Critical importance of effective supervision in postgraduate medical education

In this issue of the Journal, Hore and colleagues discuss clinical supervision in postgraduate medical education.1 They identify multiple difficulties and signal the need for adequate training and supervision, and for environments that support such supervision.

Previous articles have discussed the concepts of clinical supervision and educational supervision. There are a number of definitions of supervision; a useful one is “the provision of guidance and feedback on matters of personal, professional and educational development in the context of the trainee’s experience and providing safe and appropriate patient care”.2 This definition links provision of care with personal, professional and educational enrichment. It is further underpinned by the notion of provision of guidance and feedback. Supervision can be considered to have at least three discrete functions: educational, supportive, and managerial or administrative. Supervision should be regular, structured and should relate to agreed-upon learning objectives.3

There is evidence from the Netherlands and the United States that training in teaching skills results in positive changes in the teaching and supervisory behaviour of medical doctors.4,5 Additionally, when provided effectively, supervision not only improves trainees’ performance, but also improves patient outcomes.4,5

Health authorities are increasingly recognising that support of education and supervision may lead to better health outcomes. Indeed, closer to home, the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals (the Garling inquiry) identified a number of issues in the New South Wales health service;6 for example, Recommendation 30:

The educational supervisor has been considered the most critical figure in ensuring the effectiveness of postgraduate medical training.7 Appropriate supervision demonstrates evidence of commitment by educational supervisors to trainees. Critical elements of effective supervision include: providing constructive feedback; offering career advice; helping set learning objectives; listening rather than talking; taking into account trainees’ individual needs; and being encouraging. This type of supervision leads to improved professional development among trainees.8

Hore and colleagues’ article clearly shows that the Achilles heel of supervision is the environment within Australian hospitals in which supervision is delivered. They argue for the creation of systems, environments and cultures that support high standards of conduct and effective clinical supervision.1

The Royal Australasian College of Physicians, which trains the largest number of trainees in Australian hospitals, has recently developed a new basic training program called the PREP (Physician Readiness for Expert Practice) Program. The core aspect of this program is effective educational supervision provided by consultants to help trainees construct learning goals, reflect on their learning needs, work with their developing medical professionalism, and closely link their learning experience with the curricula objectives for training. This grand design has a fundamental flaw — it requires extensive supervision in the health sector. Currently, the health sector is struggling to provide the human and financial resources required for effective supervision.

Given the evidence that effective supervision not only develops the medical professionalism of a trainee, but can also lead to improved safety and better health outcomes for patients, it would seem clear that the provision of adequate supervision for our trainees is a high priority for our health system. Several comments and recommendations in the Garling report support this, such as:

There are multiple demands on our health service. Attending the sick does take priority. However, an examination of the literature around how we prepare and train our doctors during their training programs quickly demonstrates that the provision of good supervision to these trainees yields multiple benefits in that they are better equipped for the work they do, and this will be reaped many times over during that individual’s professional life. There is a need to systematically address the issues of good supervision for our trainees, with a particular emphasis on supporting them educationally and professionally.