Best practice for trainers and trainees
Early interactions can leave a lasting impact on a medical career. So what makes a good supervisor?
Trainers and trainees must work together
Many doctors will tell you that their years as a trainee were the best of their medical careers. A time when new skills, knowledge and techniques are learnt on a near daily basis. Enthusiasm is at its peak. A time when frequent mistakes will be made, but important lessons learnt. The opportunity to cut one’s teeth in preparation for the years of consultant life that lie ahead. These years do of course come with their challenges. Trainees are often thrust into an environment littered with unfamiliar equipment, new jargon and clinical uncertainty; there are the inevitable surgical mistakes and errors in clinical judgement. Not to mention the stresses and strains of frequent upheaval and the impact of busy work schedules on family and social life.
Trainees are not alone in this process though, they are surrounded by trainers, supervisors and mentors. Most trainees will tell you of their experiences of the good, the bad and the ugly of supervision, but what is it that makes a good supervisor?
“The most crucial time I spend with a new trainee is the first hour, if you get it right, this is the ticket to a successful relationship.” The words of a vastly experienced colleague. He explains to me that when meeting trainees for the first time, rather than dredging through the monotonous formalities of supervisor forms and reviewing surgical logbooks, he turns his computer off and simply says “so tell me about you”. His reasoning, as he explains, seems sound. He wants to know “what makes them tick”; where do they live, how do they get to work, where do their partners live, do they have kids, how was their last job (off the record) and everything else in-between.
By seeing a trainee as a person with a whole life that exists beyond the workplace supervisors may be better placed to anticipate problems and understand issues along the way.
“You are taught for many years how to be a good clinician; you don’t get five minutes being told how to be a supervisor.” The skills needed to succeed in supervision are not necessarily formally taught and may not come naturally to some. Trainers, like trainees, will make mistakes, but this is part of the process. Supervisors I’ve spoken to have advocated talking to their colleagues, conducting regular appraisal, taking feedback from trainees and even formal courses to help prepare for, and develop, in this role.
I would not say I see a clear correlation between those whom I consider to be excellent clinicians and surgeons and those who I consider to be excellent supervisors. I have met many good surgeons who seem incapable of explaining how they do what they do or understanding why others are unable to grasp it. Talented? No doubt. Great supervisors and educators? Not so much.
So, what makes great supervisors different? Is it that good supervisors are just more self-aware and able to identify their strengths as well as their deficiencies? Possibly. To recognise that one does not necessarily possess all of the knowledge, skills and expertise required to meet the needs of a trainee at all times is a true skill indeed. It is admittedly more subtle and hidden than the surgical skills needed to perfectly suture a corneal graft, but it is certainly no less of a skill to have. “I’m not sure how to help” is relatively easy to say, but to follow this with “but I’ll find someone who does” is a necessary trait for good supervision.
It is of course reasonable to not know all the answers; sometimes being a sounding board is all that is needed. It may indeed at times be best not to tell trainees all the answers you know. Knowing when to stimulate discussion, play the devil’s advocate, and construct and develop thoughts and plans together plays a key role in developing trainees.
A colleague quite openly talks about her struggles through medical training. As she openly explains to her trainees, it’s okay to be vulnerable, and it’s okay not to cope at times. By sharing her own experiences and being open about her own vulnerabilities she says she hopes this allows her trainees to start a conversation about their own concerns and issues early before problems spill over. I suspect many of us would find it hard to be so open and honest, but the potential benefits for both parties are clear to see.
What is required of a trainer may well change over time. Speaking to colleagues regarding the early years of training the character traits that were most admired were of someone who exuded confidence and provided calming reassurance. It is easy to understand why when, as one colleague put it, “I was petrified every time I went to work that I was going to blind someone”. To watch a tentative, quivering, cack-handed junior take a blade to the eye of a patient and not show your anxiety must take a whole new level of confidence and calm indeed.
Trainees towards the end of their training no longer yearned for a calming presence beside them; they instead appear to look to their supervisors increasingly for mentorship, as a role model and to help guide them through the transition between trainee and consultant.
So how can trainers be all things to all men? Is there a one-size-fits-all? Probably not. All trainees have their preference, a supervision style that some may find empowering, exhilarating and the freedom to push the limits their competence, may make others uncomfortable, nervous and resistant. As supervisors, just as with our patients, we must explore the ideas, concerns and expectations of trainees to facilitate tailored, bespoke and targeted supervision to maximise the trainee experience.
The little things
Good supervision isn’t all about tackling the big career events or the difficult conversations. Like in many walks of life, sometimes it’s the little things that count and this may well be a good starting point for anyone embarking in their role as a supervisor.
