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Abstract

Background: Clinical supervision (CS) is not an established support system among physicians. Family physicians (FPs) have used Balint groups as a form of clinical supervision. In all, not much is known about the prevalence of physicians’ attendance to or needs for CS. Objective: We studied what proportion of FPs compared with other physicians have attended or report they would need CS and whether having patients who request certain tests or medicines is associated with FPs’ attendance to or need for CS. Design: A postal survey for all working-aged Finnish physicians was performed in 2008. Special questions concerning CS (eg, Balint) and patients’ requests were included. Results: Response rate for the survey was 74% (N = 13 708). Special questions were responded by 10 559 physicians of whom 1252 were FPs. FPs had attended CS more often than other physicians (42% vs 29%, P < .001). Of FPs, 25% reported a need for CS with no availability of it. FPs experienced with or needing for CS were more often than other FPs females, had participated in continuing medical education, and reported that patients with requests have increased in recent years. Conclusion: Both experience of CS and a need for CS with no availability are common among Finnish FPs. Experiences of patients with requests may reflect a need for CS among FPs. Studies on the content, significance and effectiveness CS among FPs are needed.

Keywords

clinical supervision Balint groups family medicine primary health care patients’ requests

Introduction

In medicine, clinical supervision (CS) has been defined as activities that provide monitoring, guidance, and feedback on matters of physicians’ personal, professional, and educational development in the context of care of patients.¹ This definition refers mainly to the educational aspects of CS. Physicians’ CS can also address the emotional aspects of clinical work and be supportive.² However, the culture of CS is not well established among physicians.² Family physicians (FPs) have used Balint groups as a form of supportive CS.^3,4

Balint groups have been used in family medicine by FPs in clinical practice since the1950s.^{2,4-
6} The aim of Balint group work is to enhance participants’ personal and professional development through regular, time-limited, professionally led case-based reflective group discussions. Typically, a Balint group has 2 to 8 participants and 1 or 2 specially trained supervisors. A supervisor can have a professional background of a FP, psychiatrist, or psychologist.⁷ Balint groups support physicians in coping with work pressures and alleviate stress but they are not a form of psychotherapy.^2,3,5 The availability of supportive CS (eg, Balint) for physician is inadequate.^3,8,9

However, not much is known about CS activities among FPs or other physicians. To our knowledge, there are no large-scale epidemiological studies investigating the prevalence of physicians’ attendance to CS or their needs for it. There is evidence that unnoticed needs for supportive CS exist among physicians, while their work is both cognitively demanding and emotionally charging.¹⁰ Among FPs, stress and even burnout are not uncommon phenomena.^11,12 According to several references important sources of stress in physicians’ work are patients’ requests for specific issues in the consultations.^{13-

17}

In the present study, we investigated the prevalence of Finnish physicians’ attendance to CS and their experiences of needs for CS, and focused more specifically on FPs. We also investigated how physicians’ experiences of patients’ requests for specific issues from them were associated with their attendance to or needs for CS. The study questions were as follows: (1) What proportion of FPs, compared with other physicians, attend or have attended CS? (2) How commonly do FPs experience a need for CS? (3) How are the FPs’ characteristics and experiences of patients’ requests for specific issues associated with their attendance to or need for CS?

Material and Methods

This study was based on a survey that the Finnish Medical Association has performed yearly since 1982. The questionnaire is mainly (60% of items) the same every year, with the aim of producing structural knowledge about Finnish physicians. Each year, special questions (40%) with selected focus of interest are included. Information on physicians’ age, gender, and specialty is collected from the same register.

In 2008, the survey questionnaire was mailed to all 18 603 physicians who had been licensed in Finland that year or before and who were not yet retired in March 2008. The special questions asked about CS, continuing medical education (CME), and experiences of patients with requests for specific issues like certain diagnostic tests, procedures or medicines. In the questionnaire, CS was not defined but there was a reference to Balint groups. Table 1 shows the items in the questionnaire and how the participants’ responses were grouped.

Table 1.

Special Questions to the Physicians Concerning Clinical Supervision (CS), Continuing Medical Education (CME), and Patients’ Requests for Specific Issues.

