Artigo 2 The doctors, their patients, and the supervision: How are supervisions

THE DOCTORS, THEIR PATIENTS, AND THE SUPERVISION: HOW ARE SUPERVISIONS MODULATED IN PSYCHIATRY SETTING?

Os médicos, os pacientes e a supervisão: como as supervisões são moduladas no contexto da psiquiatria?

Maria Eufrasia de Faria1, Rodrigo Almeida Bastos2, Egberto Turato Ribeiro3

1. Psychologist, doctoral student at the Department of Medical Psychology and Psychiatry, Faculty of Medical Sciences, State University of Campinas, Brazil.

2. Nurse, doctoral student at the Department of Tocogynecology, Faculty of Medical Sciences, State University of Campinas, Brazil.

3. Full Professor in Practice of Sciences at the Department of Medical Psychology and Psychiatry,Faculty of Medical Sciences, State University of Campinas. Brazil.

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ABSTRACT

Objective To understand the supervisory relationship established between the resident doctors and their supervisors, as modulated by stereotypical patients in an adult psychiatric outpatient clinic of a university hospital.

Methods Qualitative research with a phenomenological-humanistic approach. Subjects were 15 residents and 3 supervising physicians. Audio recordings of the in-person supervision of the resident’s patient care. There were 935 minutes of clinical discussions recorded, distributed over 66 audio recordings.

Results The residents conformed to three basic configurations: (i) configuration of defense, (ii) configuration of impotence, and (iii) configuration of perplexity. Though these three categories do not represent the totality of all of the possible conformations in the setting under scrutiny, they allow for an overview of the supervisory setting.

Conclusions The tone of the supervisions was modulated from the embryonic specificities of the demands presented by the clinical cases. These apprehensions stem from the patient's disease, illness, and sickness, representing concerns and clinical reactions resulting from the amalgamation of the resident supervisor and of the clinical case to a common denominator. These conformations are very relevant due to their pedagogical, formative and scientific value for the psychiatrists involved.

Keywords: qualitative research, psychiatry, clinical supervision, specialized medical education.

Introduction

Public policies, research, and clinical practice reveal the growing recognition of clinical supervision as the basis for high-quality mental health services.[1,2] Although clinical supervision plays a fundamental role in specialized medical education, it is the least investigated aspect of clinical practice, especially in regards to the contents taught during supervision. The work of Kilminster and Jolly [1] on medical bibliographical reviews is a seminal study on this subject. This study has provided essential recommendations for further scientific research in this area and, to this day, it continues to be a reference to several scientific studies. However, there is a demand for robust empirical studies that approach the processes of supervision in their real contexts.

Farnan et al. [3] published a systematic review of the effects of clinical supervision in medical residency, including psychiatry. Even if the object of their investigation differs from our research, their studies inform the direction of research in the field of clinical supervision. Farnan et al., in agreement with Kilminster and Jolly [1,2], reinforce that there are few empirical studies about the supervision processes from the perspective of the clinical practice, resulting in methodological limitations and a decrease in quality on the findings.

Supervision is a broad, complex, and continuous process. Like every relationship, it is dependent on the individuals involved and it is subject to style changes. For this reason, supervision has been understood as a mediator process to learning, as well as an aid to the human and professional development of those involved [4,5]. It is also used as an instrument for reflection, change, and transformation, with the pedagogical route as the mobilizing factor in this process [6,7].

Subjects involved in supervisions in the clinical setting of healthcare tend to value highly both aspects of form and content as well as the interpersonal aspects of supervision[9,10]. All these variables bring to the professionals involved emotional demands, which emanate mainly from the physician-patient relationship[11,12,13]. When this relationship includes psychiatric patients, emotional demands gain some specificities [8,10].

