“We’re All in the Same Boat:” Potentials and Tensions When Learning Through Sharing Uncertainty in Peer Supervision Groups

Abstract

Charlotte Tulinius presents some of the challenges of peer supervision groups in Denmark. In providing examples of how groups work, she illustrates core principles across different methods, including the application of reflexivity in the context of a patient-centred approach. Dr. Tulinius explores the cultural conditions and perceptions of GP professionalism that support the development and maintenance of peer supervision groups such as the concept of ‘sameness’. Her focus on the different ways groups are supervised provides insight into how groups can vary in their gain from participating in peer support groups. To illustrate some of the differences, she presents results from a study following three peer supervision groups over time. The chapter concludes with a discussion on the challenges in designing groups for sharing of uncertainty in ways possibly unique to Denmark but indeed relevant to anyone who wants to set up professional development based on uncertainty engagement methods.

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

In Denmark, GPs have participated in peer supervision groups for more than 30 years. Nowadays it is taken for granted that a newly qualified GP will join a supervision group within a few years of settling into a GP surgery. A recent study (Nielsen and Söderström 2012) has shown that approximately a third of all GPs participate in supervision groups, two thirds have been active in a supervision group at some stage in their professional life, and in 2003 95% of all GPs were organized in a peer group for supervision or professional development. The groups have different names, but have very often started as a “Tolvmandsgruppe,” later developing into a supervision group or a continuing professional development (CPD) group (Nielsen and Tulinius 2009).

Tolvmandsgruppe directly translated means “12-man group.” The concept has been used for at least 200 years in Denmark in many professions from cycle racing to editorial boards, describing the sharing of knowledge and decisions in a group of people. For Danish general practice this means groups of up to 12 GPs formed within a geographical area, the groups functioning as local professional peer support groups. Practicing within the same area, members can discuss their challenges within the local context and conditions of practice. Although some groups do not use a specific supervision model, I use the term “peer supervision group” throughout the chapter to simplify the description. (See Fig. 11.1 for an overview of GP education in Denmark, and Figs. 11.2 and 11.3 for an overview of the GP’s role in Danish primary care.)

These groups are so much a part of the discourse of GP education that being part of and learning how to work in a peer supervision group has been mandatory in medical specialist training for general practice since 2007. As part of its medical educational reforms in 2002 the Danish National Board of Health chose the “seven roles of the doctor” from the Canadian CanMEDS-2000 project as the educational framework for the construction of new curricula for all medical specialties in Denmark (Royal College of Physicians and Surgeons of Canada 1996). When constructing the new national GP curriculum, participation in a peer supervision group was suggested as a possible learning strategy for GP trainees to develop their roles as scholars, communicators, and professionals. A group of GPs already functioning as supervisors in GP peer groups from all parts of Denmark developed a description of core values and a training program for supervisor faculty development for these new trainee peer groups.

Before the educational reforms, an important factor in the breakthrough of peer supervision groups was a regulatory initiative to educate GPs in counseling to manage the increasing number of patients with mental illness (Nielsen and Tulinius 2009). The supervision initiative might have been triggered by other professional issues, but a change in the management of mental health just happened to be the incident that in general made many GPs aware of their need for peer support to sustain their professional development. The groups were also approved very early on in their development as a legitimate form of CPD, releasing (symbolic) funding for GPs.

Fig. 11.1

Overview of GP education in Denmark. Medical School in Denmark lasts 72 months. All medical graduates go through foundation training of 12 months, 6 months in a hospital post and 6 months in a general practice post (or two posts within two different hospital specialties). After foundation training the young doctor has the possibility of applying for an introductory post in up to two different specialties, making it possible to ensure the right choice of medical specialty. These posts are of 12 months duration in all specialties except general practice where an introductory post is normally only 6 months. However, if a young doctor has not been employed in general practice during foundation training, he or she qualifies for an introductory post in general practice of 12 months. The trainee has to prove mastery of eight basic competencies gained during the introductory post to qualify for application to a specialty training post. Specialty training posts are directed by a national competency-based curriculum, and consist of a clinical education and a theoretical education as illustrated in the figure

No matter where you are in Denmark, it takes no more than half an hour in a car to reach the sea. In Danish history living with, from, and on the sea has played a very prominent role in Danish everyday lives. Although industrial production and agriculture took over dominance of the national economy a long time ago, sailing and being close to the sea are still important parts of the culture in sports, the preferred summer holiday location, and in the language. To allow the reader to get a little more of the cultural flavor, I have employed some of the maritime metaphors used in Denmark to describe experiences with Danish GP supervision.

From one of the many islands of Denmark: Sejrø. (Photo Arthur Hibble)

The chapter is divided into four parts.

• In Part 1, “The Journey of a Peer Supervision Group,” there are examples of how a Danish GP supervision session might be run. I describe some common features of the different methods used in Danish GP peer group supervision sessions.

• In the second part, “The Waters to Navigate,” I enumerate the cultural conditions and perceptions of GP professionalism that support the development and maintenance of supervision groups in Denmark. An essential feature seems to be the double focus on teamwork between the group members and the supervisor, and on the role of the supervisor, issues that are also explored in this chapter.

• Part 3, “Is It Worth the Journey?” explores the published effects of supervision sessions, including some of the research results from a study following three groups over a period of 2 years.

