Portal de Periódicos da CAPES

Being a good educational supervisor

2020; Elsevier BV; Volume: 21; Issue: 3 Linguagem: Inglês

10.1016/j.bjae.2020.10.002

2058-5357

J. Barrie, S. Walwyn,

Medical Education and Admissions

Learning objectivesBy reading this article, you should be able to:•Explain the process of educational supervision of a trainee.•Assess your approach to supervision in the light of educational theory.•Detail the pitfalls and difficulties in educational supervision.•Describe how educational supervision can be affected by the personal factors of the trainee and the supervisor.Key points•Educational supervisors should understand the principles of good supervision and be trained in these principles.•The educational supervisor's approach to supervision should be non-judgemental, objective and personalised to the needs of the trainee.•Both the educational supervisor and the trainee should prepare thoroughly for meetings beforehand.•The supervisory process should consider all aspects of the trainee's role and not be limited to clinical work only.•All meetings, evidence and discussions relating to educational supervision should be carefully and thoroughly documented. By reading this article, you should be able to:•Explain the process of educational supervision of a trainee.•Assess your approach to supervision in the light of educational theory.•Detail the pitfalls and difficulties in educational supervision.•Describe how educational supervision can be affected by the personal factors of the trainee and the supervisor. •Educational supervisors should understand the principles of good supervision and be trained in these principles.•The educational supervisor's approach to supervision should be non-judgemental, objective and personalised to the needs of the trainee.•Both the educational supervisor and the trainee should prepare thoroughly for meetings beforehand.•The supervisory process should consider all aspects of the trainee's role and not be limited to clinical work only.•All meetings, evidence and discussions relating to educational supervision should be carefully and thoroughly documented. The supervision of postgraduate trainees in clinical practice has been defined as, 'The provision of guidance and feedback on matters of personal, professional and educational development in the context of a trainee's experience of providing safe and appropriate patient care'.1Kilminster S. Cottrell D. Grant J. Jolly B. AMEE guide no. 27: effective educational and clinical supervision.Med Teach. 2007; 29: 2-19Crossref PubMed Scopus (270) Google Scholar Whilst the precise manner in which training is organised varies from jurisdiction to jurisdiction, the principles are universal. In the UK, supervision is divided into clinical supervision (which covers the trainee's clinical work) and educational supervision (which covers the trainee's overall educational progress). These are overseen by a clinical supervisor and an educational supervisor (ES), respectively. In anaesthesia, the trainee may receive clinical supervision from a number of colleagues. The role of the ES in coordinating and overseeing training progress becomes more important in this system. An ES is defined as one who 'is responsible for the overall supervision and management of a doctor's educational progress during a placement or a series of placements. The educational supervisor regularly meets with the doctor in training to help plan their training, review progress and achieve agreed learning outcomes. The educational supervisor is responsible for the educational agreement, and for bringing together all relevant evidence to form a summative judgement about progression at the end of the placement or a series of placements'.2General Medical CouncilPromoting excellence: standards for medical education and training. R2.15. General Medical Council, London2015Google Scholar The role of the ES therefore has educational, supportive and administrative functions.3Evans C.S. How to be an educational supervisor.in: Cooper N. Forrest K. Essential guide to educational supervision in postgraduate medical education. Wiley, Chichester2009: 21-31Crossref Scopus (1) Google Scholar The ES also has to balance the learning needs of the trainee with service needs of the department in which they work, and advocate for the trainee's training needs within this. In some countries, including the UK, the ES also has a 'gatekeeper' role, as the final report plays a key role in deciding whether a trainee has fulfilled the requirements of the training programme, and can proceed to the next stage of training. Fulfilling these roles will require the ES to use a range of skills:3Evans C.S. How to be an educational supervisor.in: Cooper N. Forrest K. Essential guide to educational supervision in postgraduate medical education. Wiley, Chichester2009: 21-31Crossref Scopus (1) Google Scholar,4Davys A. Beddoe L. Approaches to professional supervision.in: Beddoe L. Davys A. Best practice in professional supervision: a guide for the helping professions. Jessica Kingsley, London2010: 24-49Google Scholar(i)Teach.