The modulating elements involved in clinical supervision in psychiatry take into account the common factors of the various theoretical models of supervision in this area[9,20]. Therefore, the context of clinical supervision in psychiatry happens in a space where supervisors and residents share their personal experiences and subjectivities[14]. Thus, the management of the emotional issues experienced by the professionals and the teaching of the medical practices occur in the same space, as illuminated by each clinical case. There are few studies that discuss the supervisory processes in the very settings in which the supervisions develop. [1,3]

In this sense, this study hypothesizes that it is possible to identify and name the different configurations of psychiatric clinical supervision using the patients' biopsychosocial profiles and their demands as a starting point. The objective of this study was to explore, in a university outpatient clinic, how the patients' biopsychosocial profiles and their demands configure the clinical supervisions in psychiatry, involving both supervisors and residents. Therefore, we believe that the findings of this study have implications for clinical practice and for specialized medical education as well.

Methodology

This is a qualitative study on clinical supervisions taking place in a university psychiatric outpatient clinic, based on a clinical-qualitative approach[15] through the use of purposeful sampling [15,16]. We monitored the number and availability of resident physicians and their supervisors enrolled in the study, directing efforts to be present at the weekly clinical supervisions. Eligible participants were physicians enrolled in a psychiatry residency program and the psychiatric supervisors of a psychiatric outpatient clinic at a Brazilian university hospital. Each supervision was recorded an taken as a unit to be analyzed, including the placements of both supervisors and resident physicians. Supervisors and residents authorized the recordings by signing a consent form.

The recording of the session was managed by one of the authors of this study (M.E.), who has experience and formal training at the graduate level in qualitative methods, as well as training in psychology. Clinical supervision occurred in the meeting room of the psychiatric outpatient clinic between the beginning and the end of each case. For these reasons, there was no need to elaborate a structured instrument to collect the data.

As participants, there were 03 supervisors and 15 residents, coded according to Table 1. The clinical cases of adult patients coming from the discharge of the psychiatric ward were recorded new clinical cases and specialties in general.

Table 1. Coded characterization of the study participants in regards to gender and function.

There were 935 minutes of audio-recordings, distributed over 66 files. We obtained approval for this protocol at each study site before each supervision. The participants received no incentive or compensation. The supervisions were transcribed by an author that removed all personal information that could identify the persons involved.

Nº Code Office Gender Nº Code Office Gender

1 SP1 Supervisor M 10 R7 Resident 1st Year M

2 SP2 Supervisor M 11 R8 Resident 1st Year F

3 SP3 Supervisor M 12 R9 Resident 2st Year F

4 R1 Resident 1st Year F 13 R10 Resident 2st Year M

5 R2 Resident 1st Year M 14 R11 Resident 2st Year M

6 R3 Resident 1st Year M 15 R12 Resident 2st Year M

7 R4 Resident 1st Year F 16 R13 Resident 2st Year F

8 R5 Resident 1st Year M 17 R14 Resident 2st Year M

The recordings were then analyzed using qualitative descriptive analysis to identify the themes articulated by the professionals during the supervisions. The first author undertook the initial and ongoing analysis of the data, developing the primary concepts. The second and third authors carried out a secondary analysis. This triangulation enhanced the trustworthiness of the concepts extracted [17]. Overarching concepts were developed to give a final sense of how the supervision process in psychiatry is modulated according to the subjective aspects of each case and each professional.

Results

A total of 66 recordings were competed. Among the participants, 6 were women and 12 men; 15 were psychiatry residents, and 3 were supervisors. We were able to identify three major configurations in supervision: Configuration of Defense; Configuration of Impotence and Configuration of Perplexity.

TABLE 2. Characteristics of the Configurations of Supervision

Category _{Related to: Evidenced by:}

Configuration of defense

 Emotional overload of the team.  Unestablished links;  Transference of responsibility. Configuração de impotência  Apprehensive clinical conditions and situations;  Precarious emotional

support.

 Focus on the infirmity;  Difficulties implementing

the therapies.

Configuração de perplexidade

 Clinical rarity or richness;  Challenging patients.

 Cases involving human human or scourge.

 Therapy influenced by the astonishment with the situation.

Configuration of Defense

It is the clinical case-based supervision setting that addresses an emotional overload experienced by the team caused by the multiple clinical and the relationship demands.

Difficulty establishing a mutual correspondence causes ineffective implementation and execution of the therapy. It also causes exhaustion, fatigue, and trauma.

