A couple of weeks ago I invited Sarah, another GP in our practice to observe one of my surgeries. All the patients were warned before-hand that another doctor would be there. She watched and listened intensely and took notes as I consulted. Before calling in some of my patients, I explained about their background:
I’ve known Brian for about 7 years, he was diagnosed with Parkinson’s disease when he was just 45, and has had several falls, fracturing his hip and shoulder in the last couple of years. He had to take early retirement and sell his building firm and has been severely depressed. His wife does everything she can to look after him, but she’s at a loss, and to be honest so am I. He’s lost a lot of weight because he stopped eating. I asked the psychiatrists to see him but he hasn’t had an appointment yet. I’ve really been worrying about him.
Being able to describe to another clinician, an experienced, trusted peer, how much I knew about my patients along with my concerns and fears, was really powerful. Like every doctor who values continuity of care I know the majority of my patients, but being given the opportunity to describe them to Sarah, really made me think about how important this is.
So much of what we do in clinical practice is done in silence. While I listened calmly and intently to Mehmet my mind was silently whirling, trying to identify clues that might help me make sense of his constellation of symptoms and the investigations he’d been through and medications he had tried. So much of general practice is spent in the ‘swampy lowlands’ between suffering and disease, where symptoms are far easier to describe than to explain. The tools of our trade: protocols, pathways, guidelines and diagnostic categories can be applied to a minority of the problems our patients present with. Multimorbidity is the price we’re paying for longevity, so we can now survive with an array of diseased organs, but they’re intricately connected; a drug for one is poison for another, and if one fails the others struggle to take the strain, in often unpredictable ways.
But working in isolation, we rarely articulate the uncertainty that characterises so much of our work. The limits to how much we can tolerate move in and out with the tide of our resilience. Confidence and strength, far from being sure of the answer, is being able to live with the anxiety of not yet, or perhaps never knowing. My friends and colleagues are more stressed than ever before, and an inevitable consequence appears to be more referrals to hospital where the burden of uncertainty can be shared, a phenomenon already understood. Sarah and I shared the uncertainty, and discussed how to help Mehmet.
I had watched Sarah in a surgery the week before. One of the things she asked me to look for was the way she concluded consultations, she wanted to know how to conclude a difficult discussion with one patient and not keep the others waiting – we have only 12 minutes for each appointment. I had written recently about how we give reassurance, whether we do so for our benefit or our patients, and how giving confidence might differ. I took notes and we discussed how she worked, how patients responded, where she thought it went well, and how it might go better.
Opening your practice up to close scrutiny and learning from the experience, means being able to say, ‘I’m struggling with this’, it’s not about showing off, so much as exposing yourself. The majority of doctors never do this. To do this requires trust; that the person you’ve invited in, understands what you’re trying to do and that they are there to help. John Launer’s wonderful work on clinical supervision, teaches us that a very powerful way to help one-another learn is by curious questioning – helping the person you’re supervising to think deeply about the way they’re consulting. He concludes,
Collectively, good conversations can be transform a working culture from one that is technocratic, impersonal and potentially dangerous, to one that is both kinder and safer.
The Berwick and Francis reports into poor patient care at Mid Staffordshire hospital recommended above all, that patient safety depends on lifelong learning, aware perhaps, that the features that unite under-performing doctors are isolation and lack of insight. Sadly all of the emphasis has been on more regulation and inspection and the experience of many clinicians is that they have less time for education and are less supported than ever before.
US surgeon and writer, Atul Gawande argues convincingly that the most experienced doctors can benefit from coaching in the same way as professional sportsmen and women do. Gawande, an experienced surgeon, was used to operating independently, without supervision, but invited a respected colleague to watch him perform a routine operation. His colleague made several critical observations that made Gawande realise that unless supervision is required or actively solicited, opportunities to improve the quality and safety of patient care will be missed.
We owe it to our patients and each other to open ourselves and our practice up to our peers who can provide education and support in equal measure. Clinical supervision should be for life, we cannot afford not to make time for this.
Postscript.
Several people have asked how we found time.
We both came in on our half-day to observe, in our free time. This isn’t sustainable, but it was far more valuable than many (most) conferences or ‘educational’ meetings I have been to, and I would happily use some of my study leave to do this in future.
A Better NHS 
Great to see someone actually caring to this degree in what is rapidly becoming a sausage factory; get the meat in, get the meat out,
Beautifully said. I am a P.A. and I couldn’t agree more. I believe that all practitioners should have some kind of supervision whether self-imposed or regulated. One thing that I have always found troubling is the non-communication between those caring for the same patient. This is vital in order to diagnose, treat and understand our patients the best we can. Thank you for sharing.
May I contribute as a patient, albeit one from a ‘medical’ family? Oh and a former TQM trained consultant and Life coach.