(ii)Facilitate rather than direct.(iii)Challenge without being threatening.(iv)Career guidance.(v)Mentor and support.(vi)Help the trainee engage with the organisation.(vii)Administer, for both regulatory and accountability purposes. In many countries, postgraduate training follows a cyclical process, illustrated in Figure 1. There is an initial meeting between the trainee and the ES at which learning objectives for the stage of training are agreed. During the trainee's episode of training, there will be a number of interim meetings at which the learning agreement agreed at the initial meeting is reviewed and revised as appropriate. At the end of the training period, there is a final meeting, often followed by an external review of the trainee's progress, at which a decision regarding procession to the next stage of training is taken. (In the UK, this is taken at the annual review of competence progression [ARCP], although the cycle is not necessarily annual elsewhere.) The cycle begins again, either with the same ES or a different one, depending on the arrangements of the training programme. This article will describe aspects of the role of the ES in terms of initiating the supervisory relationship, interim supervision and review before progression in training. It also briefly discusses some aspects of educational theory underpinning supervision. Whilst most research is undertaken in the face-to-face supervision of trainees in approved training programmes, the principles can be applied to remote supervision or supervision of doctors in non-training posts. Areas specific to UK practice are identified as such. The range of roles undertaken by the ES gives an indication of the skill set that they require and the extent of training needed to undertake these roles. Being an ES places some obligations on the supervisor even before meeting the trainee. First and foremost amongst these is that the supervisor should understand the duties and remit, be trained to fulfil these duties and keep up to date with changing requirements. The supervisor should also understand the educational objectives of the trainee's stage of training, including the requirements for any examinations or other assessments and the requirements for any assessment of competence before progressing in training. The supervisor should also review the trainee's portfolio, if possible, to gain an appreciation of the trainee's relative strengths and limitations.3Evans C.S. How to be an educational supervisor.in: Cooper N. Forrest K. Essential guide to educational supervision in postgraduate medical education. Wiley, Chichester2009: 21-31Crossref Scopus (1) Google Scholar Ideally, meetings between the trainee and the ES should take place shortly after the trainee joins the department, in a private space at a mutually convenient, dedicated time, although pressures of workload and office space may make this difficult. The initial meeting aims to discover and reconcile three things: the learning needs of the trainee, the educational opportunities of the placement and the requirements of the curriculum.5MacDonald J. Identify learning outcomes for learning agreements.Educ Prim Care. 2012; 23: 128-130Crossref PubMed Scopus (2) Google Scholar The meeting should therefore be long enough to allow this. The learning needs of the trainee will reflect the trainee's prior experience, development needs, special interests and intended career progression. Some of these will be guided by the requirements of the training programme, whilst others are more personal to the trainee. These learning needs should be developed in the light of a recognised framework for organising educational goals, of which the most commonly used is Bloom's taxonomy of learning.6Krathwohl D.R. A revision of Bloom's taxonomy: an overview.Theory Pract. 2002; 41: 212-218Crossref Scopus (2826) Google Scholar Bloom's taxonomy aims to encourage development from a basic understanding of the topic through the ability to apply and critique understanding to a creative development of ideas. The taxonomy describes six levels of learning, from recall through to the generation of new ideas (Fig 2). These levels are expressed in terms of verbs, progressing from 'low-level' verbs that indicate recall, but not necessarily understanding (e.g. describes, demonstrates, etc.) to higher-level ones that indicate the ability to critique, synthesise and evaluate the material (e.g. apply, prioritise, generate alternatives, etc.). The educational opportunities of the placement will vary from department to department depending on the clinical case mix, workload and the specialist interests and skills of the trainers. As far as possible, the training offered should reflect the particular strengths of the unit, for example, building on any expertise in total i. v. or regional anaesthesia. These three aspects form the basis of the learning agreement between the trainee and the department. The learning objectives are prioritised in terms of the degree of gap to be covered, urgency, feasibility and opportunity to deliver, and then formalised as specific, measurable, achievable, realistic, and