An Underappreciated Risk of Educational Supervision
It is unlikely that you can remain as an educational supervisor for any length of time without finding yourself at some point with a later stage trainee that gives you severe cause for concern and has you begging the question of how they got to this point with ‘these’ outstanding issues. You know you have an obligation to tackle these issues. You probably experience heart-sink. It’s a deeply human problem you are dealing with, not just a technical one, but before you take a deep breath and approach it with common sense and a supportive attitude, you might want to reflect on the uncomfortable reality that this scenario carries risk for you too. Put plainly, you are also vulnerable and your approach needs to consider this too, on a level playing field with the professional issues at hand.
The primary obligation, understood by all and enshrined in Good Medical Practice from the GMC, is that of safety for the patient. If you discover a trainee with questionnable knowledge and skills, you have to consider what the risk is to patients both in their immediate work and where they go from here. It makes the “how did they get to here?” question that much more galling that when you consider that they will have passed through rotations and programmes without this being dealt with. In some respects, the safety angle is easy to deal with from a safety perspective, they either need more tightly supervised practice or to be removed from practice (where the concerns lie, not necessarily universally). However, both of these courses of action carry the risk that things unravel in other ways, which we will come to.
The second area of obligation is to the trainee. Regardless of their own contribution to this late problem, they trust their development to the hands of a deanery programme delivered through organisations that attach educational supervisors to them. That’s you. In these types of scenarios, we need to consider that there are career, financial and human consequences to the trainee and it is the emergence of these personal threats, real or perceived, that invoke from of our deepest defensive tendencies. Handled incorrectly, we can turn a supportive obligation into the reverse – a personal attack on the supervisor. This highlights the importance of not only adopting the right approach to create the best outcome for the trainee but also approaching it in the right manner behaviourally so as to avoid triggering these more animalistic responses.
Finally, you have an obligation to both Trust and deanery. In accepting the role of supervisor, you undertake to address issues like these in a manner that creates the right outcome for the trainee but with an equal degree of mindfulness when it comes to the organisation’s reputation and any likelihood of litigation. Regardless of your well-meaning intentions, your employer will not thank you when they find themselves in a tribunal, or plastered across the headlines of the local paper for allowing a trainee to kill Auntie Mavis after you had identified cause for concern. In some respects, this highlights perhaps a fourth obligation that is inherent throughout this – an obligation to ensure you are also secure.
The Capacity Trap
A common trap for supervisors to fall into is prioritise their actions based on the wrong criteria. Consider this as a scenario. You are a small department, under-resourced, with an increasing case load and not remotely enough time in the day and certainly not enough pennies in the Trust bank account. Your concern arises in one of two middle grades, each critical to the efficient flow of patients through the department. This is a classic scenario where your own croc brain could cause you to associate the hierarchy of risk to the wrong things.
The rather simplistic croc brain could easily compute that the you have two concurrent risks – the risk to patient safety and the risk to departmental productivity (which can also carry a patient safety risk within it too). It doesn’t help that our prehistoric brainstem processing places a high degree of pertinence on proximity. When you are considering the risk of being eaten by a Raptor, its proximity is a rather important part of threat assessment. So, consider this; the minute you remove someone from practice or double up to closer supervision, you are adversely impacting productivity and we know how managers can think about that. It is carries a sense of certainty about consequences and many of them are personal. On the flipside of this, a trainee you have some concerns over only ‘might’ make a mistake and only ‘if’ they happen to need to use that skill. The consequence is perceived as far more distant and it is easy to see why the decision to leave someone practising can seem like the right one.
I don’t want you thinking I am saying automatically remove the individual from practice. What I am saying is you probably don’t know and yet you are taking decisions based on invalid risk evaluation. It is imperative that you learn how to recognise this mental processing at work and adopt a risk management process that avoids these traps. You are probably already thinking that this is easier said than done. Technical errors are easy to spot but behavioural traps tend to be discovered with the benefit of hindsight, at least by those who don’t know how to approach these issues in the right way.
