTS dimensions. The Quality of the research evidence available-how reliable is the evidence? the Utility of the evidence-can the methods be transferred and adopted without modification, the Extent of the evidence, the Strength of the evidence, the Target or outcomes measured-how valid is the evidence? and the Setting or context-how relevant is the evidence? The evidence available can be graded on each of the six dimensions. In the ideal situation the evidence is high on all six dimensions, but this is rarely found. Usually the evidence may be good in some respects, but poor in others.The teacher has to balance the different dimensions and come to a decision on a course of action based on his or her professional judgement.The QUESTS dimensions highlight a number of tensions with regard to the evidence in medical education: quality vs. relevance; quality vs. validity; and utility vs. the setting or context. The different dimensions reflect the nature of research and innovation. Best Evidence Medical Education encourages a culture or ethos in which decision making takes place in this context.

Best Evidence Medical Education

There is a need to move from opinion-based education to evidence-based education. Best Evidence Medical Education (BEME) is the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. It involves a professional judgement by the teacher about their teaching taking into account a number of factors — the QUESTS dimensions. The Quality of the research evidence available — how reliable is the evidence?, the Utility of the evidence — can the methods be transferred and adopted without modification?, the Extent of the evidence, theStrength of the evidence, the Target or outcomes measured — how valid is the evidence? and the Setting or context — how relevant is the evidence?The evidence available can be graded on each of the six dimensions. In the ideal situation the evidence is high on all six dimensions, but this is rarely found. Usually the evidence may be good in some respects, but poor in others. The teacher has to balance the different dimensions and come to a decision on a course of action based on his or her professional judgement.The QUESTS dimensions highlight a number of tensions with regard to the evidence in medical education:quality v relevance; quality v validity; and utility v the setting or context. The different dimensions reflect the nature of research and innovation. Best Evidence Medical Education encourages a culture or ethos in which decision making takes place in this context.

The structure of memorized knowledge in students and clinicians: an explanation for diagnostic expertise.

Summary. This paper provides for the first time evidence of a consistent difference in the memory structures of novice and expert clinicians. The diagnostic performance of first‐ and third‐year clinical medical students, senior house officers, registrars and consultants on four clinical problems in general medicine was studied. Comparisons were made of all diagnostic interpretations offered and the forceful features (personally important pieces of information which act as a key to particular memory structures which in turn give rise to the clinical interpretation) from which these were derived. Results demonstrate that the numbers of interpretations made and the numbers of forceful features identified did not differ significantly between groups (P>0.05). However, the actual interpretations made in three out of four cases, and the actual forceful features identified in all cases, did differ significantly between groups (P<0.05) The numbers of interpretations made by all groups were large and demonstrated enormous variability. Highly individualized multiple responses to clinical information are associated with easy diagnoses. We conclude that there is no difference between groups of differing clinical experience in the breadth of thought but that there are marked differences in the precise content and structure of thought. This allows coherent explanation of variation in diagnostic expertise with clinical experience. The significance of the findings is discussed.

What is effective supervision and how does it happen? A critical incident study

Objectives  To identify the key features of supervision from the perspectives of educational supervisors and specialist registrars.

