Supervision and the culture of general practice

Abstract

Supervision is a well-known and well-theorised activity in some professions where experienced practitioners contract to facilitate, guide or educate the novice. Supervision is uncommon in medicine, which has traditionally employed more didactic teaching processes. In the general practice community in New Zealand, practitioners use a variety of methods of professional maintenance, with educative mentoring or supervision being a recent innovation. In this form of supervision, general practitioners (GPs) discuss their work with an experienced supervisor, with one focus being to learn counselling or psychotherapy skills.

This study examined the experiences of GPs who use supervision, with particular reference to how supervision impacts on their practice of medicine. The context for this inquiry included the background philosophical assumptions of the biomedical paradigm, current problems in clinical practice and the culture of general practice in New Zealand.

The research used a qualitative methodology, with seven GP respondents being interviewed at length about their use of supervision. A focus group with four of the participants followed initial analysis of the individual interviews. Interviews and group discussion were analysed within a social constructivist paradigm.

The respondents' stories of learning about supervision led to the construction of a collective story. This could be outlined under the four broad themes of dissonance and exploration, self-awareness and professional development, the supervised practice, and defining supervision in general practice.

However, before these GPs could make effective use of supervision, they needed to work through a number of personal and cultural barriers. The findings of the research suggest that supervision is a powerful method of learning, being an embodied experience through the supervisor-doctor relationship. Some of these GPs used their supervisor to learn how to do psychotherapy in general practice. The supervisor also acted as sounding board for all the respondents to discuss other work issues, such as practice management and peer relationships. One outcome of regular supervision was validation about their work, contributing to a heightened sense of self in the work environment. Supervision facilitated a model of reflective learning that is relatively uncommon in medicine. This was achieved through rigorous attention to self-awareness, resulting in facilitated career development.

In a supervised practice, the GP incorporates an increasing acuity for patients' psychological problems. There is an emphasis on the doctor-patient relationship, with awareness of the roles and boundaries around the GP’s work.

Supervision was seen to be different to work in peer-groups or in personal psychotherapy, but there were similarities. The role of the supervisor was defined to include sub-roles of teacher, facilitator, analyst and evaluator. In this study there was invariably no form of summative evaluation. The results led to a definition of supervision in general practice.

Studying these successful supervisor-doctor relationships gave unique insights into the barriers that prevent further utilisation of supervision or other forms of mentoring in general practice. These barriers include broad issues of the traditional epistemological assumptions of modern medicine. Having supervision appeared to have a major impact on the style of medical practice that is exhibited by these GPs. There are implications of these findings for both undergraduate and postgraduate medical education.

This research was grounded in a social constructivist paradigm that linked theory, research and clinical practice. From the evidence presented here, these practitioners have incorporated biomedicine into a wider medical model that offers a resolution to the current paradigmatic crisis of modern medicine.