Good supervision can be as simple as encouraging a trainee to have a regular cup of coffee. After all, as we all know, a thirsty and caffeine-depleted surgeon is not a pretty sight. Remind them to take a lunch break. Show them where to put their coat on the first day. Introduce them to the friendliest and most welcoming of the clinic nurses, and warn them who the grumpy ones are – “it’s not just you, he’s like that with everyone”. Simple things, but collectively hugely powerful.
A trainee who feels comfortable in their environment will be more willing to ask questions, positively contribute to departmental development, flag up safety issues and reflect back a positive and supportive demeanour. Ultimately, all of which will improve patient experience and safety, which is always our primary objective.
The supervisors who did not volunteer for their role can sometimes be painstakingly obvious to those unfortunate souls that are assigned to them. Rushed meetings at the end of clinical, slow or non-existent email replies. It is important that healthcare organisations engage with clinicians to improve participation in supervision through education and training. A poorly prepared and reluctant supervisor will only breed unhappiness for both trainees and themselves alike, which is of no benefit to anyone.
Some clinicians and supervisors do feel trainees are too protected, mollycoddled and hence too cautious and lacking sufficient exposure. Phrases like “it’s not like it was when I was a registrar” can on occasion be heard rattling around the consultant office corridor. Things have certainly changed in medical education and training over the past few decades, and on a whole, many would say for the better. But is there value in a hands-off, sink-or-swim approach? Or is this ‘freedom’ merely providing trainees with just enough rope to hang themselves? Speaking to colleagues there were some who did indeed like the challenge of being “dropped in at the deep end”, but it’s fair to say there were many who did not. On the whole though, it seems that the advocates of “the best supervision is less supervision” approach are probably going the way of the dinosaurs.
Trainees – The Ugly?
Supervisors are only half of the equation. The trainee is key to the whole process. So, what makes a good trainee? What do supervisors expect? Speaking to my supervisors, the message is clear. They want ‘trainable trainees’. Someone who does the basic things right and has a positive attitude. Reliable, hardworking, willing to learn and a self-awareness of their limitations are phrases I heard time and again.
There is an amusing anecdote of a first-year resident some years before my time walking into the theatre of arguably the best cataract surgeons in the region and declaring “by the end of this year I’ll be a better surgeon than you”. Needless to say, they didn’t last long. As good as a supervisor and trainer may be, trainees must bring their own key set of skills and attitudes to make this relationship work.
Trainees too often provide unofficial peer supervision and mentorship of their more junior colleagues. I can recall my first year in ophthalmology training and the support, guidance and encouragement shown to me by the senior registrars; still junior enough to remember being new but senior enough to offer advice, guidance and encouragement.
Many trainees wish to get involved in research, either through their own interest or as a requirement of their training programmes. One senior academic I spoke to explained that much of her role is to help show trainees how involvement in research will help inform their decisions and increase their confidence in exploring their own ideas and questions.
Academic supervision is often about gently guiding a journey through a project from conception and design, through to fruition. For me, my journey through academia, guided by an outstanding team, was an unparalleled time of learning and personal development.
Some top tips from a senior academic for those wishing to embark on research were to have a clear and focused question or risk being overwhelmed. Ask early and often – most problems can be overcome if tackled early. Start writing early, blank paper can be intimidating; anything, even if rubbish, is better than nothing it all. Don’t take reviews too personally!
The world is a strange place for us all at the moment. The post-COVID-19 era will certainly be different. We must be proactive and innovative in how we work and train, the role of the trainer and mentor may be more important now than ever before.
I suspect we will see increasing use of long-distance learning via video conferencing, e-learning modules and simulation. It may be that for many trainees their first ‘capsulorrhexis’ will be performed on a grape sat at their dining table, or their first ‘trabeculectomy’ on an apple in their back garden whilst watching YouTube!
The risk of accepting that less can be taught and therefore less is learnt is certainly real but from my own experience of the enthusiasm, creativity and resilience shown by my own trainee colleague, trainers, mentors and educators the possibility of ascending to an even higher level of excellence in our ability to train and educate is the much more likely outcome.
Supervisors, like the trainees they oversee, come in all shapes and sizes. Each with their own experiences, their own lessons learnt and their own ideas. Some will take to it more naturally whilst others may have to work at it over time. However, from my own experiences I can say that each trainer, educator and supervisor I have had has added value to my career. A piece of advice. An observation or opinion. An ear to listen to my concerns. We all have something to offer our trainees and colleagues. Being a supervisor is a journey of constant development, learning and improvement but a journey that all of us should take because the effort put in will most certainly pay huge dividends for all parties involved.
Dr Sansom is a Specialty Trainee at the York Teaching Hospital NHS Foundation Trust, Yorkshire, UK, and was the winner of the 2019 John Henahan Prize