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Medical conversations inviting


change Lisa Miller Medical supervision


In the world of medicine and dentistry,


“supervision” is oſt en taken to mean overseeing someone’s performance, watching what they do, and helping them with advice and solutions. T e medical model of consulting may


mirror this type of interaction. T e contexts of interactions within medicine are laden with hierarchy – trainer to trainee, expert doctor to vulnerable patient (Lupton, 1994) and the communication exchange can oſt en be solution focused. Training within the medical world


has tended to encourage a linear approach to thinking, in which we look for causes and make diagnoses. We like to separate out systems and problems and isolate them. T roughout the specialties and subspecialties from palliative care to orthopaedic surgery, the model of consulting and supervision can be a variation on the same theme. We frequently ask a check-list of closed questions. We oſt en make interpretations, or think we “know“ why something has happened. Doctors oſt en feel organised by the pressure of time and the quest for certainty (Mason, 1993) and look for the shortest route, as they see it, to get to the “solution”. T is approach can be perceived to save


time and, in some contexts, is lifesaving. However, the constraints of this approach can mean we fall into a pat ern in which we think we “know” what is “right” for a patient or supervisee. Perhaps sometimes, we forget whose story it is. T is approach can frequently lead us into diffi culties, especially when there may be complex ethical issues, or concerns involving beliefs and values and not just technical mat ers.


A changing culture? Over the last 15 years, John Launer and


a team of clinicians, many of whom are GPs, have contributed to a culture change within the world of medical and dental training in London.


16 It started in 1995 with workshops run


by John Launer and Caroline Lindsey at the Tavistock Clinic in London (Launer & Lindsey, 1997) entitled Working with patients, families and teams. With training as family therapists, John and Caroline saw that the theoretical foundations of family therapy and narrative medicine (Greenhalgh & Hurwitz, 1999) had much to off er not only the medical consultation but also the supervision of postgraduate doctors and dentists in speciality training. In 2001-2, I at ended their course and


it opened my mind to a diff erent way of communicating. T is training had theoretical foundations in narrative medicine, social constructionism and systemic family therapy (Launer, 2002). We were introduced to a conversational approach based on the Milan team’s concept of circular questioning (Palazzoli et al., 1980) and Karl Tomm’s technique of interventive interviewing (Tomm, 1988). We were encouraged to investigate contexts and meaning. We explored multiple perspectives and we were introduced to the concepts of refl exivity (Tomm, 1987) and refl ecting teams (Andersen, 1987). Aſt er a short break, I returned in 2006


to the Tavistock and, with a core group of 12 or so others, trained under John Launer and Helen Halpern’s tutelage in order to develop my own supervision skills and learn to train others (Serendipitously, at the same time, my husband had started his masters in systemic therapy at the Kensington Consultation Centre, so I was able explore this new way of thinking at home and at work). T is approach to training in supervision skills has now fl ourished. In 2003, it was adopted by the London Department of Postgraduate Medical and Dental Education (known as the London Deanery) as the basis for training GP trainers in supervision (Burton & Launer, 2003). In 2007, it was taken up by the London Deanery for training all doctors and dentists in the skills of supervision and is now


incorporated into the Deanery’s faculty development-programme for clinical teachers in London (London Deanery, 2011). T e London Deanery currently off ers


one-day and three-day supervision-skills courses and a professional certifi cate in advanced supervision-skills for clinical teachers in conjunction with the Tavistock Clinic. We run thirty one-day workshops and six three-day courses annually, as well as the longer course. All at endances are voluntary and many are oversubscribed. Since 2007, over a thousand clinicians from within the M25 boundary (a ring road around the outskirts of London) have been trained with this model (Launer, 2010a).


What has allowed this cultural change?


Perhaps the recent social and cultural


changes within the world of medicine and dentistry have made it possible to change views of supervision amongst doctors, dentists and their clinical teachers. T ese include the professionalisation of postgraduate training (MMC 2010; PMETB, 2007), the introduction of formal systems of appraisal and revalidation (GMC, 2010), and closer interdisciplinary working. In addition, there is the infl uence of wider intellectual movements such as complexity theory, whole-systems approaches, social constructionism and narrative studies (Launer, 2010a). T e ground has been prepared


for a broader general acceptance of diff erent ideas and exploring new ways of communicating as medical and dental postgraduate training has been restructured (PMETB, 2010).


Conversations inviting change workshops


I am now part of a team of around


twenty GPs (and one dentist) who have completed the Tavistock training for medical supervision run by John and Helen.


Context February 2012


Medical conversations inviting change


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