Chapter 2 – Supervision, autonomy and asking for help

By: Dr Rob Fleming

SAS and locally-employed anaesthetists have different requirements for supervision, depending on their career stage, their areas of expertise and the work they are undertaking. A SAS career should take a doctor from more direct supervision, to less direct supervision, through to true autonomy.

For doctors earliest in their careers, supervision serves several important purposes. As well as ensuring patient safety, good supervision provides an opportunity for ongoing clinical education and professional development. For doctors seeking to progress their careers, it provides an opportunity for learning conversations and facilitates gathering evidence towards achieving your career goals. Supervising and supporting Specialty Doctors and locally-employed doctors today, helps to create the Specialists and Consultants of tomorrow. This chapter is primarily focused on clinical supervision in the workplace. Educational supervision, mentoring and support for professional development are covered in greater depth in other chapters.

As detailed in Chapter 1 of this handbook, the current SAS contracts are the Specialty Doctor, and the Specialist, which have different requirements and expectations associated with their eligibility criteria. The higher threshold within the Specialty Doctor pay scale also 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 resident doctor in formal training.
• Specialty Doctors who have passed throug the higher threshold of the pay scale should have demonstrated 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.
• The Specialist contract carries an expectation of autonomy within that doctor’s area or areas of expertise. Specialists should therefore be empowered to work with true responsibility for their patient workload, as consultant colleagues are. This is a defining characteristic of the senior role.

N.B Where Specialists contribute to ‘resident’ rotas in their areas of expertise, it is important that their autonomy is still acknowledged and respected within these roles. This autonomy is hard earned, and is a defining characteristic of this senior role. Specialists should also be supervising less senior colleagues and supporting the professional development of the next generation.

Locally-employed doctors, such as ‘trust doctors’ and ‘clinical fellows’ as detailed in the first chapter of this handbook, are on non-standard, non-national contracts. As such, the eligibility to be appointed into these roles varies from one organisation to another. As with early career Specialty Doctors, supervision and support for locally-employed doctors should be provided in keeping with their level of experience. Once more, we would strongly encourage doctors and employers to consider whether a SAS contract would be more appropriate for many of their existing locally-employed doctors.

The following levels of supervision are defined by the Royal College of Anaesthetists, in the document ‘Guidance on supervision arrangements for anaesthetists.’

It is important to recognise the difference between being the named anaesthetist for a list, and being autonomously responsible for that list. A Specialty Doctor above the higher payment threshold, for example, might be working regularly with supervision level 3 or 4 as detailed above. However, they should still know where their support is coming from should they require it, and the person supporting them should know what they are up to.

Different departments manage this need in different ways. Some departments have several senior colleagues as named ‘mentors’ to supervise doctors in neighbouring theatres. Other departments have a senior anaesthetist who is not allocated a list, and who instead supports all the lists being undertaken by supervised doctors.

While methods to achieve this differ, 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:

Cappuccini Test
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 for their work.

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.

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