Re Paul Springer’s comment about the ‘sausage factory’; I would point out that the patient is unaware of the other people you have seen – their experience is limited to the consultation. So you ideally you would strive to see each of us as a fresh start and not be bludgeoning yourself about how you dealt with the last patient or some other tension. Actually because of patient confidentiality yours is a job that allows you to ‘reinvent’ yourself several times an hour! Feedback as described here is invaluable and ought to happen more often. But I have observed a similar effect with a medical student present where the GP performed the Epley Manoeuvre for me. It was actually a fun consultation (as it is truly weird!) and is still working 9 months later (as I have left a message to inform him). GPs are in a lonely profession but recognising this and sharing is surely a workable option?
I have had a consultant spend more than 6 minutes complaining about government changes to the NHS which yes I care about but actually in the brief period I was with him were simply not on my agenda (and I had not made any complaint to trigger this!).
The ‘curious questioning’ is a powerful idea above – but eye contact must be made or it can still seem as though you are on autopilot. Staring at the computer screen for the majority of the consultation seems to be increasingly the norm. I recently took my 16 year old daughter in to see a GP re painful periods and she was taken aback by this and was making faces to me that the doctor totally missed – I had to explain afterwards that indeed it was the norm these days but her reaction really brought home to me how it has become acceptable. Actually Paul that does give the ‘sausage machine’ impression to the patient!
Interesting that you focus on having supervision from your peers. Do you employ “Sarah” and if you employ “Sarah” do you really think “Sarah” will give brutally honest feedback to her employer? How do you know “Sarah” won’t just confirm your cognitive biases and tell you what you want to hear rather than challenge you?
I think it would be a lot more useful to let patients supervise your practice – after all, they’re on the receiving end of a consultation. Do you think the atrocities of Mid-Staffs would have occurred to the same degree if doctors had actually listened to patients and their families and sought honest feedback at every encounter and acted upon that feedback instead of devaluing patient opinion?
Learning from the patient may be a novel idea to the medical profession – but why not try it? Wouldn’t it be better for all concerned to hear it straight from the horse’s mouth? Why not go “meta” and ask you patients at every encounter how they feel the consultation is going and what they might do differently and what they want to achieve? Have you considered that Mehmet might have clear ideas about his complex medical situation? Why not seek Mehmet’s opinions and discuss your uncertainty with him – do you really think patients are impressed with medical uncertainty covered up with bravado – why don’t you tell the patient you’re struggling? Is there a pedestal position to maintain? Also, you and “Sarah” may have a completely different value system to Mehmet – it’s Mehmet’s body – shouldn’t his values and ideas dictate the state of play?
If the aim is to get emotional support, then it would be better to consult an independent psychotherapist to discuss the difficulties you have in coping with your emotions. If the aim is to improve patient care – you need to consult patients – it’s their opinions that should count.
Thanks for your contribution
Sarah and I are both employed, salaried GPs. I am more experienced and have previously been her employer. The power differential is interesting and we explored that in some detail before planning the session.
Honesty is a vital part of feedback, but brutality has no role in supervision and supervision isn’t the same feedback, which is why I linked to John Launer’s work.
Supervision requires expertise, which is gained in the postgraduate GP training that both Sarah and I have completed.
I have completed further training in supervision and Sarah is taking a course at the moment.
Patients are invited to give feedback (which is not the same as supervision) in a variety of ways, through a patient survey, the practice website, NHS Choices and shortly also the Friends and Family Test
Learning from patients isn’t novel. In my own practice patients have been teaching my students and me for the last 10 years, there is a considerable academic literature about patients as teachers, most medical schools employ expert patients as teachers and there are national programs.
THe views of patients like Mehmet are actively solicited, what Carel refers to as ‘epistemic justice’ and the issue of unequal power relationships is explored, in part through her concept of ‘epistemic privilege’ and other theoretic models from within medicine and social sciences. We use a mixture of consultation models to try to explore patients’ values, testimony, interpretations and so on. I’ve written another blog about medicine and power which explores this in more detail and several blogs exploring how issues like shame and stigma affect the doctor-patient relationship. We’re also interested in how professionals’ moral predispositions impact on practice, which is the subject of other recent blogs.
Supervision is theraputic, but it is not therapy. Both theraputic supervision and therapy have a role. The boundaries may be indistinct, but that is part of the consideration.
Underneath what may appear to be straightforward observation and feedback, is a far more sophisticated process.
Thanks for prompting me to add this, I hadn’t realised how it might have been perceived without it.
The narrative above describes two GPs giving up their free time to engage in a process that likely enhances quality, safety, CME not to mention improved GP job satisfaction ( which is an ever increasing issue). How can we make initiatives like this appear worth while to those funding our health services? (I am a GP trainee, so still get the benefit of regular case discussions with my GPs trainers/ analysis of video – consultations – I find them invaluable).