“Over the last year, I've been arguing that the issue is not just medicine. She (the patient) verbalized an intention of high lethality. Now, when I return (to the doctor's office), I know it will be a heated situation. I'm afraid I even might get involved in an altercation there in the office. Are we on this level?" (R7 to SP2).

The team faces the patient’s unavailability affecting the fluidity of the relationship and treatment. The patient accommodates in her psychic illness and asks for the team's endorsement for this condition of inertia. This situation reflects on the relationship of engagement and involvement of the psychiatrists with the patient.

"The most disturbing of all is that she does not want [treatment], she does not ask herself that question. She has the symptom, she has the suffering, she has the wear and tear ... Kicking the can down the road, right? And she asks us to help pour oil over troubled waters. To give some medicine. "(SP2 to R2).

This neglect observed in some clinical cases makes it impossible to establish links and a more consistent relationship of involvement between the team and the patient. These clinical interpersonal behaviors are marked by the attribution of responsibility, oppression, or scenarios of mental abuse that extrapolate the praxis of clinical medical practice. There are clinical cases where resident-supervisors experience disturbing moments.

"In a second moment, I think you will only be able to do something to lower his risk with Quetiapine, if you can ‘stroll around the swamp.’ But it has an emotional demand. He's going to present his violence to you above the risk of suicide, understand? [...]. This is the bottom line: you are not responsible for his life, and you will not have control over all the perversities that he will do."(SP1 to R5)

Configuration of Impotence

This configuration regards the diseases and the criticality of the clinical cases. It concerns, above all, to the constitutive, evolutionary, and structural processes of the

pathology. Although the team may have a wealth of clinical resources and of intervention management techniques, actions are commonly used only in the palliative sphere. The scenario of the illness and its consequences prevent a more functional and effective intervention.

"Confused family members. It's a completely unhealthy family situation. Dude,

things are getting worse as time goes by. It gets more and more unbearable, more and more ... And what now? What can we do to intervene at this level? Her town does not even have a doctor. It makes me want to cry right here." (SP2 to R7)

The criticality resulting from the aggravation of the pathology and the context of the patient's psychosocial conditions afflicts the team. This emotional restlessness is potentiated when the team observes both a lack of support in the patient’s family and a shortage of social and institutional resources. These are clinical cases in which the clinical situation of the patient is doomed to fail. Therapeutic proposals or intervention resources will have minimal effect. Even holding the knowledge that the prognosis is harmful discourages the team.

"It's a touching story. It is a serious diagnosis. A very young patient. It's a nuclear explosion. When things are very serious, the doctors simply leave. " (SP2 for R1)

"The electro-neuro confirmed, but no one wanted to take responsibility for it. They left the boss behind ... "(R1 for SP2)

"Imagine the structure: You are 29 years old, educated, and an intelligent person who has a diagnosis of ALS (Amyotrophic Lateral Sclerosis), but has no doctor. I mean ... There are hundreds of doctors, but you don’t have one."(SP2 for R1)

Configuration of Perplexity

Discussion about challenging patients due to the richness of the clinic. These are clinical cases where the conditions of the pathology are added to situations full of mishaps, perplexity, and tragedies. These cases carry a big emotional burden as they reveal to the team, in a "visceral" way, the miseries of the human condition to which these cases are doomed.

"The parents passed away. [...] They started to tell him that he was going to be infertile [...]. He was always a more isolated person. [...] [His brother] died after drinking too much; he had a heart attack and died. One year ago, his daughter revealed who was the father of her 10-year-old son, something she never told anyone about. But it seems that the father was somebody in the family. When he found out he was shocked [...]. I[t was] probably a case of abuse. [...] What if it was this brother who died?" (R2 for SP2)

"Look, I always tell them: the advantage of you attending the psychiatric outpatient clinic is that you lose all your interest in television and soap operas. Nothing compares with what happens around here." (SP2 for R2)

These cases cause discomfort to the team because of the extent of the devastation and damages, both physical and psychic, that trigger the pathological scenario. It causes astonishment and commotion due to the inevitability of the illness, especially in the damages caused to the social, relational and emotional life of the person affected by this pathology.

