Group supervision in general practice as part of continuing professional development

Supervision in educational settings is common and most of the care professions now have an established culture of clinical supervision both for trainees and qualified practitioners [1, 2]. In the medical professions, including general practice, postgraduate supervision is not well-established [1]. However, a tradition of group supervision for general practitioners (GPs) has existed in Denmark for more than two decades. In the 1990s, the number of supervision groups in Denmark rose because an agreement was made between the Danish National Health Service and GPs that introduced an incentive payment for conducting talk therapy (counselling) in general practice [3, 4]. In the same period agreements were made about continuing medical education (CME) based on small groups. Two Danish regional progress reports on supervision groups whose data were obtained from focus group interviews showed that the GPs benefitted in terms of improved communication skills and personal as well as professional development. The GPs reported improved job satisfaction and claimed that joining a supervision group had a preventive effect on burnout [3, 4].

Group supervision is a structured educational activity with a qualified supervisor. Its point of departure is the problems experienced by GPs in their professional work. Group supervision unfolds in groups which generally have a high level of commitment, conduct regular meetings and work within well-defined boundaries. In peer supervision, GPs trained to be group leaders or facilitators may take turns, assuming the role of supervisor. The primary aim of the supervision groups is to train and assure the quality of talk treatment, to improve communicative skills and to improve management of complex encounters in the consultation [3]. Most supervision groups are part of CME. In some regions, the groups are supported and subsidised by quality development organisations [5]. The groups are totally self-directed, i.e. they have no external control and they work with a diversity of approaches. One often used model of supervision is the reflecting team model, which was developed by Tom Andersen for systems family therapy [6] and which is also being used in many other contexts apart from health care.

Another well-known model is the Balint method, which was originally developed for GPs to increase their awareness of psychological dimensions in daily consultations [7]. The Balint model is known all over the world [8]. In Sweden Dorte Kjeldmand in her thesis showed that doctors participating in Balint groups developed a more patient-centred consultation, felt more in control of their working life and enjoyed greater job satisfaction which could, in turn, prevent burnout [9]. A peer-group supervision model, the Kalymnos model, was developed by two Danish GPs in collaboration with a psychiatrist. The model was inspired by the British educationalist Colin Coles and it is well-known in Denmark [10].

Some groups have developed into profession-related groups dealing with all kinds of problems in professional. Given that the external pressure on GPs has risen with higher work load, growing patient consumerism and a lower threshold for litigation, supervision groups may in general become more likely to address the wider aspects of professional life. Little is known, however, about the current use of these groups.

As a supplement to a qualitative study on the benefit of GPs’ participation in supervision groups [11], a questionnaire was developed to obtain knowledge about the current use of and attitude towards supervision groups among GPs in Denmark.

MATERIAL AND METHODS

The questionnaire was developed by the first author based on her previous research and a literature review on clinical supervision [1-12]. The 55-item questionnaire covered questions on GPs’ working conditions and supervision in general. Those who were participating in a supervision group were asked questions about the number of different groups used, the frequency of meetings, types of supervision methods experienced, the supervisor’s professional background, and 39 questions explored the GPs’ most recent supervision experiences. For these questions, a five-graded Likert scale with the following options was used: strongly disagree, disagree, neutral, agree and strongly agree. In two open-ended questions, the responders were invited to provide their definition of supervision and any reasons for dropping out of a supervision group.

The questionnaire was pilot-tested trice for meaningfulness and relevance. Pilot-tests were conducted with GPs in different settings. The questionnaire could be completed in ten minutes and the doctors were paid for the time they used.

The questionnaire was posted to 10% of the GPs in Denmark, who made up a representative sample in terms of gender, age, seniority and organisation of practice. The sample was drawn from the register of the Organisation of General Practitioners in Denmark, where at that time 60% were male and 40% female GPs.

After thematic content analysis, the responses to the open-ended questions were categorised. The answers to the question: "How would you, in your own words, define supervision" could be categorised according to Proctor’s model of the functions of supervision [12] (Figure 1). The answers to the question: "If you have stopped attending any supervision group(s), please tell me the reason why" were categorized as time pressure, personal reasons, the professional benefit too low or group problems.