time-bound (SMART) objectives. It may be helpful to define learning objectives in terms of demonstrable verbs, progressing from low-level verbs (describes, demonstrates, etc.) to higher-level ones (applies, prioritises, generates alternatives, etc.) as training progresses.7Biggs J.B. Tang C.S. Constructively aligned teaching and assessment.in: Biggs J.B. Tang C.S. Teaching for quality learning at university: what the student does. 4th Edn. Open University Press, Maidenhead2011: 95-110Google Scholar The learning agreement should be formed at the initial meeting. Having agreed a learning agreement, the ES and the trainee should discuss how this is going to be fulfilled and how progress against it is going to be measured. These components should be aligned according to Biggs's principles of constructive alignment. Constructive alignment is based on two principles:(i)The trainees learn by constructing meaning from what they do in the context of their prior understanding of the subject.(ii)The ES makes a deliberate alignment between the curriculum, the learning objectives, the planned learning activities and the methods of assessment. The supervisor helps create a learning environment that supports activities through which the trainee is enabled to achieve the learning objectives agreed in the learning agreement. Assessment instruments align in both format and criteria with both the learning objectives and means of development. To some extent, these are constrained by the educational governing bodies and curricular limitations. However, the ES should aim to use any prescribed assessment tools in as constructive a manner as possible. For example, a trainee wishes to develop competence in ultrasound of the lumbar spine. This is judged appropriate for the stage of training and achievable in the training environment, and so is made part of the learning agreement for the trainee's placement. The ES models good practice in training on his or her own operating theatre lists, and advocates for it within the wider department. The trainee is able to optimise training by utilising the local training opportunity, facilitated by the ES, and the trainee's progress is documented via assessment tools that assess skill development. There should be a number of interim meetings between the trainee and the ES during the course of their relationship to ensure that progress towards meeting the learning agreement is being maintained. The precise number and nature will vary with the length of time for which the trainee is attached to the ES , the frequency with which the trainee and ES work together in clinical practice and the trainee's support requirements. These should involve all aspects of the trainee's work: clinical care, teaching, research and quality improvement, management and administration, pastoral care, interpersonal skills, reflection and personal development.1Kilminster S. Cottrell D. Grant J. Jolly B. AMEE guide no. 27: effective educational and clinical supervision.Med Teach. 2007; 29: 2-19Crossref PubMed Scopus (270) Google Scholar It is difficult to meet all aspects in a single session; yet, for supervision to be effective, they should all be covered over time. In addition, many of these aspects interrelate, so it can be difficult to view one aspect in isolation from the others. Rigidly working through each aspect can be ineffective and a flexible approach is required. These meetings may lead to the learning agreement being amended; as some aspects are completed, other learning needs become apparent or learning priorities change over time. Kilminster and colleagues described helpful and unhelpful supervisory behaviours.1Kilminster S. Cottrell D. Grant J. Jolly B. AMEE guide no. 27: effective educational and clinical supervision.Med Teach. 2007; 29: 2-19Crossref PubMed Scopus (270) Google Scholar These behaviours are summarised in Table 1. They assert that the quality of the supervisory relationship strongly affects the effectiveness of supervision. This involves the commitment of both parties to teaching and learning, and the attitudes and interpersonal skills of the supervisor and the trainee.Table 1Helpful and unhelpful supervisory behaviours. From Kilminster and colleagues (2007).1Kilminster S. Cottrell D. Grant J. Jolly B. AMEE guide no. 27: effective educational and clinical supervision.Med Teach. 2007; 29: 2-19Crossref PubMed Scopus (270) Google ScholarHelpful supervisory behaviours1Kilminster S. Cottrell D. Grant J. Jolly B. AMEE guide no. 27: effective educational and clinical supervision.Med Teach. 