"She's been taking the brunt of the family issues. The son is a convict. He has been jailed for the past 2 years for drug trafficking. 15 days ago he was arrested again because he beat his wife. The neighbor, that has the same age as her son, was murdered by drug dealers. And it was very violent, as in being beaten to death and left completely disfigured, to leave a message. She went to the funeral and it really impacted her. "(R7 for SP1)

"There are many things around her that are quite depleted from the human point of view. What do we do in such a situation? We do not even try to deny that she is fucked. Because it's real. We do not soften it up." (SP1 for R7)

The tone of the supervisions was modulated by the embryonic specificities of the demands of each clinical case. These apprehensions stem from the patient's disease, illness, and sickness, caused clinical/emotional mobilizations and afflictions in the team. The three configurations presented result from the amalgamation between the processes of the supervisor, resident, and the clinical case. These conformations are very relevant due to their formative, clinical, pedagogical, functional, applicable, subjective, and scientific values to the physicians involved, as table 3 shows.

Table 3: Supervisory configurations and their value implications Formative

Value

- The attribution of a type is a technical tool, equivalent to an x-ray. It helps to clarify the nuances and profiles of the supervision and of the clinical case in their structural and functional aspects.

- The common factors match the participants' discourse in a concentric format. It avoids disparate perceptions among professionals about the clinical case.

Clinical Value - The collisions of meanings broadens the horizons of understanding of those involved, potentializing and optimizing the reasoning and therapeutics implemented.

- It adds supplementary conceptual resources that assist in the recognition of the process of supervision in its functional aspects.

- The typification consubstantiates the constructs elaborated in the clinical discussions. It highlights the salient aspects of supervision.

Pedagogical Value

- It points out the didactic and formative values because it evidences the confrontation, the divergence, and interplay of the elucubrations verbalized among those involved, leading towards a common denominator of understandings.

Functional Value

- The effort to harmonize the vision of the team during the supervisory discussion process contributes to the principle of the economy of thought. - The shared reality of clinical discussion in didactic and conceptual terms leads to optimization, gains of time, improved chances of success, and team agreements.

- Mentioning some typological attributes or traces of identity usually has the power to break, with imminent force, the access to elementary or representative data of the supervision or the clinical case.

Applicable Value

- The sharing of the supervisory triad allows for the emergence of several management styles, expanding the scope of the clinical case resolution. - Supervisory settings contribute to guiding the strategies of treatment and management. This event occurs due to its topographic strength, which allows for identifying the disease, illness, or sickness, and to gauge how well the patient is coping with the situation.

Subjective Value

or Personal

Growth

- A crescent reverberation effect that allows comparing any experiences of the participants that remained latent.

- It has cathartic value in providing insights and contact with intrinsic issues, culminating in the settlement of pending issues and, consequently, fomenting the continuum of knowledge.

- It strengthens the tacit knowledge of those involved, as the clinical reports discussed create spaces for several and new professional and personal horizons.

Scientific Value

- Additional technical-conceptual model guiding the psychiatric clinical discussions.

- The supervisory settings may be scientific research models applicable to other health settings.

- Suggested future research that focuses on the supervisory settings and the correlation with psychiatric clinical management.

- Suggested future research that incorporates the subjective aspects and their effects on the supervisory processes.

- Research in this thematic area contributes to the scope of the medical literature, and above all to clinical supervision in medicine.

Discussion

This paper aims to explore how medical supervision is set up within a psychiatric outpatient clinic, examining shared experiences of the supervisors and the resident physicians during each case. Our analysis would suggest that supervisions are configured according to the clinical stereotypes of each patient. The relationship between the supervisor and the resident during each case was modulated by the emotional demands that each type of patient had both on the resident and on the supervisor, in a process known as “shared reality” [18]. This process consists of the subtle identification and apprehension of certain aspects of the patient's psychopathology. We applied the reasoning behind this concept to our research, regarding the apprehension of common factors that modulate supervision in the relational coexistence of the supervisory triad and describing the three configurations