As a significantly higher proportion of the female than male GPs responded to the questionnaire, we made a comparison between the genders (Table 1). To analyse bivariate associations, the χ2-test was used and a significance level of p = 0.05 was used.

The data were analysed using the SAS software.

Trial registration: not relevant.

RESULTS

After two reminders, 215 (59%) questionnaires were returned and used in the analyses. Response rates were higher among women than among men: 98 (67%) of the women responded compared with 117 (53%) of the men (p = 0.01). Significantly fewer GPs from single-handed practices than from group-practices responded to the questionnaire (p < 0.01). The median age and seniority in practice were similar for responders and non-responders.

Participation in supervision groups

Overall, 37% were currently participating in a supervision group, of whom 51 were women (52%) and 27 men (24%) (p < 0.001). Among female responders, 76 (78%) had at some time participated compared with 51 (45%) of the male responders (p < 0.001). Whatever their seniority, proportionately more women participated (Figure 2), though fewer female GPs with low seniority. More participants from group-practices (39%) compared with single-handed practices (28%) were participating in supervision groups at the time they were answering the questionnaire, while there was no difference in their participation percentages at at any point during their time as GPs (63% versus 60%).

The majority (85%) of the responders thought that supervision ought to be part of CME. The most frequent reasons for not participating in a supervision group (n = 85) were that participating in one self-directed learning group was sufficient (35%), lack of time (29%) or no available supervision group in the vicinity (24%). Among the GPs who had at some time participated in a supervision group, 79 (62%) had participated for up to five years, nine (7%) had participated for 5-10 years, 28 (22%) had participated for 10 to 16 years and 11 (8.7%) had participated for 16 to 30 years. Most of the groups met once a month; eight GPs reported meeting every second week.

Supervision models

The reflecting team model had been used by a majority of the GPs, irrespective of their age and sex; the second most commonly used model (35%) was cognitive behavioural therapy. Psychologists were most commonly used as supervisors (60%) followed by psychiatrists (46%). 38% of respondents had experienced having a GP as a supervisor.

Definition of supervision

The answers of 153 respondents to the question "Describe in your own words what you understand by supervision" were used in the qualitative analysis. Among the 153 respondents, 61 had never been in a supervision group. Most of the definitions contained expressions that could be categorised as formative or restorative, whereas only 20% could be categorised as normative.

Experiences with supervision

Experiences with supervision were rather similar for men and women, except for the statement "It is a relief to share difficult problems in the group". Significantly more women than men agreed to this statement (p = 0.005). Furthermore, more women than men found that they had become better at dealing with somatising patients (0.04). Most agreed that supervision provides them with a better understanding of difficult patients and better means of dealing with mental health problems and that it allows them to train talk therapy. The majority also expressed that they felt more satisfied with their jobs. Few reported having dealt with complaint cases against doctors or difficulties with colleagues or staff (Table 2).

Dropping out of a supervision group

A total of 34 responded to the question: "If you have stopped attending any supervision group(s), please tell me the reason why". The most frequent explanations given were personal ones, that the professional benefit was too low or that time pressure was too high. There was a tendency for women towards presenting problems rooted in the group itself as a cause for dropping out, while men mentioned time pressure, too low professional benefit or personal reasons for dropping out. The group problems mentioned were unstable attendance and bad group dynamics.

DISCUSSION

The study shows that group supervision is an established activity among Danish GPs of whom about one third are currently participating and almost two thirds have participated at least once and as many stay for several years.

The main findings of the present study were that more female than male GPs responded and participated in a supervision group, that the groups are still being used mainly for communication training and only to a limited extent for addressing other professional problems. Proportionally fewer single-handed than group-practice based GPs responded and fewer GPs from single-handed practices were participating in group supervision at the time of the questionnaire study, although the percentage participation rates over time were not linked to the type of practice. The lower participation observed among younger than among older female practitioners may be explained by the younger female GPs often having small children at home whom they need to care for.