2007; 29: 2-19Crossref PubMed Scopus (270) Google Scholar(i) Giving guidance and constructive, specific feedback(ii) Linking theory and practice(iii) Engaging in joint problem-solving(iv) Offering reassurance(v) Acting as a positive role model(vi) Reflecting regularly on performance as an ESUnhelpful supervisory behaviours(i) Rigidity(ii) Low empathy(iii) Failure to offer support(iv) Failure to discuss a trainee's concerns(v) Not giving feedback or doing so in a destructive manner(vi) Not giving the trainee opportunities to develop or practice Open table in a new tab Supervisory relationships can be conducted in a number of different ways, and an awareness of theoretical models of supervision can offer new ways of looking at trainee–ES relationships and of ways in which they can be less than satisfactory. The first of these is Hawkins and colleagues' seven-eyed model (Fig 3).8Hawkins P. Shohet R. Ryde J. Wilmot J. Becoming a supervisor: 'supervisor roles'.in: Hawkins P. Shohet R. Supervision in the helping professions. McGraw-Hill, Maidenhead2012: 54-58Google Scholar This was written in the context of psychotherapy rather than postgraduate medical education, but the principles are transferable. As suggested by the title, the model focuses systematically through all aspects of the trainee and the trainee's work, with emphases on:(i)Helping the trainee meet the patient's needs.(ii)The trainee's choices and clinical decision-making (i.e. what the trainee did, when and the rationale for the trainee's choices).(iii)The relationship between the trainee and the patients, how it could affect outcome or how it could be done differently.(iv)The trainee's work and well-being.(v)The relationship between the trainee, the ES and the wider department or hospital.(vi)The wider contexts in which work happens: departmental, hospital, national and professional influences; this overlaps the other five to some extent.(vii)The reflection of the ES on his or her role: why is the ES responding in the manner he or she is, and what assumptions underlie this? This may be conducted in private and again overlaps the other aspects. Again, it may not be appropriate to consider all 'eyes' of the model explicitly at each meeting, but using all aspects over time will result in more rounded supervision. A second model is that of Grant who applied techniques from literary and critical studies.9Grant B. Fighting for space in supervision: fantasies, fairytales, fictions and fallacies.Int J Qual Stud Educ. 2005; 18: 337-354Crossref Scopus (64) Google Scholar Again, she was not specifically writing about postgraduate educational supervision, but her models are still worthy of consideration. Within these models, Grant considers how the power relationships between the trainee and the ES affect supervision. She has four main models:(i)The trad-supervisor is an expert master of the discipline conveying training via an apprenticeship model. This was the traditional method of postgraduate training in the UK until recently, and aspects still exist. It may also be the experience of trainees who trained in other cultures and is one of the causes of international medical graduates sometimes having difficulty adjusting to UK practice.(ii)The psy-supervisor is a source of motivation and support for the student, and seeks to have a supportive interpersonal relationship with the trainee.(iii)The techno-supervisor is a skilled practitioner with a focus on an orderly sequence of skill development. Whilst a component of techno-supervision may be helpful in skill-based specialties, such as anaesthesia, it can be applied to other areas, such as the development of diagnostic, decision-making or management skills. There may be aspects of this model built into competency-based education.(iv)The com-supervisor views education as a commodity and the trainee an 'autonomous chooser'. In this model, supervision is the means by which the commodity of training and credentials are transferred to the trainee in accordance with the terms of the contract between them. Aspects of this model are implicit in the use of learning agreements, and in England, at least, have been formalised in the junior doctors' contract with explicit redress if the learning agreement is not honoured. Hawkins and colleagues' and Grant's models take very different approaches and, like all models, are over-simplifications of reality. However, Hawkins and colleagues offer a framework for the ongoing practice of supervision and Grant a framework for reflecting on the general approach the ES or the system is taking to supervision with any inherent strengths and limitations.8Hawkins P. Shohet R. Ryde J. Wilmot J. Becoming a supervisor: 'supervisor roles'.in: Hawkins P. Shohet R. Supervision in the helping professions. McGraw-Hill, Maidenhead2012: 54-58Google Scholar,9Grant B. Fighting for space in supervision: fantasies, fairytales, fictions and fallacies.Int J Qual Stud Educ. 2005; 18: 337-354Crossref Scopus (64) Google Scholar Postgraduate education occurs in a cultural context, and trainees tend to progress more smoothly if they share the same cultural contexts. One of the roles of education is to prepare trainees for working within this context, and both ES and trainee have relatively little power to change it.10Hodges B.D. Medical education… meet Michel Foucault.Med Educ. 2014; 48: 563-571Crossref PubMed Scopus (45) Google Scholar,11Dornan T. When I say… discourse analysis.Med Educ. 2014; 48: 466-467Crossref PubMed Scopus (9) Google Scholar This is important, as mismatch between the expectations of the trainee and the ES in the supervisory relationship may be one of the causes of a trainee getting into difficulty. Further causes of trainee–ES mismatch include cultural differences between medical practice in different countries12Tiffin P.A. Illing J. Kasim A.S. McLachlan J.C. Annual review of competence progression (ARCP) performance of doctors who passed Professional and Linguistic Assessments Board (PLAB) tests compared with UK medical graduates: national data linkage study.BMJ. 2014; 348: g2622Crossref PubMed Scopus (46) Google Scholar and the different approaches to learning and work between supervisors and millennial or generation Z trainees.13Roberts D.H. Newman L.R. Schwartzstein R.M. Twelve tips for facilitating millennials' learning.Med Teach. 