Telephone peer supervision and surviving as an isolated consultant

Mentoring for newly appointed consultants in all specialtiesis recognised and established as offering important and essentialsupport in the early years after appointment to a consultantpost (Connor et al, 2000; Roberts et al, 2002; Waters, 2002; Dosani, 2006). In some regions this is now formalised andis in line with recommendations of the Royal College of Psychiatrists(Dean, 2002, 2003).

However, it is unclear what happens after a consultant is nolonger ‘newly appointed’. Does the mentoring arrangementcontinue with mutual agreement or does the more senior consultantneed to move on to mentor further newly appointed consultants?And what about the need for ongoing support and supervisionfor the more senior and experienced consultants?

It is now well established that junior doctors need supervisionthroughout their training. Consultants supervise junior doctorsand may offer supervision to other professionals, but doesthe need for supervision and support stop once in the consultantgrade? Do senior and experienced consultants acknowledge theirneed for supervision and support? How does the consultant surviveonce mentoring has stopped and what systems and models are available to offer this ongoing supervision and support for more seniorconsultants?

Support systems

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Support systems

Support systems for psychiatrists have been described by Hollowayet al (2000). A range of different systems are mentioned,including the importance of informal support by consultantcolleagues, preferably those working in the same building. Professionalsupport may be informal and among peers, and is an importantpart of ongoing practice and professional development throughoutthe career of a consultant (Benbow & Jolley, 1999). Thisinformal learning occurs by the exchange of stories and clinicalmaterial during the working day (Hunter, 1991; Roberts et al, 2002) among a network of professionals (Eraut, 1994; Roberts et al, 2002).

In the Northern and Yorkshire regions during the mid-1990s,a doctors’ development and mentoring network was setup to develop mentoring training for consultants. Subsequentevaluation of the scheme showed that together with training,the consultants valued the co-mentoring and the supportivenetwork of senior doctors that the training provided. This was particularly mentioned by several consultants who had feltisolated (Connor et al, 2000).

With the introduction of mandatory continuing professional development (CPD) peer groups, meeting with consultant peers is now a regularoccurrence, at least twice a year (Royal College of Psychiatrists, 2001).Although there is a clear agenda for these meetings, the formatand structure of these CPD groups varies greatly, with someallowing more time for more informal peer group discussionsof clinical and other issues and for support. They certainlyresult in a more formal, structured and peer-reviewed processand in personal development plans and CPD being verified andvalidated, but how much supervision and support do they providefor the isolated consultant?

Isolation

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Isolation

Consultants may be ‘isolated’ for a variety of reasons.These include geographical isolation (for example working asa single-handed child and adolescent consultant in a largerural area or within a sectorised service located within acommunity base), and the isolation that occurs within serviceswhere competition for resources, rivalry or conflict may makeopen and honest communication between consultant colleaguesdifficult. Isolation may also result, even if working in alarger centre, from work pressures and not having time forlunch or coffee breaks with consultant colleagues (Roberts et al, 2002).Working without consultant peers can be stressful. Day-to-dayinformal discussion with peers and reflection of complex clinical, team and managerial issues becomes difficult and the qualityof the work may suffer.

Usually, an essential and large amount of invaluable clinicaldiscussion and support occurs between multidisciplinary teamcolleagues. Staff sensitivity and staff support groups areother models of support that enable teams to deal with complexmental health and emotionally powerful feelings and conflictsin their practice (Haigh, 2000). However, consultant psychiatristsmay feel isolated within a multidisciplinary mental healthteam, and there may be conflict between the consultant’sroles as manager and supervisor that makes open multidisciplinaryteam discussion difficult. Furthermore, other issues (for examplecertain interpersonal ones) can arise that cannot be discussed appropriately between a consultant psychiatrist and team colleagues.

There is a continuing problem with the retention and recruitmentof psychiatrists and to tackle these issues there is a needto address and decrease work-related stress, ill health andburnout (Roberts, 1997; Benbow, 1998; Allen, 1999; Egerton et al, 2005). Consultants have a responsibility to ensure that their ownneeds for supervision and support are met (Roberts, 1997).Although New Ways of Working for Psychiatrists (Royal College of Psychiatrists, 2004;Department of Health, 2005) may go some way to addressing thepressures and stresses on psychiatrists, it does not addressthe issue of isolation.

Telephone and peer supervision

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Telephone and peer supervision

Peer supervision has been described in the field of psychotherapyfor over 50 years (Todd & Pine, 1968; Counselman & Weber, 2004)and is established as a method for supervision of psychotherapytrainees, counsellors, supervisors, mental health professionals and other practitioners in the helping professions. The supervisionmay be delivered in various ways, including within a groupwith a supervisor or in a leaderless peer group (Hunt & Issacharoff, 1975;Hawkins & Shohet, 2000).

