Quality in Primary Care Open Access

Keywords

general practice, psychiatry, qualitative study, supervision

Introduction

Many of the helping professions, such as nursing, psychotherapy and social work, have well established traditions for on-going clinical supervision.[1–5] In the medical profession, this is not the case, and most literature on clinical supervision concerns individual supervision during training.[2,4,5] For general prac- titioners (GPs), Balint groups were considered to be the first supervision groups. These groups were initiated by Michael Balint[6–8] in the 1950s in order to increase GPs’ awareness of the psychological di-mensions in daily consultations.

The model is known in many countries and well described, even if the number of groups has been low.[6,7,9,10] Nowadays, other group-based supervision models are used as well[11,12] such as models based on systemic family therapy and cognitive–behavioural therapy. However, although some literature on small group supervision for GPs in Australia has emerged during the last decade,[13–15] supervision for GPs has generally been sparsely described, and the prevalence of supervision groups for GPs in different countries is not known.

In Denmark, group supervision for GPs has been known since the 1970s when Torben Bendix, a psy-chiatrist, started such groups for training GPs in psychotherapeutic skills.[16] In the 1980s psychiatrists and psychologists in Denmark proposed that treat-ment options for patients with mental health prob-lems could be improved if GPs were trained through supervision to conduct talking therapy (counselling).

Today, about one third of GPs in Denmark attend supervision groups[12] and some of the groups initiated during the 1990s still exist. In regional surveys from 1997 and 2001, GPs report a number of professional and personal advantages of participating in super-vision groups, e.g. improved communication skills and increased job satisfaction.[17,18]

This paper is part of a larger study of GPs’ partici-pation in supervision groups in Denmark.[12,19,20] The aim of this study was to explore GPs’ experiences concerning the benefits of group supervision for improving their treatment of mental disorders.

Methods

To gain insight into the meaning and significance of group supervision from the perspective of experienced GPs, a case study[21,22] was carried out of one super-vision group led by psychiatrists.[21–27] The group, which was initiated in 1996 by one of the psychiatrists and one of the GPs consisted of 10 GPs and the two psychiatrists who were qualified supervisors. At the time of the study, half of the GPs had participated in the group since the beginning, while the youngest GP had participated for 18 months. The age range of the participants was 45 to 62 years (mean 56 years), and seniority in general practice was four to 30 years (mean 17 years). Supervision sessions were held 10 times a year, about once a month, and took place at community psychiatry premises after hours (4 to 6 p.m.). Each session started with a GP (the supervisee) presenting a case either by video or verbally. Hereafter, the sessions took the form of open dialogue between the supervisee, the group and the supervisors. The supervisors did not see the patients themselves and the GPs had responsibility for the treatment of the patients. Every 2 to 3 years the group arranged a two-day course with an overnight stay, where the two psychiatrists would teach or train counselling skills to the GPs. The cases presented in the group were usually about common mental disorders. Half of the cases were presented using video, half by verbal communication.

The study was based on participant observations of supervision sessions and interviews with attending GPs and their supervisors. Data were collected between February and November 2008 by the first author (HN) who is a GP and a qualified supervisor. During the observations, HN was present at the supervision sessions without participating in the dialogue.

Ten supervision sessions were observed, followed by an interview with the GP who had presented a case. The observation notes described as authentically as possible the content of the case presentations as well as much of the dialogue in the group. The presenting GPs were interviewed immediately or shortly after the sessions about their expectations and needs, how they had experienced the process and how they had benefitted from the supervision. A semi-structured interview guide was used for the interviews.

Seven of the GPs were interviewed in more detail 2 to 4 weeks after their case presentations about the supervision session, how they experienced the super-vision session and how they experienced the way in which the supervision had influenced their sub-sequent work with this particular patient, with other patients and with their continuing medical education. The GPs were selected to obtain variation in gender, seniority in general practice and length of partici-pation in the group. In addition, supervisors were interviewed individually about their background, how they experienced the group, and how this supervision had influenced collaboration between general practice and psychiatry. After the last observation, a group interview of the GPs and the supervisors was conducted.

All interviews were recorded digitally and tran-scribed verbatim. The notes from the observations and the transcribed interviews were analysed using systematic text condensation, which is a descriptive approach presenting the experience of the participants as expressed by themselves.[23,28] First, a general im-pression of the whole material was established, the text was then broken up into meaning units, which were organised into themes. Next, the various themes were gathered across the material and subsequently coded into sub-themes. Text condensates were made con-taining the meaningful expressions identified across the material. Finally, the interpretation of the data was discussed by the authors at a series of meetings.