2012; 34: 274-278Crossref PubMed Scopus (139) Google Scholar,14Schenarts P.J. Now arriving: surgical trainees from generation Z.J Surg Educ. 2020; 77: 246-253Crossref PubMed Scopus (10) Google Scholar The latter is compounded if the ES, the trainees and wider department members are from a number of generational groups with differing expectations and approaches (Table 2).Table 2Summary of generational differences.Baby boomerGeneration XMillennialGeneration ZBirth dates1946–19641964–19841984–19931994–2000Focus in young adulthoodReflectingCompetingBuildingImprovingTransition to middle ageDetached to judgementalFrenetic to exhaustedEnergetic to hubristic∗Conformist to experimental∗Approach to digital technologySuspiciousCompetentSophisticatedNativeAttitude to authorityRespectfulChallengeUnimpressedCooperative∗Predicted traits. Open table in a new tab ∗Predicted traits. Most trainees have to maintain a portfolio to demonstrate their progress towards fulfilling their learning objectives and achieving the requirements necessary to progress to the next stage of training. Portfolios are often multipurpose instruments, aiming to act as a tool to inform assessment, to demonstrate personal and professional development and to promote reflection. It may be difficult to fulfil all three roles within a given portfolio structure. However, the effectiveness of a given format is related to the ease of use and flexibility. A portfolio may be on paper or in electronic form; the effectiveness of the latter is also related to the efficiency of the information technology systems of the institution. Review of the portfolio should act as a prompt for a discussion between the trainee and the ES to discuss the learning that has occurred and promote further development with revised learning goals. The ES can ensure that a wide range of evidence is submitted, and review the extent to which any reflection is consistent with all the evidence in the portfolio. Portfolios may be perceived negatively by trainees. If the portfolio is used as part of a formal assessment of the trainee, then this may potentially lead to unwillingness to document honest reflections or evidence that shows room for development, particularly if the trainee believes these may become available to a third party, directly or otherwise. Non-assessed portfolios may not be used to best effect by trainees if they are not convinced of their value as a developmental tool.15van Tartwijk J. Driessen E.W. Portfolios for assessment and learning: AMEE guide no. 45.Med Teach. 2009; 31: 790-801Crossref PubMed Scopus (123) Google Scholar,16Driessen E. Do portfolios have a future?.Adv Health Sci Educ. 2017; 22: 221-228Crossref PubMed Scopus (37) Google Scholar Trainees undertaking dual training in anaesthesia and intensive care medicine may have to manage more than one portfolio, increasing their administrative workload; the ES may be able to help facilitate learning opportunities that benefit both. However, when used constructively, the portfolio can form a framework for documenting and reflecting on learning, be a trigger for learning conversations between the trainee and the ES and help plan future learning needs and direction (Table 2). A further role of the ES is in providing career guidance to the trainees. This includes helping the trainees to identify how their skills, strengths and interests can best be used in the context of the local medical environment. The trainees should be encouraged to identify their skills and experiences from within and outside medicine, with the latter in particular being often underestimated. For example, a trainee who served as president of her country's student group at a university had arranged a visit from her nation's ambassador to the campus, but had not realised how the skills she demonstrated in doing so related to her medical career. Another trainee, whose hobby is modifying racing cars to improve his performance, had not realised how the process of reflection and quality improvement this involved could transfer to anaesthesia. Trainees should also be encouraged to explore both career and personal factors in reaching their decision and also to explore all aspects of the careers they are considering. The ES should encourage the trainees to consider how they become more competitive, and may help with critiquing application forms or practice interviews. As anaesthetists, we may be supervising