On this page:

Introduction

Engaging learners

Giving learners feedback

Delivering effective feedback

Assessment

Encouraging learners to observe your practice

Using video observation

Suggested further reading

High-quality clinical supervision is essential in any medical environment. Growing and building a sustainable supervisor system in a teaching practice is dependent on building a cohort of skilled supervisors. In an ideal general practice community of learning, all GPs and registrars are involved in teaching and supervision.

There is a variety of ways in which ML supervision can take place. There is no ‘one size fits all’, and many practices will adapt and change depending on the workforce, practice size and patient demands. It can be exhausting for one supervisor to take responsibility for all learners. Sharing the clinical supervision responsibilities among two or three doctors (at least) can achieve a better balance for learners, supervisors and patients. Sharing supervision across all doctors working in the practice may not be practical, but this model works well for many practices. Involving GP registrars in supervision of medical students can be very successful, because near-peer teaching is generally well received by students. Ultimately, the model of teaching a practice uses will depend on individuals and their desire, skills and confidence.

There are some essential components to effective supervision, regardless of the context or level of teacher. Many clinical supervisors will learn these skills throughout their career through formal skills programs, or informally through role modelling, mentoring or trial and error. Developing the key basic skills of supervision is important for the success of any ML learning environment.

On this page, we discuss some key supervision skills required in the clinical context and provide some tips and simple rules to assist supervisors at all levels. These skills include:

• engagement of the learner;

• giving feedback effectively;

• assessment of learning;

• clinical skills teaching; and

• observation of the learner.

The supervision skills described here can also form a useful teaching session for registrars and junior medical staff involved in student teaching. Ultimately, these skills can be practised and improved throughout the career of all teaching GPs.

Supervision is an active process, centred on the learner’s needs and learning styles. While these vary from learner to learner, it is important to acknowledge that everyone in the practice is an adult learner, be they medical student or experienced GP.

The basic first step in an ML practice is engaging learners. There are certain basic tenets of adult learning that apply to supervision at any level. Adult learning is most successful when:

• There is a high degree of personal motivation or relevance.

• The content is within their capacity to learn.

• The learning experience is meaningful.

• There is active involvement in the learning process (that is, learners are doing rather than watching).

• The learning is experience-centred and the learner can reflect on that experience.

• Clear goals are set.

• Regular feedback is provided.

Engaging medical students

Students want to be involved and active. Even the most enthusiastic student finds sitting in a corner and watching someone else consult to be monotonous. After a few patients, it is hard to remain fully focused. If students know they will be asked to contribute to the consultation in some way, then they will remain focused and present. Learners enjoy doing things and being helpful, even if it is simply getting a piece of equipment or taking the patient’s blood pressure. Students like to contribute to patient care and make a difference.

Students like to be asked for their opinions on issues and expect to be respected for their opinion. Questions that empower students are appreciated, and the learner is usually happy to contribute by looking information up for the supervisor or clarifying latest evidence. Ultimately, students enjoy connecting with patients and forming a therapeutic relationship. The highlight for students is usually when a patient wants to return to see the medical student again in the future. These strategies and other tips are summarised below.

Providing feedback to a learner on their actions or behaviours is critical in the learning process. Giving effective feedback is a key skill for all members of the teaching team. Multi-level learning in a practice will involve learners giving feedback to each other in a variety of different situations.

GP registrars who are involved in supervising medical students and GPs who are not accredited supervisors will need to receive training in this skill. Most accredited GP supervisors receive training as part of their mandated continuing professional development in teaching. Modelling constructive feedback behaviours to other supervisors in the practice is an important responsibility of a principal supervisor.

Challenges in giving feedback

There are numerous reasons that we find it difficult to give feedback. A key issue for supervisors in an ML practice is learners being at different stages of their careers. As a result, expectations about performance of individuals will be quite different. Supervisors need to be familiar with the competency level and assessment requirements for students and GP registrars. Different stages of learning require feedback with a different focus.