Results

In the following, the results are presented in four sections according to the themes emerging from the analysis.

Impact on skills related to mental health issues

The GPs often doubted their own psychiatric competencies and hoped to gain new insights and tools for developing their work with patients suffering from mental disorders.

Well, you have thoughts about whether you are good enough [at handling of mental health problems], don’t you? Then you can bring [the case] to the group ... and hear what to do, and [I wonder] what can I do ... (GP-A)

The GPs reported that the psychiatric supervisors had taught them about psychiatric assessment and interviewing, and how to conduct talking therapies. They had mostly learned about common mental disorders, which had been taught sparsely during medical education, and they felt that they had improved their competencies in finding, diagnosing and treating patients with such common mental disorders. They also reported that group supervision had encouraged them to carry out talking therapy, and that they now treated many patients who previously would have been referred to mental health specialists. The use of video-recordings from the consultations provided the participants with the opportunity to give specific feedback on clinical behaviour; some GPs reported how such feedback had influenced their subsequent interactions with the patients. The GPs also recounted that they had become more aware of treatment options in the local mental health services.

The ‘spill-over’ of supervision into non-psychiatric consultations

The GPs experienced that participation in the group had had an impact on their psychiatric skills as well as on their communicative skills in general.

They felt that they had improved their communi-cation with all patients and that they allowed them-selves more time for reflection.

... The most important benefit from supervision has been the general impact on me and my interaction with the patients. It is not only [learning about] talking therapy, but the communication in general, the consultation process and all that ... myself, my role and also these common things, how [I am] seated in relation to [the patient] and the interaction, isn’t it? So the influence on [my] professional work is important ... (GP-C)

All GPs in the supervision group reported gaining some benefit from every session. The GPs generally found great benefit in listening to and witnessing the cases and problems of their colleagues. They often recognised problems similar to those they had experi-enced in their own clinic. They acquired new perspec-tives and learned from their peers.

Prospective presenters in the group sessions often considered bringing a case that would be of special interest to other group members according to themes recently discussed.

The turnover of group participants was low and the GPs found it valuable to belong to a group consisting of peers they had known for many years. They ascribed their confidence in disclosing uncertainties to the trust gained from such long lasting relationships.

... because we have known each other for so many years I am willing to disclose my uncertainties. (GP-H)

Furthermore, the GPs expressed that the supervision sessions had become an important part of their professional life. They felt committed to the group and expected serious participation from every supervisee. They perceived the continuity of the group to be important since it provided opportunities for on-going feedback and made it easier to share difficult situations that arose during their professional life such as complaints or relationships with other health pro-fessionals or trainees. The participants valued the feedback on their handling of mental health problems and on other aspects of their work which was carried out ‘alone behind closed doors’.

Although they claimed that they had become more confident after being in the group for so long, the uncertainty when presenting a case was sometimes followed by some tension and self-consciousness, especially if they were presenting a video.

... I wonder, what they [the peers] are thinking about the way I handled the case, and things like that, I remember that [impression] ... so when [I] get the feeling, that it was not that stupid, [I] feel a relief... (GP-C)

Here, the acknowledgement and appreciation from both the supervisors and their peers about how they had handled a case was important. An atmosphere of trust was considered important, and in order to maintain such an atmosphere the group only admitted new members by consensual decision.

While being in a group for a long time had certain advantages it also presented some challenges. Thus, in the early days of the group, most participants had been eager to make presentations, but after some time some members became more hesitant. In order to avoid such hesitation and to ensure that everybody pre-sented an equal number of cases, each GP had been scheduled for a presentation twice a year. However, this led to some presentations not being based on an urgent need for supervision and, conversely, more urgent needs were sometimes not addressed.

 ... I had to bring some case, and he was the [only] person I had in talking therapy. I did not have any other at that time, so I thought it would be convenient to bring this case. (GP-G)

... If you have got an urgent problem, a long time may pass before it is your turn. (GP-H)

While the GPs had initiated many talking therapies for their patients during the first years of supervision, the number of talking therapies had gradually declined. The participants explained this decline by pointing to an overall change in Danish general practice towards greater time pressure due to an increase in the variety of tasks expected to be carried out by GPs. In such a situation, consultations that were considered to be particularly exhausting (such as consultations con-cerning psychological problems) were likely to be given a lower priority.

