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of his wife. Alison had felt frustrated that this patient’s wife seemed to be inappropriately managing his medical problem (suggesting a hospital referral for something that could be managed in primary-care) but felt that she was not able to respond to the patient in a way that would be most conducive to his health. She had writ en the referral for him and did not think he had noticed her frustration, but wanted to discuss what to do the next time he came. Alison: I fi nd this man so diffi cult. He suff ers with diabetes and coronary heart disease. He waltzes in and usually tells me that his wife has suggested that he is referred for his medical problems to the hospital. I don’t always think these referrals are necessary and I know I could manage him bet er in general practice if only he gave me the opportunity. Lisa: Is there anything else you think it would be useful for me to know about this situation? Alison: He works as a senior manager in a large successful organisation and his wife is a consultant in a local hospital and I feel intimidated by them. Lisa: Intimidated? Can you tell me more about being intimidated? Alison: Yes, I dread it when he comes into the surgery and make demands of me. He seems so overbearing. I feel that I have to follow what he wants, even if I don’t feel that it’s the best way to manage the problem. Lisa: If he was, for instance, an unemployed small Asian woman, what diff erence do you think this would make to your interaction? Alison: Oh, that would be completely diff erent. I think I would be able to discuss his medical problems more easily with him… (and Alison went on to describe her thoughts about his illness). Lisa: If this patient and his wife were listening to this conversation now, what do you think they would say? Alison: I think they would be surprised by my feeling of powerlessness, and I think they would possibly accept my help. I think they are so used to hospital medicine that they don’t really know about what we can off er in primary care.


Before I took the systemic training,


I would probably have off ered advice early on about how to manage the patient next time (“Yes, I fi nd this type of patient diffi cult too – why don’t you try this...” type of suggestion).


18


From this conversation, maybe


Alison refl ected on the causes for the consultation being diffi cult for her and had some space to think about the reasons she felt intimidated. It gave her an opportunity to consider how the patient and his wife view medical care from their positions, which perhaps freed her to introduce them to the expertise she could off er from a primary care point of view. My work is more enjoyable and,


perhaps, my conversations are more courageous and have an element of honesty and meaning they used to lack. Sometimes, I am off the mark and ask too many questions (for example, when the patient has just come because they want a blood test for cholesterol, or when the trainee just wants some direct advice) but, for the most part, I think I have developed a greater understanding of the communication that happens in any interaction. I have become more skilled at facilitating the unsticking of stuck stories with others (be they patients, trainees or peers).


Outcomes from our courses We invite both numerical and


narrative feedback from our courses. T e participants give us high-satisfaction ratings for our courses (usually either “good” or “excellent”). Participants consistently report that these skills are eff ective in supervising both peers and trainees. T ey free both teachers and learners from traditional paternalistic or interpretive forms of supervision (Launer, 2010a). Paradoxically, asking open-ended questions and withholding advice may encourage a more meaningful supervision than the traditional prescriptive model. T e London Deanery recently invited a team from Cardiff University to evaluate the impact of our three-day course on participants (using interactional analysis). T ey remarked that the participants particularly valued the small-group supervision work and noted there was rudimentary evidence, from the evaluation, of improvement in organisational performance and patient outcome as a result of the course (Bullock et al., 2011) .


Conclusion Over the last ten years, the fl avour of


conversations between medical clinicians and their trainees, and between peers in


supervision, has changed considerably. Teaching through humiliation is no longer tolerated and training in education for clinical teachers has become mandatory (Swanwick, 2009).T ere have been many infl uences for this cultural shiſt . In London, one model of supervision


now promoted within the world of postgraduate education of doctors and dentists is based on narrative ideas, social constructionism and systemic family therapy. T e hope is that this may, in some way, have a positive impact on patient care. T ank you to Helen Halpern and John


Launer for helpful comments on earlier draſt s of this article


References Andersen, T. (1987) The refl ecting team: Dialogue and meta-dialogue in clinical work. Family Process, 26: 415-428. Bullock, A., Monrouxe, L. & Atwell, C. (2011) Evaluation of the London Deanery Training Course, Cardiff University. Burnham, J. (1992) Approach-method- technique:Making distinctions and creating connections. Human Systems: The Journal of Systemic Consultation and Management, 3: 2-26. Burnham, J. (2010) Creating refl exive relationships between practices of systemic supervision and theories of learning and education. In C. Burck & G. Daniel (eds) Mirrors and Refl ections: Processes of Systemic Supervision. London: Karnac. Burnham, J., Palma, D. & Whitehouse, L. (2008) Learning as a context for diff erences and diff erences as a context for learning. Journal of Family Therapy, 30: 529-542. Burton, J. & Launer, J. (2003) Supervision and Support in Primary Care. Oxford: Radcliff e Medical Press. Claxton, G. (1996) Implicit theories of learning. In G. Claxton, T. Atkinson, M. Osborn & M. Wallace (eds) Liberating the Learner: Lessons for Professional Development in Education. London: Routledge Medical Press. General Medical Council (2010) Revalidation. Retrieved from: http://www.gmc-uk.org/ doctors/revalidation.asp Greenhalgh, T. & Hurwitz, B. (1999) Narrative- based medicine: Why study narrative? British Medical Journal, 318: 48-50. Launer, J. (2002) Narrative Based Primary Care. Oxford: Radcliff e Publishing ltd. Launer, J. (2008) Conversations inviting change. Postgraduate Medical Journal, 84: 4-5. Launer, J. (2010a) A Narrative Approach to Teaching Supervision Skills. Given at the COMET Conference, Boston University. Launer, J. (2010b) Supervision, mentoring and coaching. In T. Swanwick (ed) Understanding Medical Education: Evidence, Theory and Practice. London: Wiley-Blackwell. Launer, J. & Lindsey, C. (1997) Training for systemic general practice: A new approach from the Tavistock Clinic. British Journal of General Practice, 47: 453-456. London Deanery (2011) Supervision Skills for Clinical Teachers. Retrieved from: http://www.


Context February 2012


Medical conversations inviting change


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