Learners have diverse personalities and learning styles—some students are keen to jump in regardless of making mistakes, while other students are more cautious. A shy learner can appear to lack confidence, and supervisors may feel they can’t give specific or direct feedback for fear they will further diminish the student’s confidence.

Often a supervisor may lack confidence, doubting their own ability to pass on knowledge. This is not uncommon in general practice, because students have previously been taught by specialists in the hospital environment. GP supervisors may feel less knowledgeable than their hospital based counterparts. Often students and registrars challenge the evidence base for specific clinical management choices, and the supervisor may be uncertain of the correct answers.

Students who are very concrete in their thinking are often particularly challenged by the uncertain patient presentations that are commonly seen in general practice. It is not uncommon for these students to cope by presenting an arrogant or condescending attitude, which may feel threatening to a GP supervisor. Ultimately, all teachers want to be liked and admired by learners and don’t want to be regarded as negative or unkind. Often supervisors provide poor feedback as a way of avoiding perceived conflict.

No matter what the level of the learner, there are basic principles that can be used to give effective feedback. These are summarised below.

It is useful to have a theoretical framework in mind when supervising students. Listening to the learner and helping them reflect on what they are doing and what they might do differently is a priority in using feedback to promote learning. A theoretical framework facilitates learning and feedback processes.

The learning cycle

A common model used to describe the learning process is the ‘learning cycle’, first described by Kolb (see references). This model describes learning as a series of iterative processes:

• observing;

• reflecting;

• identifying learning; and

• implementing actions that arise from the learning.

In providing the learner with feedback, the teacher assists the learner to progress through the four phases of the learning cycle. When using this theoretical model to teach, the supervisor can: describe an observation to the student; assist the student to reflect on that observation; and identify learning that the student can implement in the future.

Models for delivering feedback

Various theoretical models can be used for giving feedback to learners. It is useful to have one of these models in mind when giving feedback. Different supervisors will have preferences for different styles of interaction, and some will use a combination of styles depending on the situation. Informal feedback is commonly used in general practice. However, informal feedback is usually teacher-centred, often lacks structure, and this style tends to promote one-sided discussion.

Other theoretical models that could be considered by supervisors to provide structured feedback include:

• Pendleton’s rules;

• Effectiveness model; and

• Calgary-Cambridge model.

Pendleton’s rules

The Pendleton’s rules model for feedback can be used for providing feedback after observing the learner conducting a patient consultation. After observing the consultation, the supervisor asks a series of questions of the learner. The questions are designed to guide the learner’s reflection and are followed up with the supervisor’s reflection on what they observed. This model is appropriate for all levels of learner.

Effectiveness model

The Effectiveness model is also appropriate to use after observing a consultation. This model focuses on future strategies based on reflected learning from the current situation. By focusing on effectiveness within the current consultation, the Effectiveness model tends to be less concrete and judgemental. The discussion focuses on what behaviours the learner could continue with, and what behaviour should be reduced. This leads to less discussion about good and bad and more about enhancing performance. The Effectiveness model is quite simple as it requires only two questions posed by the supervisor to facilitate the learner’s reflection.

Calgary-Cambridge model

The Calgary-Cambridge model follows three steps. This model is very useful for students as it can be used to provide feedback on very small or specific skills. The focus of feedback is not on right or wrong, but rather on what was learned from the experience.

Coaching techniques

There is a huge amount of literature within the world of management, leadership and coaching that provides different ways to enhance performance and motivate people to change. In the context of medical training, a variety of coaching techniques could be applied when giving feedback. Experienced learners (for example, more senior registrars) usually value being challenged at a deeper level about their role and behaviour within a consultation and the impact this has on patient care. The aim with many coaching models is to allow the learner to gain deeper personal awareness that will lead to profound change in their practice. This process may also allow them to connect with the deeper meaning of their work.