As the number of talking therapies had declined, the group decided that everyday consultations or other professional difficulties, such as complaint cases or problematic relationships with medical trainees, could also be the object of supervision. Regarding the super-vision model, some of the participants considered changing to a reflecting team model, where the presenter would be more protected than in the current model, where the whole group was involved in an open dialogue. Some GPs also had reservations about the use of video, which they found might be tech-nically difficult or too intruding for the patients. The personal relationship with the two psychiatrists was experienced as important for the atmosphere of trust in the group.

Collaboration with mental health services

According to the GPs, participation in the group had improved collaboration with the local community psychiatry centre. In particular, it had become clearer for the GPs which patients to refer. The personal relationships with the psychiatrists made it easier for the GPs to approach mental health services.

Similarly, the psychiatrists acting as supervisors reported that the referral letters from the GPs had become more precise, and they found it positive that the GPs could manage talking therapies and medi-cation of patients who otherwise would have been referred to specialists or not treated at all. The super-visors also found it valuable that they had gained more insight into the working conditions in general prac- tice, and their respect for the competencies of the GPs had increased.

... the most important thing I have learned is respect for the working conditions in general practice and how difficult it is to realise [treatment] ideals in this domain with the existing conditions. (Supervisor 1)

Discussion

In recent years, more attention has been paid to the importance of improving treatment options for com-mon mental disorders in primary care, but new initiatives are still needed.[29–34] Many GPs are familiar with talking therapy, which is seen as an integral part of the GP’s work,[35] and some suggest that focused psychological  treatment  should  be  provided  by _GPs.29,36,37

This study explored the experiences of GPs partici-pating in group supervision with psychiatric specialists as supervisors. The study concerned one supervision group with GPs who were motivated and interested in mental health problems and in talking therapy. Hence, the benefits cannot be expected to apply to all GPs and some GPs will possibly not find the supervision method feasible or appropriate. Furthermore, some participants may have presented an overly positive version of their experiences out of loyalty to the group or due to the fact that the interviewer was a colleague who had supervised other groups. However, not all statements were entirely positive. Some participants claimed that the professional background of the in-terviewer made them more comfortable about being interviewed on the subject of supervision.

Overall, the study found participation in an on-going supervision group to be meaningful and pro-fessionally valuable for the GPs. First, the GPs experi-enced that supervision had improved their psychiatric skills and that they had become more confident in employing talking therapy. This perceived impact of supervision was greatly appreciated, because even experienced GPs sometimes doubted their compe-tencies with regard to patients with mental health problems. This finding is consistent with other studies

showing that peer support and supervision are helpful, especially with respect to mental disorders.[35,38,39]

Second, the GPs experienced group supervision to have an important supportive function in their pro-fessional life in general. Thus, the GPs became more aware of their professional role in all patient encoun-ters, and furthermore the supervision group became an arena for dealing with other professional difficult-ies, such as complaints or problems relating to having a trainee. These results regarding the supporting

Functions of supervision groups seem to be in accord-ance with studies suggesting that participation in continuing medical education group or supervision group may have a preventive effect on burnout.[19,40,41]

Third, the participants experienced that group supervision had to some extent improved local col-laboration between the GPs and the local mental health service, especially in the sense that the GPs’ referral letters had become more accurate according to the psychiatric supervisors. The participants also found it helpful that the psychiatric supervisors be-came more aware of the working conditions in general practice.

The results of this study indicate that participating in a continuing supervision group can be beneficial for GPs in several ways. Most importantly, in the present case, the supervision group helped to develop and maintain the GPs’ skills in dealing with mental health problems, even when the basic competencies had been learned. Thus, compared with more didactic methods for professional education such as cathedral courses, which do not seem to have any substantial impact on clinical behaviour,[42] the learning benefit of super-vision could possibly be substantial since supervision is an interactive method that combines several mech-anisms of learning. Thus, supervision is learner-driven, and based on activating and engaging the professional through a sense of practical relevance and inter-personal commitment.[43–45] However, more studies are needed to assess the impact of supervision groups on clinical practice and outcomes. The practical chal-lenges experienced by some GPs in the case study suggest that the specific form and procedures of on-going supervision groups should be evaluated period-ically and discussed among the participants.[46]

Acknowledgements

We thank the general practitioners and their super-visors for participating in this study.

Funding

The project was supported by the Committee of Multipractice Studies in General Practice and The Danish Research Foundation for General Practice.

Ethical Approval

Not required.

Peer Review

Not commissioned; externally peer reviewed.

Conflicts of Interest

None.

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