The potential benefits and pitfalls as well as the importanceof a structure with regular review and evaluation have beendescribed by many authors (Zorga et al, 2001; Campbell & Coombes, 2002;Counselman & Weber, 2004). For more senior practitioners/professionalsand supervisors, one-to-one peer supervision may be organised (Hawkins & Shohet, 2000; Claveirole & Mathers, 2003).However, peer supervision is less commonly used by doctors, including psychiatrists (Arnott et al, 1996), nor is it describedwithin psychiatric training.

The telephone method of supervision is normal practice for theclinical service supervision of junior doctors. It is alsoused for distance supervision, consultation and training oftrainee counsellors, psychotherapists (Wajda-Johnston et al, 2005)and other health professionals in different settings (Thompson & Winter, 2003).

We describe a model of telephone peer supervision between twosenior consultant psychiatrists that can enhance professionalpractice and provide essential supervision and support forthe consultant in an isolated setting. We use a broad definitionof supervision to include discussion of clinical cases, particularlyfocusing on the medical or psychiatric aspects, discussion ofmanagement issues, and reflection on our own responses to andmechanisms for coping with clinical and team issues. This willbe further illustrated in the following account.

Personal experience of telephone peer supervision

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Personal experience of telephone...

In 2001, we set up regular supervisory telephone calls in responseto the increased time we were spending outside work talkingabout work-related issues. We had trained together as seniorregistrars and in the 1990s had taken up consultant posts inisolated rural areas at opposite sides of the UK. Both of uswere working in poorly resourced specialist child and adolescent mental health services (CAMHS) and were initially single-handedconsultants. The supervision sessions were set up before theRoyal College of Psychiatrists started a mentoring system fornew consultants and before CPD and personal development plangroups became mandatory. We ring-fenced 1 hour per fortnight for these sessions, agreed the structure and subsequently includedthis in our job plans. These supervisory telephone calls havecontinued for over 5 years.

At the beginning of each session we set a prioritised agenda,including the time needed for each item. Usually two or threeissues would be discussed at each session and might consistof:

the review of a case that is particularly complex, high risk,presenting with unusual psychiatric phenomena or requiringthe use of the Mental Health Act 1983
discussion of a clinicalconundrum, for example‘what antipsychotic should I usein a teenager who is very overweight, epilepticand developed galactorrhoea on the previous two antipsychoticstried?’
difficult management, team and service issues and the consequent frustrations
review of relevant clinical governance guidelinesand best practiceas linked to clinical cases
considerationof a personal or interpersonal issue that mightaffect our workperformance; during the course of the supervisionwe discussed,for example, personal bereavement, coping withillnesses andtheir effects on the functioning of small teams
sharing ofsalient points from training events.

Although overall the experience has been positive, there havebeen some problems. It has been hard to entirely ring-fencethe time, either because of pressure of work or feeling guiltyabout not using the time for patient contact. There have beensome practical problems such as availability of telephone linesand confidential rooms. We also considered the effect on team members; do they see it as important that their colleague isrecognising their own need for support and reflection, or isit excluding of the team that these issues are not being takento them?

The telephone sessions have also had an effect on our pre-existing friendship. Initially the friendship gave us the feeling ofsafety necessary to discuss anything, but latterly the telephonesessions became our relationship and the friendship diminished.

Conclusions

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Conclusions

We see this method of peer telephone supervision as providingvaluable and essential supervision and support that would otherwisehave been hard to obtain in our isolated settings. We considerthat the telephone sessions have improved and enhanced ourprofessional practice. They have enabled us to compare servicesin two different rural areas with differing priorities and fundingof CAMH services, but nevertheless struggling with similar problemsof stretched, poorly resourced services and difficulties inrecruiting and retaining trained CAMHS professionals. In timesof personal difficulties it has kept us working safely.

In our opinion, peer telephone supervision should be seen ascomplementary to CPD peer groups, multidisciplinary discussions,mentoring networks, use of email and email forums and otherforms of supervision and support, not as a substitute. It isa practical method and we would emphasise the importance of formalising and structuring the peer supervision telephonearrangements. The supervision and support may be one factorthat would help prevent burnout. Pre-existing friendship isnot necessary, but the peers need to be able to trust and respectone another and communicate openly without fearing criticism or feeling threatened. Review and evaluation of the arrangementis also important and any difficulties should be addressed (Hawkins & Shohet, 2000; Counselman & Weber, 2004). It could be extended for use by consultants working in differentcountries or continents, particularly in the current era ofcheap internet telephone communications.

We would recommend that it be considered by all consultantswho need supervision and support or feel isolated, for whateverreason.

References

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