trainees whose aspirations lie in fields other than anaesthesia, for example (in the UK), doctors in the foundation programme or pursuing acute care common stem training. Doctors are increasingly pursuing more flexible careers, including areas of work outside traditional medicine, and career uncertainty amongst trainees may be increasing.17Howard J.V. Career planning and advice.in: Cooper N. Forrest K. Essential guide to educational supervision in postgraduate medical education. Wiley, Chichester2009: 44-62Crossref Scopus (2) Google Scholar,18Lambert T.W. Smith F. Goldacre M.J. Career speciality choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys.Postgrad Med J. 2018; 94: 191-197Crossref PubMed Scopus (23) Google Scholar Career guidance, therefore, involves consideration of areas of work, in which the ES may have no direct experience. The degree of career support required may range from simple discussion of information through shared exploration of options with the trainee to formal counselling to explore a distressing difficulty. There may be a point at which the ES has to judge if he or she is the most suitable person to provide this, or whether to suggest involving others. The trainee–ES relationship includes aspects of development and supervision. This leads to a power imbalance with the ES seen as having a gatekeeper function via the role in determining progression of training. The power relationships between the trainee and the ES vary with the mode of supervision adopted by the ES. Taking Grant's models as an example, the 'trad' model is one of deference from the trainee, the 'techno' model is one of surveillance under instruction, whilst the 'psy' model is more one of mutual respect.9Grant B. Fighting for space in supervision: fantasies, fairytales, fictions and fallacies.Int J Qual Stud Educ. 2005; 18: 337-354Crossref Scopus (64) Google Scholar Mentoring has been advocated as a model for supervision that minimises power and hierarchy in the supervisory relationship. However, the tension between development and supervision is not removed.19Manathunga C. Supervision as mentoring: the role of power and boundary crossing.Stud Contin Educ. 2007; 29: 207-221Crossref Scopus (88) Google Scholar McKimm and Forrest explored difficult supervisory relationships in terms of psychological 'games', based on the theories of transactional analysis.20McKimm J. Forrest K. Using transactional analysis to improve clinical and educational supervision: the drama and winner's triangles.Postgrad Med J. 2010; 86: 261-265Crossref PubMed Scopus (14) Google Scholar They described the 'drama triangle' of victim, persecutor and rescuer. Victims believe they cannot cope and discount their ability to manage situations; persecutors seek to control or belittle the victim, whereas rescuers, whilst trying to 'help', do so in a manner that discounts other people's ability to manage. No one is helped, with the victim and the persecutor being reinforced in their own positions, and the rescuer making a rod for his or her own back. On occasion, one party may switch position, leaving the others confused; in the aforementioned example, the victim may turn persecutor and claim he or she is not getting enough support from the ES. One example is the trainee who, approaching the ARCP with an empty portfolio, implores the ES to help. The ES does so, expending considerable time and energy in the process, only for the trainee to repeat this in the next cycle. Awareness of such 'games' can help prevent the ES being embroiled in the trainee's game, or starting 'games' of his or her own. At times, the ES–trainee relationship can be actively harmful to the trainee. This is often related to failure by the ES to adhere to the basic principles of supervision, in particular by being overcritical of the trainee, by shaming or public embarrassment of the trainee or failure to appreciate cross-cultural spaces (race, gender, sexuality or religion).21Beddoe L. Harmful supervision: a commentary.Clin Superv. 2017; 36: 88-101Crossref Scopus (11) Google Scholar Beddoe distinguishes between 'bad' supervisors, who are judgemental, controlling or disengaged, and 'weak' supervisors, who are benign but too informal, so avoid difficult conversations. Both can be harmful. Harmful supervision is often unrecognised in or unchallenged by departments, but can result in physical, emotional or social consequences for the trainee. The trainee requiring extra support is the subject of an additional article. In many places, supervision of the trainee is organised on a cyclical basis culminating in a formal review of the trainee's progress, at which a decision is taken regarding the trainee's suitability to proceed to the next stage of training. In the UK, this decision is taken at the ARCP usually held in May or June, after which the educational cycle begins again, either with the same ES or a different one. Before the ARCP, the trainee and the ES should meet for the final time in that educational cycle. At this meeting, the overall progress of the trainee should be discussed in light both of their initial (or amended) learning agreements and the requirements of the training programme for progression.22Committee of Postgraduate Medical Deans of the United Kingdom 8th edition. A reference guide for postgraduate foundation and specialty training in the UK: the Gold Guide. vols. 26–58. 