• The fourth and final part of the chapter, “Voyages of Discovery, or Just Staying in the Same Professional Duck Pond?” will draw on examples from the earlier parts of the chapter and on my experience of being part of several peer supervision groups as a member, a researcher, and as an educator. Here I discuss potential tensions and challenges when peer supervision groups are set up to support learning through the sharing of uncertainty in “the Danish way”.

The Journey of a Peer Supervision Group

Many Danes have sailing as a hobby. From Svendborg Sund (South Funen), Denmark. (Photo Arthur Hibble)

Fig. 11.2

GPs and their role in Danish primary care

The Focus and Method May Vary

At least two methods are commonly used among Danish GPs, the Balint method (Balint 2000; Kjeldmand 2006) and reflecting teams (Andersen 1996), but there are several other approaches used around the country (Nielsen and Söderström 2012). Some groups are mainly focused on clinical updates, others are focused on professionalism in more general terms, and some are mainly social.

No matter what the approach, one thing seems to be the same: implicitly or explicitly sharing uncertainty among GPs regarding the management of their daily work, challenges in working with patients, regulatory bodies, implementation of new treatments, guidelines or new educational reforms, changes in local services for their patients, and so on. In groups that are mainly focused on professional development, group sessions can provide room for a systematic approach to the work, based on a challenge or question that has created uncertainty in one of the group members. In groups that are mostly focused around social networking, group sessions will provide a room for the individual GP to vent ideas or challenges in a less systematic way, but on a needs basis.

The methods, learning objectives, and aims of peer supervision groups are the focus of continuous discussion. The use of a wide spectrum of methods, and different perceptions of what peer group supervision is among GPs, became apparent when the Danish College of GPs advertised for possible facilitators/supervisors for the trainee supervision groups. GPs came forward who were part of (or trained to facilitate) groups using the Balint method, the reflecting team model, the Bendix method, and a model called “TERM.” The Balint method is described in detail in Chapter 4 of this book; the reflecting team model is a “fishbowl” type of model described in Fig. 11.4 (see also Chapter 7).

The Bendix method and the TERM models have been used to train GPs in the management of difficult encounters with patients, with a specific focus on communication skills and strategies. The Bendix model is based on audio recordings of the GP and patient, and at these supervision sessions the GPs train in active listening, often with the tape recording as the point of departure (Bendix 1991). The TERM model (The Extended Reattribution and Management Model) is used as a training program for doctors managing so-called “functional disorders” in general practice (Fink et al. 2002). On the business cards of course organizers and trainers across the country you can see an even wider spectrum of supervision activity described as “psychotherapeutic supervision,” “cognitive therapy,” or “mindfulness.”

The implementation of mandatory supervision still leaves much to be desired. In fact this learning strategy has only been fully implemented in half the country; evaluation of the initiative where it has been implemented is very sparse. The important issue, however, is that the Danish College of GPs now acknowledges supervision as paramount in the training of GPs in order to learn how to manage their CPD, defined as “professional development, personal development, development of self care, and taking part in supervision.”

The Common Core of Supervision Sessions

For groups I have been part of, have observed, or set up, a common element is that the sessions are experience-based, allowing the individual GP to present, explore, and discuss a selected problem in depth as a case, and with a supervisor as part of the set-up. The supervisor is sometimes labeled “the facilitator” or “the interviewer,” and in the descriptions of the sessions, I have chosen to use the term “supervisor” or “facilitator” for the person who leads and has the main responsibility for the process of the session. The presenting GP works with the problem as a “case” throughout the session, supported by the rest of the group. Through exploring questions, the supervisor supports the case presenter in refining the description of the problem. The rest of the group members listen to the case presentation, reflect and make associations with what they hear, and offer their reflections in parts of the session. The case presenter is then offered the possibility of reflecting and perhaps integrating the group’s reflections and associations in order to come closer to an understanding of what the case is about, as well as possible ways forward. Based on the grass roots, bottom-up ethos of development and often self- directed learning, peer group supervision demands a lot from both members and facilitators.

Cases brought to peer groups are typically about clinical challenges or the difficulties of interaction, collaboration, and teamwork between GPs and other colleagues, other professions, and patients. A typical case in a peer supervision group working with clinical challenges could be described as the “heart sink” patient, the patient who makes your heart sink by just seeing him on the list of the day’s encounters (O’Dowd 1988 ). It could be the patient who challenges your professionalism implicitly or explicitly: the patient encounter that makes you realize that your clinical knowledge or skills have become a bit rusty. Or it could be the patient with a need that puts you in a professional or perhaps ethical dilemma. If the patient is a child, how do you protect and support the patient at the same time as supporting a complex family situation that is part of the patient’s problem?

Cases focusing on cooperation difficulties might be experiences with another colleague inside or outside the GP surgery, with team members within or outside the medical profession, or they could be of a professional–political character, for example, “How do you handle a surgery when your secretary is on long-term sick leave?” or “How do you handle a hospital doctor refusing to receive a patient you refer to her?” Cases may also be of a more organizational or philosophical character, for example, “who takes care of the pastoral needs of my patients if I don’t?” or, “Am I a healer?”—a “suburban shaman” as Cecil Helman (2006) described it—rather than a medical “techno-rational professional,” to use Schön’s (1987) term. Some groups will also discuss issues that are less clinical and more within the role of the academic. Critical appraisal techniques, management models, or ethical and medico-legal cases would be typical for these discussions.