The Incapacitating Effects of Competence: A Critique

IntroductionToday we are talking about competence-based approaches to education and train-ing. Two or three years ago, it would have been audit or, on the other side ofthe Atlantic, the impact of Health Maintenance Organizations on education. Morerecently, the debate has raged about the relevance of evidence-based medicine.Ten years ago, we might all have been extolling the management of education byobjectives. For years, we have watched the exponents of problem-based learningvery successfully setting out their pitch. We have believed in horizontal integration,vertical integration, adult learning principles, small groups, authentic assessment,....who knows? Some of us might even be prepared to defend lectures and rotelearning. Which one of us has not made up for the child-centred education ourchildren receive by making them chant tables in the car on the way to school?So, what are we to make of this history of changing educational fashion andpractice? Does the truth change so frequently? Does educational research move sofast? Does the problem change so quickly that we constantly need to find new solu-tions? Probably not. Are we seeking the holy grail of education, unable to convinceourselves that there really is not one? Possibly. But there are other explanationstoo for our constant hurtle through a Kafka-esque landscape of metamorphosingeducational entities which we grasp and believe in until they shrink back into theshadows and become memories of another beautiful outfit that the Emperor wore.And here we are. This month’s panacea is competence-based education [if thatis not a contradiction in terms]. And I am here to represent the anti-panacea schoolof educational development. I am also here to represent the profession of medicine– because someone has to defend it against imported and inappropriate ways ofthinking that are quite possibly threatening to the profession itself, and strangely,often the worst enemy of the profession is the professionals themselves.If it is any compensation, most other professions are being attacked by the samedisorder. Law, social work, education – all are displaying signs of narrowing to sets

Primary knowledge, medical education and consultant expertise.

Summary. We have studied the knowledge of students and clinicians that they actually used to follow up four problems in general medicine. Some unexpected similarities and differences in their readily accessible or primary knowledge were found in groups from first‐year clinical medical students to consultants. There is no linear increase in the quantity of primary knowledge with experience, but qualitative changes are very much more important. At all levels individuals show a remarkable dissimilarity in the knowledge they use to solve clinical problems, so that the bulk of personal knowledge used is individual. Comparatively rarely do people use the same knowledge to solve any one clinical problem. However, there is evidence of a general tendency towards increasing uniformity in knowledge as a result of the medical school years. After houseman level, individuality increases again. These changes result in consultants achieving an identical profile to first‐year clinical medical students in terms of the extent to which their primary knowledge bases are held individually or in common. These findings suggest that consultant expertise is actually based on individual experience rather than a common core of knowledge. The influence of medical school in providing such a common knowledge base is (1) limited and (2) reversed by clinical practice. The results suggest the necessity for increased vocational and practice‐oriented components in medical education, particularly in postgraduate education.

Clinical supervision of SpRs: where does it happen, when does it happen and is it effective?

Objectives  To establish what supervisory methods are used in postgraduate medical education and to determine how effective, particularly in relation to patient care, these methods are perceived to be.

Surgical training: the impact of changes in curriculum and experience.

INTRODUCTION Craft specialties, such as surgery, rely on practice to acquire skill. Yet recent changes in training in the United Kingdom have decreased experience and altered the balance of curriculum content. Most recently, the European Working Time Directive has led to a reduction in working hours and expansion in the number of trainees. The impact that these changes have had on operative experience, patient management, communication, and teaching skills is unclear. This study aims to assess the effects of the changing curriculum and work patterns on the experience of trainees at senior house officer (SHO, equivalent to junior resident) level in general surgery. METHODS A structured questionnaire was sent to general surgery trainees at the SHO (n = 52) and specialist registrar (SpR, n = 69) levels (equivalent to senior resident) in the Severn Deanery, United Kingdom. RESULTS In all, 70% of both SHOs and SpRs responded. SpRs had spent a mean of 50 months (21 months in general surgery) at the SHO level, compared with 24 months (9 months in general surgery) for current SHOs. A total of 90% of SpRs could perform an open appendectomy unsupervised by the end of their SHO training, compared with 28% of current SHOs. In all, 63% of SpRs and 8% of SHOs could undertake inguinal hernia repair unsupervised at SHO level. In addition, 90% of SpRs and 84% of SHOs felt operative skills have declined, whereas communication and teaching skills were deemed the same or better. Of the respondents, 88% of SpRs and 76% of SHOs thought surgical training was getting worse. DISCUSSION Trainees are spending less time in surgery at the SHO level, and this is reflected in reported operative ability. The introduction of communication and teaching skills into the curriculum has had a perceived benefit. The reduction in working hours must be offset by implementing measures to maximize limited training opportunities. The potential implications of these changes in training and experience on patient outcomes remain to be determined.