2020https://www.copmed.org.uk/images/docs/gold_guide_8th_edition/Gold_Guide_8th_Edition_March_2020.pdfDate accessed: November 24, 2020Google Scholar At this meeting, a decision is reached regarding suitability for progression to the next stage of training and, in the UK, an indication of the recommended outcome from the ARCP. This should be an open process with full discussion between the trainee and the ES so that the result of the ARCP panel's discussion is not a surprise to the trainee.23Health Education EnglandEnhancing training and the support for learners: health Education England's review of competence progression for healthcare professionals.2018https://www.hee.nhs.uk/sites/default/files/documents/ARCP_Review_Final_v4.pdfDate accessed: November 24, 2020Google Scholar If the supervision of the trainee has been conducted thoroughly, there will have been a number of opportunities for the trainee who is not progressing as expected to be identified and supported.23Health Education EnglandEnhancing training and the support for learners: health Education England's review of competence progression for healthcare professionals.2018https://www.hee.nhs.uk/sites/default/files/documents/ARCP_Review_Final_v4.pdfDate accessed: November 24, 2020Google Scholar Ideally, the trainee should be given the opportunity to feedback to the ES on the supervision that the trainee has received. The report of the ES seeks to summarise the educational progress of the trainee, as discussed in the final meeting. It should include an assessment of and triangulation of all the evidence contained within the portfolio. Trainees in the UK are subject to revalidation with the postgraduate dean acting as responsible officer for trainees. The ARCP is also the vehicle for informing revalidation decisions and training progression. As such, the report of the ES to the ARCP should include information of relevance to revalidation, particularly if the trainee has been involved in any serious untoward incidents or complaints and their resolution or otherwise. Whilst this may seem to blur the educational and supervisory roles of the report of the ES and the ARCP, it does give opportunity for the ES to encourage learning to occur from these circumstances.24Black D. Revalidation for trainees and the annual review of competency progression.Clin Med. 2013; 13: 570-572Crossref PubMed Scopus (3) Google Scholar Unfortunately, a study of the quality of ES reports to the ARCP demonstrated that less than 30% were 'satisfactory'.25Hopkins L. Robinson D.B. Brown C. et al.Summative supervisor reporting: a quality performance perspective.J Surg Educ. 2019; 77: 88-95Crossref PubMed Scopus (1) Google Scholar The main issues are related to failure to review all the evidence (specifically the logbooks and comments from clinical supervisors) and failure to use the free text tools to expand on or justify the recommendation given. In the UK, progression to the next level of training is decided by the ARCP panel of senior educators in the region who meet to review the trainee's portfolio and specifically the report of the ES. The trainee is not present. Trainees recognise the need for an assessment of progress and that the ARCP has the potential to guide further education.26Viney R. Needleman S. Griffin A. Woolf K. The validity of the annual review of competence progression: a qualitative interview study of the perceptions of junior doctors and their trainers.J R Soc Med. 2017; 110: 110-117Crossref PubMed Scopus (15) Google Scholar,27Nally D.M. Elsey E. Humm G. Mohan H.M. Perceptions of the annual review of competence progression (ARCP) in surgical training in the UK and Ireland: a prospective cross-sectional questionnaire study.Int J Surg. 2019; 67: 117-122Crossref PubMed Scopus (2) Google Scholar They also recognise that the process has the potential to promote reflection and constructive feedback, and to give an opportunity to voice concerns. However, many feel the ARCP is less than satisfactory, being often viewed as a clerical activity that is seen as time-consuming and demotivating. Positive experiences of the process are related to greater involvement and discussion with the trainee. Acting as an ES to a trainee is first and foremost a relationship between the ES and the trainee, in which the trainee's personal and professional development is the focus. A good ES is an individual who puts the trainee's personal and professional relationship in focus; who understands the importance of fairness, empathy and trust involved in the role; who is willing to invest both time and emotional effort in the development of the trainee on a personal and professional basis; and who is able to commit to the extra challenges that may have to be faced, the skills that may have to be used and the time needed to provide support of the trainee.