At the heart of coaching practice is a conversation in which the teacher or coach leads by asking questions that allow the learner to reflect for themselves and explore their own experience. This is similar to the way in which a therapist might use questions within psychotherapy. Ultimately, the coaching process teaches a learner to be self-reflective.

The following is a list of questions that may be helpful to consider using when giving feedback. These questions are particularly helpful when the learner has expressed frustration or strong feelings about a consultation. If the learner has experienced difficult problems or patient encounters, you could The following is a list of questions that may be helpful to consider using when giving feedback. These questions are particularly helpful when the learner has expressed frustration or strong feelings about a consultation. If the learner has experienced difficult problems or patient encounters, you could encourage the learner to take some time to reflect on a few of these questions, then have a follow-up discussion the next day.

The One-Minute Master model

The One-Minute Master model is more concrete and specific than other models. The One-Minute Master model can be used when discussing cases or management plans with a learner when you haven’t observed the consultation.

The 4Ws

The 4Ws model can be used with students when they are observing your consultations. This strategy helps to promote learner engagement in observation. The 4Ws is also an excellent strategy to understand the diagnostic process of GP registrars and junior doctors, particularly when you haven’t observed their consultation.

One of the challenges in supervising learners at different levels is being aware of which skills need to be taught as part of each learner’s curriculum and assessment requirements, and to what level of competency those skills need to be taught. It is sometimes a challenge determining who might be best to teach specific clinical skills to learners.

One of the challenges in supervising learners at different levels is being aware of which skills need to be taught as part of each learner’s curriculum and assessment requirements, and to what level of competency those skills need to be taught. It is sometimes a challenge determining who might be best to teach specific clinical skills to learners.

Often a GP registrar will be able to explain or demonstrate a skill to a junior learner in a more structured and clear manner than an experienced supervisor. This is because GP registrars have recently learned the same task and the experience of breaking the task into a series of steps is still consciously in the registrar’s mind. In contrast, an experienced supervisor is more inclined to practise the skill unconsciously. This is one of the reasons why near-peer teaching of certain skills can be so useful in an ML teaching practice.

Often skills have changed over time, and registrars and students will be able to upskill supervisors on the latest developments. Most supervisors were trained in the days of ‘see one, do one, teach one’ and many of us probably acquired some terrible habits and skills because of this approach. In the current environment of monitoring clinical competency, the four-step approach is a better way to approach skills teaching.

The four-step approach may not be necessary or appropriate in all clinical situations.

If a learner believes they already have a skill, but as the supervisor you want to check the learner is performing the skill correctly, then the fourth step of the four-step approach can be used. Oral description of the skill by the learner helps a supervisor evaluate the learner’s understanding of the principles, risks and pitfalls associated with the skill.

Assessing a learner is an important part of any training and supervision. Assessment is important for several reasons:

• To assess a learner’s knowledge, skill, attitudes or competence level.

• To develop an understanding of learning needs of the individual to inform planning for future learning opportunities.

• To ensure patient safety and quality of care.

Principal supervisors are ultimately responsible for any formal assessment requirements of learners in their practice; however, the whole teaching team may contribute to informal and formative assessment processes. This includes practice nurses, who may observe a learner in the treatment room, and the practice administrative staff, who may receive feedback on learners from patients. In some practices, feedback is formally sought from patients using formal tools (for example, Doctor Interpersonal Skills Questionnaire).

Much of the clinical activity in general practice occurs ‘behind closed doors’ in the consulting room, where the learner may be alone with the patient. However, it remains important, for all the reasons listed above, to ensure the supervisor is able to observe the learner’s clinical activity directly. Observation may take the form of sitting in and directly observing consultations or reviewing videotaped consultations. Conducting random case audits is another method of assessing a learner’s patient management.

Directly observing learners

Learners benefit throughout all stages of their training (from student to registrar) from being observed and provided with feedback about their performance. Learners value having GP supervisors sit in on their consultations. It can be tempting to permit the more senior learners (such as registrars) to get on with patient care, but we all know it is easier to describe how you manage patients than it is to put this into practice. For example, students can tell you that they would assess suicide risk in a depressed patient; however, when it comes to actually assessing risk, the student may have no idea of the questions to ask or how to approach a patient.