Question	Answer Options	Categorizations in Statistical Analyses
Do you attend or have you attended clinical supervision (eg, Balint groups or other)?	1. I currently attend	1 and 2 = “previous/current attenders”
	2. I have attended, but am not attending now	3 = “wishing nonattenders”
	3. I wish to attend, but CS is unavailable	4 = “no-need nonattenders”
	4. I do not need CS
Did you participate in CME arranged somewhere other than at your workplace in 2007?	1. Yes	1 = yes
	2. No	2 = no
Do you have patients who request certain laboratory or other diagnostic tests? Do you have patients who request certain medicines?	1. Very often	1 and 2 = “often”
	2. Often	3 and 4 = “seldom”
	3. Seldom
	4. Very seldom
Has the number of patients who request certain laboratory or other diagnostic tests increased in recent years? Has the number of patients who request certain medicines increased during past years?	1. Clearly	1 and 2 = “yes”
	2. Somewhat	3 and 4 = “no or don’t know”
	3. No
	4. I don’t know

Do patients’ requests complicate the physician–patient relationship?	1. Fully agree	1 and 2 = “yes”
	2. Somewhat agree	3, 4, and 5 =“no or do not know”
	3. Do not know
	4. Somewhat disagree
	5. Fully disagree

In the analyses, we focused on 2 groups of physicians: specialists in family medicine (FPs) and others. In Finland, the family medicine the specialist curriculum takes altogether 6 years after becoming a licensed physician. In the Finnish health care system, FPs work mostly with outpatient care in primary health centers (PHCs). Some physicians in Finland have double specialties. In this study, physicians whose most recent specialty was family medicine were counted in the group of FPs. The other group included physicians with latest specialty other than family medicine, physicians with no specialty, and those who were in the process of specializing (group: other physicians). The data were analyzed using cross-tabulation, and statistical significance for differences in categorical variables between groups was determined using χ² tests. P values <.05 were considered significant. All statistical analysis was done with SPSS 17.0 (SPSS Inc, Chicago, IL).

Results

Response Rate

The response rate for the survey was 74% (13 708 of 18 603). Of the responders, 10 559 answered the questions concerning CS. Of these physicians, 1252 were FPs and 9307 belonged to the other group (Figure 1).

Figure 1.

Flowchart of the survey.

Family Physicians and Other Physicians Compared

The proportion of females among FPs was similar to the proportion of females among the other physicians. A larger proportion of FPs as compared with other physicians was aged older than 50 years (58.9% vs 39.5%, P < .001). Most FPs worked in outpatient care in PHC (71.2%) the other physicians worked mostly in hospitals (49.7%). FPs had participated more actively in CME than the other physicians (91.6% vs 88.2%, P < .001). Likewise, FPs had attended or were currently attending CS more often than the other physicians (41.8% vs 29.4%, P < .001). However, a larger proportion of other physicians than FPs wished to attend CS, but it was not available, (25.2% vs 29.4%, P = .0021). Among other physicians, the proportion of those who had no need for CS was also larger than among FPs (32.9% vs 41.2%, P < .001; Table 2).

Table 2.

Characteristics of the Physicians (n = 10 559), Their Attendance to Clinical Supervision (CS), and Continuing Medical Education (CME) During the Past Year.

Variable	Family Physicians (n = 1252)	Other Physicians (n = 9307)	Pa
Females, n (%)	712 (56.9)	5557 (59.7)	.0064
Work sector,^b n (%)			<.001
Primary health care	891 (71.2)	2130 (22.9)
Hospital	95 (7.6)	4630 (49.7)
Other	266 (21.2)	2547 (27.4)
Age, n (%)			<.001
<40 years	84 (6.7)	2947 (31.7)
40-50 years	431 (34.4)	2686 (28.9)
51-63 years	737 (58.9)	3674 (39.5)
Previous/current attender to CS, n (%)	523 (41.8)	2737 (29.4)	<.001
Wishing nonattender to CS, n (%)	316 (25.2)	2739 (29.4)
No-need nonattender to CS, n (%)	413 (33.0)	3831 (41.2)
Attendance to CME, n (%)	1086 (91.6)	7678 (88.2)	<.001

Difference between the groups tested with χ² test.

Work sector—primary health care: health center, occupational health. Other—private sector or not working.

