Chapter 2 – Supervision, autonomy and asking for help
By: Dr Rob Fleming
Different SAS anaesthetists will have different requirements for supervision, and these requirements will depend on the stage of their careers, their areas of expertise and the work they are undertaking. A career as an SAS doctor can take a doctor from more direct supervision, to less direct supervision, to autonomy.
The current SAS contracts are the Specialty Doctor, and the Specialist, which have different requirements and expectations associated with their eligibility criteria. In addition, the higher threshold within the Specialty Doctor pay scale delineates more experienced Specialty Doctors from less experienced Specialty Doctors, based partly on their supervision requirements. These two contracts therefore create three cohorts with the SAS workforce, with different expectations.
New entrants into the Specialty Doctor role are potentially early within their careers, and should therefore be expected to have supervision and support in keeping with their level of experience. This should be the same as that provided for a comparably experienced doctor in formal training.
Passing through the higher threshold of the Specialty Doctor pay scale carries a requirement to demonstrate an increasing ability to take decisions and carry responsibility without direct supervision. Doctors above this threshold should therefore have less direct supervision arrangements, but still be supervised unless otherwise agreed.
Becoming a Specialist carries an expectation of autonomy within that doctor’s area or areas of expertise. Specialists should be empowered to work with responsibility for their patient workload, as consultant colleagues are. This is a defining characteristic of the senior role.
The above levels of supervision correspond with the levels defined by the Royal College of Anaesthetists, in the document ‘Guidance on supervision arrangements for anaesthetists.’
||Direct supervisor involvement, physically present in theatre throughout
||Supervisor in theatre suite, available to guide aspects of activity through monitoring at regular intervals
||Supervisor within hospital for queries, able to provide prompt direction/assistance
||Supervisor on call from home for queries able to provide directions via phone or non-immediate attendance
||Should be able to manage independently with no supervisor involvement (although should inform supervisor as appropriate to local protocols)
||Autonomously practising anaesthetists requiring no supervision
Where there is an ongoing requirement for supervision, as described above, this supervision should meet the defined national guidelines for adequate supervision. The ‘Cappuccini Test’ (Cappuccini Test – The Royal College of Anaesthetists) exists to identify situations where supervision arrangements are inadequate or undefined.
The Cappuccini Test consists of the following questions:
Questions for the doctor being supervised:
Who is supervising you (name)?
How would you get hold of them if you needed them now?
Questions for the supervising doctor (named above):
Which lists (i.e. who) are you currently supervising?
What surgical specialty are they doing now, do you know of any issues that they are concerned about?
If they required your help, would you be able to attend?
Where supervision arrangements would not pass the above test, this means one of two things: either ongoing supervision is required but it is currently inadequate or this doctor is now demonstrating an ability to work with autonomy. If the latter, this provides an excellent opportunity to discuss whether progression to the Specialist contract might be more appropriate.
Asking for help
For doctors who are working with an ongoing expectation of supervision, the ability to consult your supervising colleague and seek support forms part of the supervision standards. Some doctors are understandably apprehensive about progressing beyond this supervision and working autonomously; however, being responsible for your own patient workload does not mean you are unable to ask for help.
Becoming a Specialist, or a consultant, should not require working outside of your capabilities or being unempowered to seek support. The General Medical Council (GMC) guidance on this is very clear. Good doctors make the care of their patients their first concern, and this includes recognising and working within the limits of your competence. Everyone should be able, and empowered, to consult colleagues where appropriate. No one is an island.
The Royal College of Anaesthetists’ Guidelines for the Provision of Anaesthesia Services: ‘The good department 2023’ chapter, suggests that departments should have a nominated anaesthetist immediately available to provide cover in clinical emergencies, as well as advice and support to other anaesthetists. It goes on to say that departments should positively encourage an overt culture of seeking support regardless of grade if working solo, or if a second opinion or some practical help would improve the situation.