In some peer supervision groups, GPs pay a supervisor to facilitate their group. It is possible to apply for financial support to establish a new peer supervision group, but the funding will only pay parts of the costs. These supervisors are very often psychologists, psychiatrists, or GPs with supervisor training of some kind. Many groups, however, work with one of the GPs in the group as the facilitator on a rota system. This arrangement works well for several of the models, such as the reflecting team model.

Different Kinds of Expertise Are Involved

Many groups will have chosen the model they use to run the group, but these models do not themselves direct the focus of the discussions. Learning in groups of peers is dependent on different kinds of expertise in the group. As a part of the national GP curriculum the Danish College of GPs needed to write an educational program for the supervision element of GP training. Not surprisingly, this was not easy. The solution therefore was to ensure the faculty development of GP supervisors, giving them a shared understanding not of a specific model to be used, but a set of general values, and the competences for working in teams to be achieved through the program. These reflected the experiences of GP peer group supervision in all their diversity.

Seen from an educational perspective, Danish peer supervision groups are designed to allow learning to happen not because a professional expert is “telling” the learners, but because nonprofessional experts are sharing their experiences in order to gain a common understanding of a phenomenon. The learners are clinical experts, and experts on their working conditions, situations, and experiences gained from their work, but educationally they are seldom experts. The empowerment of clinicians through the peer group work consists not necessarily of widening their clinical content knowledge (although it might), but definitely widening their understanding of how to learn and develop as professionals, managing their clinical knowledge in their specific work settings. Fish and Coles (1998) have very elegantly described how to give professionalism back to professionals, a principle that very nicely captures the values of Danish peer group supervision.

Theoretically, nonprofessional expertise can also be understood through the lenses of social anthropology. The ethnographer, J. P. Spradley (1979). defined the “good informant” as a person who is a living part of the phenomenon you are studying, one who is able and willing to describe the phenomenon in nontheoretical terms, and who has the time to work with the researcher. The anthropologist learns from sharing knowledge and interpreting the shared knowledge together with the informant, negotiating an understanding that is neither the researcher’s original understanding nor the informant’s, but an understanding they have developed together, and is understood by both.

This phenomenological point of departure provides a good theoretical basis for understanding learning in peer supervision groups as the process of sharing experiences, adjusting professional/clinical behavior into alignment with the peer-acknowledged consensus. All doctors are experts on the clinical settings and situations they have experienced and bring to the group, and they are all good communicators, willing to give time, and most often communicating these in an (educationally) nontheoretical way. For supervision sessions, GPs bring their understanding to the group, share their understanding, and are open to negotiate their understanding by listening to peers.

The Waters to Navigate: Peer Supervision as a Culturally Embedded Professional Activity

The Danish Viking ship Museum in Roskilde offers the chance of going out in a boat like the ones used by the Vikings. (Photo Arthur Hibble)

Fig. 11.3

General practice in Denmark

This part of the chapter is about the key contexts, cultural conditions, and perceptions of GP professionalism that support the development and maintenance of Danish GP peer supervision groups.

There are probably several reasons for the popularity of peer supervision groups among Danish GPs. From the literature I cannot claim to know exactly why they are popular, but in this part of the chapter I describe possible professional and cultural factors contributing to the development of peer supervision as an activity that is taken for granted as part of professional life among GPs:

• The development of Danish general practice as cooperatives

• The inspiration from abroad and the cultural perception of GP professionalism

• The cultural concept of sameness

• Reflection and reflexivity

• Uncertainty as a general condition of work (and life)

• Striving to keep the human being at the center, including for the professionals themselves

The Development of Danish General Practice as Cooperatives

Denmark is a very small country, where good ideas can spread fast. Societies, unions, and cooperatives where ideas can be discussed have thrived for more than a century. In some parts of the country it will still be taken for granted that you are a member of at least one society, and if you are a homeowner, you are very often part of and expected to be active in the homeowner’s association covering your small local area. The foundation of the family doctor arrangement was sygekasserne (“disease societies”), based on the cooperative ethos, and established in the second half of the nineteenth century. Here people with a low to average income could be insured to have parts or all of their medical expenses paid by the disease society when seeing the disease society doctor with whom they were signed up (Vedsted et al. 2005).

In many parts of the Danish society there is a high acceptance of solving problems in small groups with similar interests, values, ideas, or perhaps similar challenges, translating into GPs working in group surgeries, and the tolvmandsgrupper described above.

Inspiration from Abroad and the Cultural Perceptions of GP Professionalism

Danish GPs have searched for inspiration from UK general practice for more than two generations, even before general practice was given medical specialty status in 1993. Since the mid-1960s individuals or groups of GPs have come to the United Kingdom to visit GP surgeries in the search for inspiration on professionalism, and work by Colin Coles, John Launer, the Tavistock Clinic, and Balint are always coming up when you discuss supervision in Danish general practice.

If a group of GPs decides to start a new supervision group they are entitled to approximately 2,750 Euros (US $3,600) per year to cover their expenses for supervision sessions. Of this they can use a maximum of 25 Euros (US $32.50) per person per day for refreshments, making it possible for groups to have a sandwich when they meet and meet at least 10–12 times a year. Thus being part of a supervision group, meeting regularly with the same group of peers is today acknowledged among Danish GPs, and perceived as a CPD method authentic for general practice and efficient for self-directed professional development (Tulinius and Hølge-Hazelton 2010).