Family Physicians and Clinical Supervision

Table 3 compares the FPs who have attended CS (“previous/current attenders”), FPs with a need for CS but not having it available (“wishing nonattenders”), and FPs with no need for CS (“no-need nonattenders”). A larger proportion of female FPs than male FPs reported being “previous/current attenders” and “wishing nonattenders.” A larger proportion of FPs younger than 50 years than FPs older than 50 years were “wishing nonattenders.” Likewise, a larger proportion of FPs who worked in PHC than FPs who worked in hospitals or other work places were “wishing nonattenders.” A smaller proportion of FPs with no need for CS had participated in CME than the other FPs.

Table 3.

The Characteristics of the Family Physicians (n = 1252), Their Attendance to Continuing Medical Education (CME), Experiences of Patients With Requests for Specific Issues Versus Their Attendance to and Need for Clinical Supervision (CS).

	Previous/Current Attender to CS (n = 523)	Wishing Nonattender to CS (n = 316)	No-Need Nonattender to CS (n = 413)	P ^a
Females, n (%)	343 (65.6)	217 (68.7)	152 (36.8)	<.001
Age <50 years, n (%)	216 (41.3)	168 (53.2)	131 (31.7)	<.001
Work sector,^b n (%)				.0035
Primary health care	363 (69.4)	248 (78.5)	280 (67.8)
Hospital or other	160 (30.6)	68 (21.5)	133 (32.2)
Has participated in CME, n (%)	460 (93.5)	284 (93.1)	343 (87.9)	.0070
Has patients requesting for certain laboratory/diagnostic tests, “often,” n (%)	300 (66.1)	203 (69.3)	210 (60.7)	.067
Has patients requesting for certain medicines, “often”, %	205 (43.6)	125 (41.9)	124 (34.2)	.017
“The number of patients requesting for certain laboratory/diagnostic tests has increased,” n (%)	434 (72.7)	230 (78.2)	237 (66.4)	.0034
“The number of patients requesting for certain medicines has increased,” n (%)	279 (62.5)	200 (67.6)	203 (55.9)	.0083
“Patients’ requests complicate the physician–patient relationship,” n (%)	187 (38.5)	143 (46.7)	161 (42.9)	.067

Difference between the groups tested with χ² test.

Work sector—primary health care: health center, occupational health. Other—private sector or not working.

Family Physicians and Patients With Requests

Of the FPs, 65.2% had had patients who requested certain laboratory or other diagnostic tests “often,” and 40.1% reported that patients requested certain medicines “often.” A larger proportion of FPs who reported that patients requested certain medicines “often” than other FPs reported being “previous/current attenders” or “wishing nonattenders” to CS. Of the FPs, 72.1% thought that patients’ requests for certain laboratory or diagnostic tests had increased in recent years whereas the respective number concerning requests for certain medicines was 61.7%. A larger proportion of FPs reporting increased patients’ requests for certain tests or certain medicines than FPs not reporting these increases were “previous/current attenders” or “wishing nonattenders” to CS. Of the FPs, 42.0% thought that patients’ requests complicate physician–patient relationships. (Table 3).

Discussion

A large proportion of Finnish FPs had previously attended or was currently attending CS (42%) and a notable further proportion (25%) of FPs felt a need for CS with no availability of it. FPs had attended or they were attending CS more often than other physicians. FPs experienced with or needing CS more often than FPs not reporting a need for CS were females, had participated actively in CME, reported patients with request for certain medicines, and thought that patients with requests have increased in recent years.

Strengths and Limitations

The strength of this study is the large sample size and an exceptionally high response rate.^18,19 Since the survey was sent to all Finnish physicians, the sample is highly representative. Physicians’ surveys often have low response rates (34% to 54%).^18,19 To our knowledge, there are no previous epidemiological studies on supportive CS among family physicians or other physicians. There are some limitations concerning our study, though. It is possible that CS has cultural connections. Also, the concept of CS for physicians is not unambiguous. However, Balint groups have been used for 60 years as a form of supportive CS in family medicine and they are familiar to physicians. Therefore, introducing Balint as an example in the specific question concerning CS clarified the concept of CS for the responders. Another limitation is the descriptive, cross-sectional nature of our study. Further explorations on this topic should include multivariate regression analyses, longitudinal follow-up studies, and randomized controlled intervention studies to clarify causal relationships between background variables and CS as well as the efficacy of clinical supervision.