The Prehistoric Processing in the Modern Trainee Brain
The issue you, and the trainee, face is that nothing gets to your neocortex without first passing through your rather primitive risk radar or croc brain. This is a scenario that calls for an exceptionally carefully considered and designed, rationale approach. It’s just a shame that the croc brain sees things in rather binary terms – danger or not, eat it or be eaten by it – and to make matters worse, has little more than a binary set of responses; fight, flight and possibly freeze. The minute you say “I’d like to discuss your performance”, the trainee’s risk radar starts ringing alarm bells and invokes one of the above responses. It also does something else that can have far more serious consequences. It largely turns off the ability to calmly and rationally think things through. This is a masterstroke in evolutionary terms.
Man was granted the capacity to consciously think things through. We’ve used this capacity to take over the planet and we’re not far off giving space a good go to. However, just how long would man have lasted if he thought through, rationally, his circumstances and all of the slight nuances of ‘about to be eaten by a lion’. Consequently, the croc brain continues to function and process on this basis – always on the look out for threat and when it is sensed, a near-instantaneous selection of fight or flight, definitely before careful analysis. Without going into the chemical processing involved, it is important to realise that this reaction is NOT overcome easily and certainly not by statements like “calm down” that instead tend to have a further inflammatory effect. But so what?
Well, quite apart from the trainee not listening to, understanding or reflecting on what you are raising, we need to think about the two primary responses – fight or flight. Both of them place you in a vulnerable position. The latter response makes it very difficult to address the issues and if they are not addressed, increases the chances of an incident being attached to your failure in supervision. That could mean going off on sick leave or actively avoiding you. At the very least, it means you are more likely to go back with your own croc brain in ‘fight’ mode, increasing the chances of the first response – fight – from the trainee. Whether first or as a secondary effect, you do not want this response.
What forms might ‘fight’ take? We need to consider that the trainee feels threatened. The croc brain has one driver – defeat the opposition to remove the threat. That’s you. The opposition. At least in the croc brain’s interpretation. Given that you are in a more moderate mode at this point, you are likely to be surprised at how this can unfold and especially how fast. The next ‘event’ in the sequence (and I have witnessed or reviewed cases involving all of these) could be:
- You are accused of bullying
- Reported to the deanery for poor supervision
- Trust training failures reported to the deanery
- Sexual harrassment accusations
- Vilified on social media
- Lack of professionalism
- Racial motivation
- Sexual discrimination
And hopefully you now see the risk attached to the wrong approach; one that invokes a defensive fight response in the trainee and consequently puts you in their crosshairs. If you are thinking “but the above wasn’t true” you are falling into the trap of naively believing that a false accusation does not have consequences. At the absolutely very least, it will create one of the most unpleasant periods of your professional life as your obligation to tackle poor performance becomes a personal struggle to prove your innocence.
The Take Home Message
If you are currently thinking “crickey, that’s the last time I supervise a trainee” then please appreciate the thought as a perfect example of your own croc brain in action. It’s not a rationale response but it is an explainable one. What would happen, though, if senior doctors decided to avoid supervision? You’d erode succession planning, for one. That’s not going to help your long term survival when there aren’t enough doctors in your own hour of need. We saw this type of effect happen around child protection, where the perceived risk and accusations that went with the role simply dried up the number of people willing to do it. We are currently seeing it with Boards, resulting in a high level of resignations, too many interims and no continuity. It’s the same effect – they feel threatened and so they run, in this case.
A more objective response is to recognise the complexity of this area, acknowledge that developing knowledge and skills can’t be left until you are stuck in the middle of problem and ensure you develop the requisite approaches, strategies and knowledge of the law (yes, we didn’t cover that vulnerability but as soon as you mention poor performance there are precedents and principles that must be adhered to) so that you can adopt the right path. The good news is that the right approach to these types of issues, a combination of the technical/HR principles and rules with the right behavioural skills and approaches, results in comparatively painless resolution, a safer service and more often that not, the trainee you help becoming a life-long raging fan and advocate for you and your service. Now that’s rewarding.