The Cultural Concept of “Sameness”

The acceptance of professional development through sharing experiences in a peer group may also be supported by what anthropologists would call Scandinavian “sameness” (Haastrup 1990; Hervik 1994). Sameness in the Scandinavian contexts describes how people take the notion of being equal for granted. The concept of Scandinavian sameness demonstrates a strong linkage between equality and alikeness—homogeneity—among Scandinavian people. Sameness has been used to explain the strong development of feminism in Scandinavian countries as well as the development of legal regulations of work, for example, the Nordic worker–carer model which has given support to equal access of affordable day care for all children, maternity leave for fathers, and equal opportunities for both genders in the labor market (Boyle 2011). Although there is a fluid border between sameness and otherness in anthropological terms, it has also been suggested as one of the drivers for the political tendencies of nationalism, and as a way of understanding these (Hervik 1999).

When working with GP trainers I have met the influence of Scandinavian sameness in GP trainers’ discomfort in assessing trainees. When a trainee works in the GP surgery he or she is welcomed as a peer, an equal professional, and the concept of sameness seems to contradict the judging of your peer in the assessor role. In this way “sameness” might also support the flat hierarchy of a peer supervision group, making every experience equally worthy of discussion among GPs. No perception, no attitude, or no case could ever be described as less necessary to discuss in the peer group if of concern to any of the members of the group.

Reflection and Reflexivity

The use of reflection in relation to work-related experience is connected with an understanding of the consultation as patient-centered. In Danish general practice, a common understanding of the consultation includes the concept of inner dialogues and reflexivity. Reflexivity I define as “a self-conscious account of the production of knowledge as it is being produced” (Baarts et al. 2000). It means being aware of your own contribution to the way you and the other person construct meaning as you talk. Supervision groups using the Balint method or the reflecting team model allow GPs to bring the inner dialogues and understanding gained from their reflexivity during their day-to-day work so they can continue the reflective process, extending their dialogues from inner ones to explicit case discussion. For some GPs and GP trainees this will mean preparing for the supervision session, using a reflective log book in an e-portfolio, or reviewing the little yellow stickers on their desks. These will help to remind them of the issues they want to discuss with their peers, so they can extend their inner dialogues in the surgery into the external forum of peer supervision (Hoelge-Hazelton and Tulinius 2012).

Reflexivity is also paramount for the supervisor facilitating the session. The supervisor has to support the case presenter in getting a more detailed case description and hence understanding of what the case is about. If the case is understood in the same way and brings out the same feelings in the supervisor as in the case presenter, the supervisor may not sufficiently challenge the presenter’s perspective. It will be equally problematic if the topic of the case is morally or emotionally unsettling for the supervisor. No matter what kind of experience or attitudes she has in relation to the case, the supervisor will inevitably contribute to the way the case does or does not unfold. If her contribution to the understanding of the case is not made conscious, or is not taken into account by the supervisor herself during the session, her perceptions, attitudes, and behaviors in the situation can actually block the case presenter from unfolding the case the way that is needed in order for the presenter to develop professionally.

Used as a tool in anthropological research, reflexivity is described as “the conscious use of self as a resource for making sense of others” (Hervik 1994, p. 68). In the setting of a supervision group I would extend this to “…and for the supervisor to understand the process of supervision and her contribution to the development of the process as the session is taking place.” The aim of an anthropological study is to gain understanding of other lives and to produce new knowledge shedding light on everyone’s life. In peer group supervision, the aim of the supervisor is to use her own awareness of herself, and of her interaction with the people in the group, to help everyone become wiser, with the help of each other’s insights, about situations and dilemmas similar to the ones presented.

Here is an example of reflexivity in action in a peer group. As a supervisor in a group of doctors I was interviewing Sharon, who presented the case of a 12-year-old girl who had come on her own to her surgery. She described the situation in highly morally colored terms: “What mother would allow her 12-year-old daughter to see the GP on her own?” Sharon asked, thus judging the girl’s mother as irresponsible, and unfit as a parent. The harsher she spoke of the girl’s mother, the more irritated I became. Or perhaps even angry. At least, I was uncertain about the truth of the statements Sharon was making. “My own mother would have sent me alone to the GP when I was 12,” I thought, “not because she was a bad mum, but because she would have been working during GP opening hours! And yet, would I myself have sent my daughter alone to the GP? Would it not be dependent on how worried I was myself?”

As Sharon was unfolding the case I knew that I would find it hard to support her opinion and her pursuit of establishing that the mother was unfit, especially if no more information was available on why the girl had come alone. I asked myself: “How can I make sure that the next question allows Sharon to develop in her own pace, with her own perspective?” In the next second, Sharon looked at me with a glimpse of uncertainty. “I am sitting here listening to your case,” I said, “and wondering if you know why the mother was not with her? Did the mother actually know that the girl had gone to see you?” I felt the tension in my question, and although this was an attempt to open Sharon’s perception towards a broader explanation, I was also pushing her towards at least thoughts of a possible justification for the girl being in her surgery on her own. My experiences and feelings had made me less open and forthcoming in my role as the supervisor, and I had had to decide whether I would communicate this to Sharon at this stage or later. Whether helpfully or not, I was now putting my own fingerprint on the process of her journey to discover what this case was about.

