For centuries, medical professionals have enjoyed the privilege of practising the art-science of healing, and patients who seek treatment expect a competent level of care. Professional accountability necessitates a system of quality control that ensures that appropriate professional standards are maintained.
Professional supervision
According to the 2016 edition of the Singapore Medical Council (SMC) Ethical Code and Ethical Guidelines (ECEG), "Teaching, supervising and mentoring junior doctors and other healthcare professionals are an integral part of professional life and form part of our professional obligation to improve the care of patients in the community."1
Much like Chinese kung fu, the teaching of medicine has historically followed the "master-apprentice" model, where the expert of the art formally assumes the role of moulding a novice through role modelling, mentorship and support, imparting knowledge and skill, and closely scrutinising the novice's progress before teaching skills at the next level. Too rapid a progression from one stage to the next may result in setbacks that could incapacitate the novice.
In professional supervision, the parallel to this would be "…the formal provision, by approved supervisors, of an intensive relationship-based education and training that is work-focused and which manages, supports, develops and evaluates the work of colleague(s)".2 This addresses functions of quality control, maintaining and facilitating the supervisee's competence and capability, and helping supervisees work effectively within a safe and supportive environment. Such an environment enables reflective critical analysis of the supervisee's performance. In addition, while supervision is often linked to the training of budding practitioners, the rehabilitation of impaired senior practitioners is another aspect that is under-recognised.2
Professional standards
Established by a body of expert practitioners, professional standards attempt to set the desired "minimum" level of competence that will be expected of one who practises medicine. In Singapore, these experts are represented by the various colleges that constitute the Academy of Medicine, Singapore, supported by their respective Residency Advisory Committees and the Joint Committee on Specialist Training. They assist the SMC and the Specialists Accreditation Board of the Ministry of Health to determine professional standards required of doctors for licencing. In legal cases alleging negligence, the professional standard is set by reasonable and responsible peers (ie, the Bolam standard).
Standards are continuously evolving, driven by new technology and quality improvement. These benchmarks may be used as a tool to evaluate clinical proficiency and safety of practice. They also ensure that medical practitioners are accountable for clinical decisions and actions, and maintain competence during their careers.
Setting clear objectives
The aims for supervision include improving competency, recognition of boundaries and limitations of skill, communication skills, workload management, commitment to professional improvement, as well as development of self-awareness and self-esteem. Accreditation bodies need to list a clear set of objectives expected of a training system. The bar needs to be set appropriately to the level of expertise desired. The entrustable professional activities programme has also been implemented in some systems.
Competent supervisors
According to the 2016 SMC ECEG, "if you teach or supervise other doctors or healthcare professionals… you must ensure that you are able to do so competently, diligently and responsibly."1
Competence as a supervisor may not come automatically with seniority. The best practitioners of a field may not necessarily be the best teachers. Recognising this, there are courses that focus on the different aspects of teaching and supervision. These courses range from understanding the residents' needs and developing assessment tools, to objectively giving feedback. The excellent supervisor is one who regularly improves one's own abilities to better reach out to the supervisee.
Feedback and reflection
It is important for timely feedback from the supervisor so that the trainee is made aware of his/her strengths and weaknesses. Given the pace of practice and heavy clinical load, this awareness may fade away before it can be used constructively. Time for reflecting on the evaluation given to the supervisee and revisiting the key points together with the supervisor is necessary.
Well-being of the supervisee
Medical practice and training are fast-paced and highly stressful activities, with increasing reports of physician burnout globally. With mental health becoming an increasing concern among healthcare professionals, clinical supervision should incorporate, as part of a holistic programme, emotional support for issues arising from working in a stressful professional environment.
Balance of risks to patient
The supervisor must constantly weigh the benefits of training against the risks to patient safety and comfort. The supervisor frequently walks a tightrope; to enable trainees to achieve a level of competence commensurate with th eir future roles as primary clinicians, and to ensure that clinical procedures are performed safely and comfortably.
When flying a kite, the control of the string tension has to be calibrated according to the circumstances. Similarly, the supervisor needs to determine: (1) whether the junior is suitably competent to attempt the task, or if they should remain an observer until they have demonstrated adequate understanding of the task; (2) the appropriateness of the situation for hands-on training (some patients may be uncomfortable with a trainer talking a junior through a procedure when the patient is conscious); and (3) the learning style of each trainee. Remote supervision may be acceptable under some situations, provided that the supervisor is able to render timely assistance when problems arise or if the complexity of the case should unexpectedly increase beyond the competence of the supervisee.
Scheduled supervisor reviews
A suitable supervision review schedule is important for the optimal effectiveness of the system. Routine periodic reviews highlight issues before they become problematic, give the supervisee timely feedback necessary for development, and assure that necessary changes will be implemented in a timely fashion.
Formal appraisals and references
Supervisors should be required to comment on the level of competence of their supervisees. These should be objective, fair, honest, justifiable and accurate assessments with respect to trainees' competence, performance and conduct. Feedback from other colleagues should be obtained as necessary.
Culture change
A "blame culture", where the emphasis is on punitive correction, can result in the loss of many learning opportunities.3 The concept of a "just culture" is gaining acceptance; this is where the emphasis is placed both on the learning from mistakes and on implementing corrective measures instead of identifying who was wrong.
In conclusion
Supervision is an essential part of medicine and understanding the fundamentals enables the training of future talent. The experienced master, through active role-modelling, mentoring and teaching, takes on the responsibility of ensuring the apprentice achieves the desired and attainable level of performance before embarking on independent practice.