The number of participants corresponds to an earlier count of supervision groups from 2003. One reason for the present level of participation may lie in the impulse caused by the incentive payments introduced in 2005 which were available in some regions when the present study was conducted. At the moment, most

supervision groups are remunerated like any other CME groups. Despite the lack of special incentives, the overall number of supervision groups appears to have remained stable from 2003 to 2008.

The personal benefit of work-based learning and supervision based on one’s own experienced professional problems may also serve to explain why the level of participation has remained at par with that previously observed. The responses concerning better job satisfaction may indicate that supervision prevents burnout as indicated in earlier reports and literature [3, 4, 9, 11, 13].

Acquiring tools to better understand difficult patients, to improve one’s communication skills and to deal with mental health problems encountered is an important task of the groups. Because the groups often continue for many years, we would expect workplace problems and complaint cases to be issues commonly raised in the groups. However, this does not appear to be the case. Still, we may reasonably assume that the restorative function is important in a profession with many human encounters, a high work load and a low threshold for litigation. It is generally accepted that CME is of importance for GPs for maintaining and improving clinical performance [13].

Besides these functions, participation in CME groups has been shown to play a role in preventing burnout [14], as not being a member of either a CME group or a supervision group was significantly associated with a doubled likelihood of burnout. This may indicate that being a group member has a positive impact on job satisfaction and the prevention of burnout. Recent reports show a high prevalence of burnout among GPs in Europe [15]. In Australia, prevention using tailored programmes [16] in which supervision groups have an important role has recently gained momentum. Bowers & Holmwood, also from Australia, argue for supervision-like peer groups, in particular for GPs who deal with mental health problems [17]. Wilson & Howell stress the importance of a GP facilitator training programme to make peer groups successful [18].

It is not possible, however, from this survey to determine whether the benefit of participation in a supervision group exceeds the benefit of being involved in another peer group. In a qualitative study [11], GPs expressed the view that participation in supervision was the reason why they did not drop out of the profession.

The experiences of men and women were equal except for the statement: "I feel relief from sharing professional difficulties", with which significantly more women than men agreed. This may indicate that it is easier for women to voice uncertainties and share difficulties. It is well-known that female doctors are consulted more often than men by difficult patients, that they have longer consultations [19] and that they may also conduct more talk therapies and thus feel a greater need for supervision. However, the significant tendency that fewer men than women participated in supervision groups may indicate that men and women have different needs.

As group supervision deals with problems experienced in the GP’s professional life and is an on-going activity that may last for years, the professional and personal benefit may be significant and may be seen as an important part of continuing professional development. Further research is required to determine whether supervision groups outperform other CME groups in terms of preventing burnout, why some doctors leave the groups and how the needs of female and male doctors may differ.

Limitations of the study

The response rate of 59% could be considered low, but it corresponds to the average GPs’ response rates for postal surveys [20]. Furthermore, the study has a selection bias because a higher proportion of women than men answered the questionnaire. Finally, the responders may be GPs with more positive attitudes to supervision groups and thus give a falsely high participation rate. The questionnaire was tested for meaningfulness and relevance, but was not externally validated.

CONCLUSION

An established tradition of supervision groups for GPs exists in Denmark with about a third of all GPs currently participating. As group supervision deals with problems experienced in the GP’s professional life and is an on-going activity that may last for years, the professional and personal benefit may be significant and the activity may be seen as an important part of continuing professional development.

Future research is required to show whether supervision groups have advantages compared with other CME groups concerning prevention of burnout, why some GPs drop out and how the needs of men and women differ.

Correspondence: Helena Galina Nielsen, Institut for Almen Praksis, Center for Sundhed og Samfund, Øster Farimagsgade 5, 1014 Copenhagen K, Dennmark. E-mail: helenani@sund.ku.dk

Accepted: 29 September 2011

Conflicts of interest:None

Acknowledgement: We would like to extend our thanks to Willy Karlslund & Volkert Siesma, Research Unit for General Practice for help with the data analysis.