When the reflecting group was invited to reflect, several of them gave stories of how they themselves had had to send their teenage children off to an appointment on their own. Would they have contributed in this way, if I had not pushed in that direction? At the end of the process I finally had the chance as interviewer to talk about the challenges I had faced in the conversation. This gave me the opportunity to describe my uncertainty about my response as the supervisor, and how I knew this had had an impact on the situation.

Uncertainty as a General Condition of Work (and Life)

Danish general practice was originally set up as it was in most western European countries, getting doctors out from the capitals and into the rural communities, close to where the patients lived and worked. Until 1993 general practice was not a medical specialty in Denmark. The perception among a lot of Danish doctors was exactly like Lord Moran’s description of English doctors “falling off the ladder” when leaving a hospital career to go into general practice (Royal Commission on Doctors’ and Dentists’ Remuneration 1960). Some doctors came from broken dreams of surgical or physician careers, others had grown up as countryside doctors’ children, knowing what their father’s or mother’s lives offered. A common condition for all of them was that “the path was made as they walked.” This description was used by the Norwegian professor of general practice Kirsti Malterud when she gave a lecture describing her career of becoming a researcher, doing research relevant for general practice work (Malterud 1988). In my opinion it is a very good description of all professional development in general practice.

To get a picture of the culture of general practice it is also helpful to listen to a group of doctors visiting but not yet fully embedded in GP culture. Studies have explored the perceptions of young doctors having their first encounter with general practice during their foundation training years, or later as GP trainees/registrars. In a focus group study of learning in general practice, a GP trainee described the constant need for professional development in general practice:

What I had heard at the hospital departments before I started was that general practice was some sort of “low-level-a-little-of-a-lot-of-specialties,” but I very quickly realized that general practice is everything that is not described in the textbooks we read at medical school. I really admire the GPs now, they just have to learn all the time. (Kjær and Tulinius 2004)

Another feature of general practice that fits with the use of peer group supervision might also be the existing learning environment in general practice, and the ethos of learning embedded in the work there. Again the fresh eyes of a young foundation doctor described this perfectly:

[In general practice] I think you learn a lot about how you work as a doctor, as an individual doctor. You detect your limitations because there is room for it. … [T]he older GPs tell you that they sometimes are uncertain and how they have experienced being afraid in professional situations. At the hospital departments the doctors don’t talk about this. You are more alone at the hospital. You are running around with the “beeper” afraid of making mistakes …. (Kjær and Tulinius 2004)

Uncertainty was and is still a given condition when working in general practice. This has been beautifully described theoretically as “finding your way through the swampy lowlands of general practice” (Schön 1987). Philosophically it would be difficult to argue against the anticipation of uncertainty as a given condition of life in general practice. The postmodern human being is described as being constantly searching for certainty in an uncertain life, minimizing the uncertainty whenever possible. It is my perception that GPs are so close to people’s everyday life, that the conditions of everyday life in general constitute an important contribution to their medical professionalism. The uncertainty of the patients’ lives is shared with and by the GP.

When asking GP trainees what they learn from patients during their training, the essence was an insight into how people in general manage the uncertainties of life, and understand and maneuver in a framework of lay knowledge to handle the challenges of illness (Tulinius, unpublished data). Sharing uncertainty in peer groups makes it possible to integrate uncertainty as a natural part of the professional development of this specific professional group, and it makes it possible for GPs to sustain professionalism despite carrying their own as well as their patients’ uncertainty in life.

In their book about producing knowledge in health and welfare through reflective practice, Taylor and White (2000, p. 200) describe how practicing reflectively may be seen to produce uncertainty, whereas working with the certainties of evidence-based research and applying them to practice can seem to be much easier. Their point is, however, that reflective practice switches the application of the technical knowledge to managing it in the encounters with the individual patient. In this way reflective practice as seen in Danish peer group supervision can support practitioners in establishing how to manage knowledge. There may be a cultural expectation for doctors these days to be professional robots in the way they perform: over the last few decades they have come under continuous public scrutiny. However, doctors are in some ways protected by their professional robe, and holding on to uncertainty could be a consequence of culturally embedded expectations for them as one of the classical professions.

Striving to Keep the Human Being at the Center, Including for Professionals Themselves

Part of modern GP professionalism is to practice evidence-based medicine, to apply the newest guidelines, working within a fixed health care budget that contributes to the needs of the health care service. This is in accordance with expectations from regulators and patients, and within a society that is changing every minute. CPD activities support updates of knowledge and clinical skills, but dealing with the pressure of keeping abreast is itself often not seen as part of CPD in Denmark. The normal human responses to these demands, pressures, and continuous developments are not addressed in CPD activities.

In fact, a normal human response to these demands is very often described as pathological in relation to professionalism: How often have you heard feedback on a professional issue start with “Now there is no reason to personalize it!” How often have you heard someone talking about an “emotional response” as opposed to “being professional”? In our culture showing anger, sorrow, or any other emotion as a reaction to a professional problem is seen as unprofessional. You are supposed to continue smiling and behaving in a way that does not distinguish you from any of your peers in terms of personality, and act as if you were stripped of emotions. However, a doctor, a human being without emotions striving to practice empathically, is an oxymoron, creating paradoxes in the understanding and management of what it means to practice professionally.

Doctors are heavily socialized from the start of medical school and throughout their careers. Being a doctor is so closely linked to identity that distinguishing between you as the doctor and you as the person is very often just not possible. If not supported, the doctor will not be able to manage the pressure and burnout and compassion fatigue have been described as consequences (Figley 2002). In peer group supervision you can take off your coat of professional armor, and allow yourself to be human with a mixed professional and personal identity, integrating the feelings of a normal human being.