The key benefit of observing learners in action is that you get to see what they are really capable of doing. Many learners can identify the gaps in their knowledge and skills. More commonly, learners are unaware of areas of incompetence or deficient knowledge because they haven’t yet experienced or contemplated the area. The only way to tell if learners are listening to patients properly and picking up cues is to observe the learner in a consultation. Being observed while one takes a history and manages a patient is great practice for student or Fellowship exams and helps learners to manage their performance anxiety.

From a practice management perspective, your learner is actually seeing patients while you are teaching them through observation and feedback, therefore conducting supervision and teaching does not compromise patient care. The following table shows some strategies for successfully observing a learner.

There are common issues that arise in consultations that can be discussed with learners, as listed in the table below.

It is useful to have a structure in place when medical students or GP registrars are observing your practice. As a supervisor, your learners will at times be sitting in on your consultations and watching how you interact with and manage patients. Some suggestions are provided below for promoting constructive observation sessions.

Video is a great way for learners at all levels to observe themselves in action. Video also provides an opportunity for supervisors to see their learners ‘behind closed doors’. Using video consultations can be a useful and time-effective means of observing learners, particularly when supervising several GP registrars. Learners are often hesitant to record their consultations because they are concerned it will interfere with patient interaction. Many learners feel embarrassed when watching themselves later. However, video is a very useful tool for exam preparation. If videotaping of consultations is a normal part of your practice, it can be good to do video debriefing with multiple learners.

Most universities and training organisations will have template marking sheets for supervisors to complete or to use as a guide when doing video reviewing. Practices may want to get formal written consent from patients for this process. Current issues around privacy and confidentiality mean that consent is crucial for any videotaping of consultations. There is a template in the Appendix resources section that can be used as a guide to develop a document that suits individual practices. It is important to check that it is consistent with the practice policies and procedures related to privacy and information storage

Benefits of video observation

A key benefit of using video observation is the opportunity to watch the video together rather than describing the consultation later. Your own relationship with the patient does not intrude into the consultation. When watching the video, you can pause and focus on specific points in the consultation, if required.

Video observation is the only way in which learners get to see and hear how they interact in a consultation. It is often the best way for a student or registrar to gain insight into how their communication skills are perceived by patients and others. Watching a video of a consultation is an opportunity to focus on body language of both the patient and the learner and consider its impact. Watching the video without sound for a short period of time can be a very powerful way to reflect on the doctor–patient interaction.

Challenges of video observation

Video observation can be very threatening as we all are very self-critical, especially when we watch ourselves on a screen. It can be difficult to convince a resistant learner to videotape consultations. It is very important to normalise how uncomfortable most people feel about self-video; however, it gets easier as the learner becomes more familiar with the process.

As a supervisor, record one of your own consultations and present it to your learners while requesting feedback. Let the learners see how you respond to watching yourself on the screen. Show them what you have learned from watching the video and formulate the process for the learners. They will learn a lot by watching your consultation.

Sometimes it helps to encourage the learner to record and watch a few of their own consultations before they bring a video consultation to a feedback session. Allowing the learner to become familiar with the discomfort of watching oneself on screen and to experience the value of watching themselves consult can increase their comfort with receiving external feedback on a video consultation.

Occasionally, a patient may have insufficient trust to consent to being recorded, particularly if the learner has little insight or poor rapport with patients. In this situation, we suggest you video ‘role plays’ with yourself or other learners acting as the patient.

Pendleton D, Schofield T, Tate P & Havelock P. The Consultation: An approach to learning and teaching. Oxford: Oxford University Press Inc, 1994.

This is a classic text for teaching consultation skills to any level of learner

References for Enhanced Supervision Skills for Multi-Level Learning