Prevalence of Clinical Supervision

Balint groups have been available for FPs since the 1950s.^4,6 In the United States, programs including Balint groups have been offered both on an obligatory and a voluntary basis to FP trainees⁶ and in Germany, Balint groups have been well established in family medicine training for several years.^4,20 In Finnish medical schools, Balint groups have been sometimes available.²¹ Despite this, not very much is known how much FPs actually attend CS programs. Therefore, it is difficult to compare the prevalence FPs’ or other physicians’ attendance to CS in our study with other literature. In a Danish study combining CME and CS, 73.3% of FPs had attended to either one or the other.²² According to another study, one third of Danish FPs attended supervision groups.²³ In our study, the FPs had more experience of CS than the other physicians. The origin of and tradition of Balint group work in family medicine⁵ may explain this.

Characteristics of Family Physicians and Clinical Supervision

We found that “previous/current attenders” and “wishing nonattenders” to CS were also participating in CME more actively than “no-need nonattenders.” According to one Danish study, FPs with burnout attended less often both supervision groups and CME than FPs without burnout.²³ Some studies suggest that peer support and self-reflection are important for FPs’ endurance in family medicine.^11,24,25

Needs for Clinical Supervision

In our study, FPs attended CS more often than other physicians. In addition, other physicians than FPs experienced more need for CS than FPs. These findings might reflect the better availability of CS for FPs than for other physicians. In literature we found no studies to compare these findings to. In our group of FPs the need for CS with no availability of it, was associated with female gender and age less than 50 years. Some studies suggest that younger FPs and female FPs experience more strain than others.^26,27 This consorts with the idea that a need for CS implicates experiences of work stress.

Among FPs, “no-need nonattenders” were more often males, aged 50 years or older, had participated less in CME, worked in sectors other than PHC, and did not feel that the number of patients with requests had increased in recent years. Among these FPs, their older age, and thus, long-term experience of work, might explain experiencing less need for CS. However, participating less in CME might reflect problematic attitudes or being stressed.^27,28

Patients With Requests and Clinical Supervision

More than two thirds of FPs reported that patients with requests had increased in recent years, which is in line with reports from other countries.²⁹ Two in 3 FPs had often or very often patients who requested diagnostic tests and 4 in 10 FPs had often or very often patients requesting certain medicines. A large proportion of FPs (42%) thought that patients’ requests complicate the physician–patient relationship. Patients’ requests often provoke unpleasant emotions in physicians^26,30; they have been associated with physicians’ stress and burnout^12,25,31,32 and altered clinical behavior.^29,31,33 Several studies have suggested that CS for FPs has helped them in dealing with work stress from challenging patients and even in changing their practice behavior.^{5,23,25,34,35}

Conclusions

Family physicians in Finland are experienced with CS. However, 1 in 4 FPs also states having a need for CS while it is not available. The use of CS and the unmet needs for CS among FPs warrant studies on the benefits and efficacy of CS.

Footnotes

Authors’ Note

This study is based on a survey conducted by the Finnish Medical Association.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Martina A. Torppa is a family physician and a medical teacher and a researcher with special interest in physicians’ work and physician -patient relationship. She is at clinical work for four days in week and in teaching and research for one day in a week. She is also a Balint group leader and is leading one group of young doctors currently.

Kristiina Toivola is a specialist in occupational health and a group analyst and a Balint group leader. She is partly at clinical work and partly doing clinical supervision with physicians.

Juho Ruskoaho is a reseacher and a statistician who is working for the Finnish medical Association.

Kaisu H. Pitkälä is a professor of Family Medicine at the University of Helsinki and also a specialist in geriatrics. She is active and productive in many fields of research in medicine. In addition to her professor duties she is at clinical work once a week.

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Clinical Supervision Among Family Physicians

Abstract

Keywords

Introduction

Material and Methods

Results

Response Rate

Family Physicians and Other Physicians Compared

Family Physicians and Clinical Supervision

Family Physicians and Patients With Requests

Discussion

Strengths and Limitations

Prevalence of Clinical Supervision

Characteristics of Family Physicians and Clinical Supervision

Needs for Clinical Supervision

Patients With Requests and Clinical Supervision

Conclusions

Footnotes

Authors’ Note

Declaration of Conflicting Interests

Funding

Author Biographies

References