Is It Worth the Journey?

At Holbæk Fjord on a cold stormy November day. (Photo Arthur Hibble)

Fig. 11.4

Working with a reflecting team

In Peer Group Supervision You Can Work with a Broad Range of Professional Challenges

Not much has been published on the effect of supervision within Danish GP peer groups. In this part of the chapter I explore some of the reported effects of GP peer group supervision. Although the study described below relates to a specific project that took place in three supervision groups, its findings may be relevant to Danish peer groups generally.

Over a 2-year period we studied three peer supervision groups of GPs. Their supervision had a topic as its focus: children in need. The aim of the project was to prevent the neglect of children by early and competent action and to strengthen the professional identity of the participating GPs in children’s cases. The specific learning objectives were to strengthen the GPs’ competencies in:

• Identification (of a child case)

• Referral (of a child to relevant local initiatives or parts of the social and health care system)

• Intervention (relevantly in a child case)

The groups met for peer supervision 8–10 times a year. They were observed and interviewed and also contributed to the evaluation of the study by written evaluation forms. The analyses of all their cases showed four general themes in relation to the challenges raised by the cases (Tulinius and Hølge-Hazelton 2010).

The general themes were challenges involving:

• Definition and maintenance of personal and professional boundaries. Examples of questions asked in this category were:

  • “How can the GP express or point out to the parents that the behavior of their child when present in the surgery shows that the parents are not setting boundaries for the child?”

  • “How can the GP approach the discovery of parents’ medicalization of a child?”

  • “What can a GP do if parents ‘experiment’ with alternative treatments for their child, rather than following the more conventional treatments prescribed?”

• Feelings of doubt, powerlessness, or uncertainty related to the GPs’ own professionalism. Examples of questions asked in this category were:

  • “Within the time and legal limitations of general practice, creating risks of misjudgments, how can the GP put herself forward as a resource person?”

  • “How do you approach a young person in crisis when there is a history of self-mutilation?”

  • “How do you as a GP support a child who functions as an interpreter for a seriously ill mother?”

• Directing attention to problems that the child or his or her family had not brought up themselves. Examples of questions asked in this category were:

  • “How do you as a GP talk about obesity in a family not aware of the issue, without coming across as moralizing or condemning?”

  • “How do you as a GP ensure the safety of children of drug-abusing parents?”

• Collaboration with other professionals working with children and families. Examples of questions asked in this category were:

  • “How does the GP deal with frustration when parents are sent by other professionals to ask for referrals from the GP?”

  • “What does the GP do when there is no action taken on a referral to the social authorities concerning a child’s safety?”

We do not know whether these themes would replicate across other topics and in supervision groups without a topic focus. However, a key ingredient of all the themes is uncertainty about the full range of GP professionalism: from uncertainty regarding specific clinical situations and the relationship with the patient, to those regarding personal and wider professional issues.

Using a mixed method evaluation design it was possible to categorize the 70 cases presented and discussed in the study. They primarily described problems concerning the parental roles, such as behavioral problems, and problems related to events such as death, divorce, war, and torture. It was characteristic that almost half of all the presented cases were brought up in the supervision because of the doctor’s anticipation of a potential problem or worry for the child/family, and not because the parents themselves presented the topic as a problem to the GP.

Many of the cases could be described as a form of indirect consultation for children, occurring when the GPs became aware of a patient’s problematic family circumstances. Several cases even described potential problems for an unborn child. The analysis and detailed cases can be found in Hølge-Hazelton and Tulinius (2010), but below are a few examples:

• “Since her divorce the mother of two teenagers has started drinking a little. The father does not want contact with his children. The GP can see the whole family feels terrible and the GP is frustrated because there is nowhere suitable to refer them.”

• “Mother with preschool child. The problem is access to the father, whom the mother describes as a psychopath. The mother wants to go ‘undercover’ with the child and consults the GP.”

• “Toddler spoils things in the GP’s office while the parents are completely passive. The GP is irritated at the child but does not want to expose the parents.”

• “A concerned neighbor of an alcoholic divorced mother of two children calls the GP. The GP knows the mother but not the children.”

• “Young pregnant women with a violent boyfriend: the doctor is concerned about the woman’s capability for motherhood.”

Although all participants in this study described tremendous professional development gained from the peer supervision sessions, the groups had an uneven result when studied at an individual GP level. There are many possible explanations for this. One explanation could be the GPs’ different experiences both in terms of clinical experiences, and experiences in the use of supervision as a CPD method. GPs with long clinical experience and prior experience of peer group supervision were more likely to develop to a higher level of professionalism and in accordance with the curriculum for the intervention, than GPs with short clinical experience and/or no prior experience with supervision

One of the more inexperienced GPs seemed to have set his expectations too high or perhaps wished for more complicated learning to happen. Referring to himself as being a novice GP, he also expressed the need to develop his own experiences rather than what he described as “transferring knowledge” from the more experienced GPs (Hølge-Hazelton and Tulinius 2012). This particular GP did not experience the supervision group as a group of peers. This might reflect that age, clinical experience, perhaps gender, and perhaps other parameters are important to consider when a new group of peers is started. It is, however, to me, also a sign of a dysfunctional peer supervision group, possibly influenced by the skills, attitudes, and professionalism of the supervisor.

Supervisors from Within or Outside the Profession Might Make a Difference to the Outcome

No matter whether the facilitator has another educational background, or is a GP himself, the task is to allow for the case presenter to get to a better understanding of the presented case: “What is this case about?” The facilitation skills comprise the same kind of openness to the structure and content of the session as an ethnographer’s acceptance of the phenomenon as it is presented to her. The ethnographer will have to follow wherever the phenomenon takes her, and explore the aspects of the phenomenon presented to her, and go with the description evolving in the collaboration between the case presenter, the supervisor, and the rest of the group. During the phase of exploration of “what is this case about?” listening and analysis skills are paramount to allow the GP to unfold the case. The learning potential is not just in understanding how to manage the specific case, but to understand the different aspects of professionalism that the case illustrates, see possible transferable aspects, and to unveil possible learning needs for the case presenter as well as the rest of the group members.

In the evaluation study of the three groups of GPs referred to above, two groups had a GP as their supervisor, and the third group had a psychologist (Hølge-Hazelton and Tulinius 2010). It is not possible to generalize from this study to all peer supervision groups in Denmark. It is, however, interesting that comparing the psychologist supervisor-led group with the GP supervisor-led groups, the learning processes and outcomes were very different: in the group with the psychologist supervisor the GP members of the group established a common understanding of holes in their collective knowledge, the learning potentials of the group, the learning needs, and how and where to go to improve their professionalism.

The groups facilitated by the GP, on the other hand, developed a strong sense of praxis and professionalism among their peers in the group (see Chapter 3) and felt supported by the development of “a collective we,” but they never reached the point of defining gaps in their knowledge or new learning objectives. In the group where the facilitator was a psychologist, the protective “collective we” did not set in as a solution to the same extent. This is not to say that psychologists are better facilitators than GPs who have gone through supervision training, but to raise awareness that the focus of professional development is different within different disciplines, and to underline that unless the supervision method is supported with clearly described processes and outcomes, the perception of what is professional development will influence the group dynamics and learning processes in the peer supervision groups.

Every year a few centimeters of Denmark disappears into the sea (Photo Arthur Hibble)

Fig. 11.5

Two kinds of supervisor

Preventing Burnout

Dr. G: ‘… Do I want to be part of a research study on life style advice in general practice!!!?? And it “only” takes three hours! Are you aware what it is like being a GP in a single handed surgery?! (Speaking very fast). I see a new patient every ten minutes, my secretary left two months ago and I haven’t found a replacement yet. I have no breaks, I work from eight in the morning till ten at night, I am behind schedule for sending in my claims, my tax accounts have to be sent in by next week, my husband is asleep when I come home at night and when I leave in the morning. I just can’t take it anymore … (starts crying).’

Dr. G was one of almost 200 randomly picked Danish GPs we talked with over the phone to recruit 40 GPs for five focus groups on lifestyle advice in general practice (Tulinius and Dencker 2001). The project was unrelated to supervision groups but its findings have implications for them.

Most of the GPs just explained that they were too busy to participate in more activities, but four others reacted like Dr G, yelling or crying on the phone with me or my colleague, a total stranger on the other end of the line. We asked for 3 hours of their lives to describe their needs and opportunities for CPD within the context of GPs giving lifestyle advice. To me it was terrifying and a very clear sign of just how much psychological pressure these professionals experienced. Did they have anyone with whom to discuss this? Who were supporting them? How close were they to breakdown or even burnout?

Evaluation reports have shown that Danish doctors who are part of a supervision group experience better communicative skills, that they develop personally and professionally; that they have better job satisfaction, and that they find supervision to have a preventive effect on a feeling of burnout (Firth-Cozens 2001; Soler et al. 2008). When examining GPs from other countries, preliminary results of studies point in the same direction as this finding: when Balint-group–trained they have better job satisfaction, higher awareness of their own feelings, better psychological skills, and more tolerance with patients with uncertain diagnoses. However, looking at other professions such as private practicing psychologists the picture is not so clear, and among these professionals it has not been possible to confirm supervision as a significant predictive factor for burnout and compassion fatigue (Clarke 2007).

Voyages of Discovery, or Just Staying in the Same Professional Duck Pond?

This final part of the chapter draws mainly on my experiences of being part of several peer supervision groups as a member, a researcher, and as an educator. Here I discuss potential challenges when peer supervision groups are set up to support learning through the sharing of uncertainty in “the Danish way”.

The Construction of the Professional “Collective We” for Better and for Worse!

“We are all in the same boat” was a Danish revue song from 1944 describing solidarity during hard times (and an only slightly concealed resistance message). It was performed during the Occupation, has been carried forward colloquially for generations, and is used today with the same meaning. It builds nicely onto the idea of Scandinavian sameness: no one is more than me, hence no one is going to tell me how to run my surgery. On the other hand, if I have a problem, other GPs will have the same problem, and we will have to solve the problem for the profession. Using the peer group as a safe place to disclose your challenges and problems, it becomes possible to find solutions that all agree on, and the professional “collective we” is born.

The “collective we” can be used as a claim for professionalism in certain groups, thus giving clout to a statement. For example, in Denmark I very often hear GPs say “in general practice we . . .,” as the start of a description of work practice, attitude, perceptions, educational practice, and the like. In Danish grammar this “we” is not describing specific persons, but rather the professional we, the cooperative concept of any GP. This concept has both advantages and disadvantages when used in a peer group learning setting.

Where uncertainty rules or at least colors every action, the need for certainty and approval rises. Postmodernist life has been described as an attempt to minimize the size, impact, and number of risks that we all unavoidably meet in life (Fox 1999). Establishing a common “we” in the group of equals then supports the development of the identity of the profession. This is how we do it in our profession, in our part of the profession, in our part of the country, in our peer group of the profession. Acknowledging solutions to cope with uncertainty offers a kind of counterweight certainty against chaos. So does agreement on what is good medical practice, as seen in the examples from peer groups.

In the study mentioned above, evaluating learning in Danish supervision groups (Hølge-Hazelton and Tulinius 2010) it was also clearly shown that the construction of a “collective we” can also have the opposite effect: limiting the development of professionals. Medicine is one of the classic professions, characterized by a monopoly on knowledge, a codified language, autonomy, authorization, self-regulation, and adherence to an ethical code of practice, giving a certain status in the society (Cruess 2006). Classical professions such as medicine can, however, also be perceived as under threat, stimulating the profession’s need to maintain its privileges, and this can possibly draw members of the profession in two directions: the establishment of new platforms; development of the original base of knowledge, language, and status; or a tightening of the original regulations and classifications, making sure that the profession is not diluted by any factors, by other professions or nonprofessions (Figley 2002).

In this connection, Saltiel (2010, p. 141) writes about reflective practice in the health care sector as follows: “… [L]anguage constitutes rather than reflects reality. Reflective accounts are as artfully constructed, as storied, as any other usage of language. They give access to how professionals construct their identities (and those of service users) and their practices but they are not, by themselves, enough.” There is no doubt that this sets high demands on the methods and structure of supervision groups to maintain the potential for professional development.

In the same study, the development and outcome of supervision was also examined (Tulinius and Hølge-Hazelton 2010). The aim was for GPs to use peer group supervision as part of their CPD in order to develop their professional identity, with the specific focus of supporting children with special needs. Several of the GPs in the groups felt challenged when working within this field. Actual knowledge was sparse in all the groups, and the experiences of dealing with these cases were at best patchy. The scarcity of professional knowledge within the topic and the focus on the “collective we,” the “us” as normal human beings in the room, meant that the GPs drew on their own family values and experiences. Moral perceptions very often took over the session, and almost no new knowledge was allowed into the forum, let alone requested as a possible learning need for the group.

In Fig. 11.5 you can see an example of the difference between the construction of a “collective we” consolidating professional identity but limiting development (Group 1), versus challenging the identity and opening the possibility for development of the “collective we” (Group 2). In the (probably unconscious) attempt to keep professional control of the GPs’ knowledge base, praxis, and cooperation with partners in supporting children with special needs, the “collective we” became protective of the current profession in some of the groups rather than challenging the professionalism of this area. The psychologist supervisor more often challenged the knowledge within the group than the GP supervisors. In this way the psychologist-led group members were sent out into more open waters than the GP supervisor-led group.

We do not know how common a lack of challenge is in GP peer supervision groups in Denmark. In the groups where the challenge of professionalism is not happening, change is probably going to be difficult because peer group supervision in Denmark is perceived as an integrated part of the professional life and characteristics of being a good GP. A way forward for supervisors who use the “collective we” as professional protection, would be to allow themselves to include competencies from the field of medical education to a higher degree. In this way they would be able to use educational principles such as the zone of proximal development (Vygotsky 1978) and an understanding of education towards professionalism as dynamic and evolving as described by Stenhouse (1967) and Jarvis (2002, 2006) to support the group’s professional development beyond the current praxis of general practice. The boat would not have to stay in the protected lakes and bays of the fiords; it would be able to go out to open sea with all the security installations needed to make for safe travel.

Far from the mainland with one of the many Danish ferries. (Photo Arthur Hibble)

Conclusion

The development of professionalism through Danish peer group supervision depends on the banks surrounding the water. The potentials of peer group supervision as established in Denmark are not difficult to spot: supporting self-directed learning in how to improve professionalism among individual doctors who have to make the path as they go about their daily work, navigating in different kinds of uncertainty within a broad range of challenges. The grass roots bottom-up design allows “giving professionalism back to the professionals” (Fish and Coles 1998), developing authentic questions and authentic answers to support GPs in their everyday clinical work.

But (because there is a “but”) unless there is an explicit educational strategy decided by the group and the supervisor in order to counteract it, this way of working is also likely to stimulate the construction of a “collective we” that can be more protective of current praxis than stimulating the development of future practice. The boat can certainly be controlled by all the rowers, but there is a difference as to whether the boat is led out into the open sea, looking for solutions and inspiration from a wider world, understanding what is not already understood by the individual crew members; or if the boat stays in the same duck pond, the crew carefully monitoring and describing the calm surroundings and unchanged depth of water, to reassure themselves that the crew is still able to maneuver in this particular pond, while their capacity to get out into the open sea is unrecognized, unchallenged, and untrained.

Doctors need to be responsive to changes in society, patient expectations, current evidence of best practice and the needs of the health service. I have no doubt that peer group supervision—supported by a supervisor and conducted in accordance with educational principles—can provide one of the best training methods for the professional survival of doctors.

Spring time with oilseed rape fields, showers, and the smell of the sea. Sejrø, Denmark. (Photo Arthur Hibble)