Category Archives: supervision

Go with the Flow

A theory can make sense in several ways including: 1. when you have an “aha” moment and think “yes, that makes sense” or “that describes what I’ve been trying to do intuitively” or 2.when it gives you some concrete implications for practice. “Flow” did this for me.  I first came across the concept of “Flow” back in 2006.  My husband told me a colleague of his at the university (who worked in the music industry and was interested in creativity) was excited about the topic and it sounded interesting so I bought  a book called Finding Flow  by Mihalyi Csikszentmihalyi (1997).

I discovered he had been talking about it since 1975 and has since written numerous other books until the present – which I discovered when I revisited it. If you want to get an easy explanation go to Wikipedia and look up Flow or the author.  Anyway, I did a 10 slide PowerPoint for registrars on the topic in a segment we used to call “Thought For The Day.” I thought the concepts were transferable to learning in General Practice with its ongoing experiences of balancing challenge and skill (and the question sometimes of why we keep doing it!)

What is Flow?

Learning theories often mention competence. Sometimes they move on to “mastery” and often they are concerned with motivation.  Csikszentmihalyi’s work is allied to the positive psychology school and he was interested in situations where someone experiences happiness doing what they like, feels lost in the moment and in the zone.  What motivates individuals to keep on achieving?  He researched the phenomenological experiences of elite athletes and artists.

More recently it has been applied more broadly to the educational context with the assumption (and some evidence) that individuals learn better when experiencing Flow. However, much of the literature refers to the school classroom and I haven’t found much on postgraduate vocational training although it appears to be very pertinent.  However, there is a post by Daniel Cabrera on Flow and education on the blog for clinical educators  It also includes Csikszentmihalyi’s more detailed schematic.

Are there times when you feel like that? I think I am very susceptible to experiencing Flow and sometimes stay up way too late when doing something that is enjoyable but challenging.  I’m no skier or marathon runner unfortunately.  It sounds mundane but I used to experience it when doing sewing and craftwork.  Later on I started to feel that way when producing a presentation for registrars.  Or writing posts for this blog!  I’m fairly new to Scottish Country Dancing and the teacher nicely balances our skills and the challenge of particular dances.  I recently did a drawing course and did not get bored spending two days drawing four grapes – but realise I have a long way to go.

When does it happen?

This is the simple graphic representation that is used to illustrate the concept.  In practical terms, think of a GP in training. There are times when the challenge feels way too much and anxiety can set in.  If this persists it can become chronically stressful and perhaps lead to symptoms of burnout.  On the other hand there are times when the challenge is low (endless medical certificates, repeat prescriptions, the same types of problems) and boredom or apathy set in.  Another job might be seriously considered as motivation drops.  But, somewhere between these two states is the sweet spot when a person’s skills are fully involved in overcoming a challenge that is just about manageable, where learning occurs in a safe environment and the enjoyment of this state leads the learner to gradually challenge themselves further and extend their skills.  The theory suggests an immersion in the task, a sense of control, and an altered sense of time (maybe not always good in General Practice!).

Looking for references I found a nice summary article on the net

Facilitators of Flow

You can read about these in more detail in any articles on Flow but in brief flow seems to require

  • An activity with a clear set of goals to provide direction.
  • A balance between perceived challenges and perceived skills in relation to the task. This balance is obviously dynamic
  • Clear and immediate feedback (a very familiar concept to educators).
  • A focus on the task itself
  • It’s also likely that the importance an individual places on doing well in an activity (i.e., “competence valuation”) is pertinent. Is being a good GP seen as a worthy goal?

In GP Training the challenges are high for the early registrar and their skills need to improve to match the challenges.  However, the level of challenge is very much influenced by supervisors and educators, standard setters and policy makers and is often related to:  the number of patients you are obliged to see, the range of patients you are seeing, the standards required of placements, background knowledge and skills and the learner’s access to timely help.  Matching help, support and supervision to the registrar’s skills (and comfort zone) is a finely tuned process and is reflected in the RACGP standard that supervision be matched to competence.

Obviously this involves supervisors and educators knowing the registrar’s level of competence and this can be harder than it sounds. It is not just important to patient safety and registrar safety but also to the registrar’s learning experience.  “Flow” encourages intrinsic motivation to learn. Csikszentmihalyi develops ideas about how to make education (and life) more enjoyable.  Does our current system make learning more enjoyable (or less so)?

We want a learning environment (and a system) that facilitates learning, that makes learning enjoyable and that inspires the learner to extend themselves further – not just a box-ticking of competencies or passing an exam. In terms of learning “theory”,  if you and the learner are overtly aware of these parameters that surround the learning environment it might help you to implement Flow more effectively and appreciate it when it happens. We can facilitate registrar experiences that move toward flow (and are therefore rewarding and motivating).

This concept could perhaps also be applied to us as educators in our working and learning journey.


Being a mentor and role model – guest post from a supervisor

In a world where the answer to any unticked educational box is an on-line module created by a third party, preferably on a contract, it sometimes seems as if the interpersonal nature of education and training has been lost.

path-upA supervisor whom I have known for twenty years, and who has been a supervisor for thirty years, commented to me that he thought the most important activity of the supervisor is to be a role model.   This is not always spelt out in textbooks, the literature and course curricula.  The emphasis is often on “teaching skills.” Over the years I have heard many GPs spontaneously recall John Vaughan’s influence on their careers whether they encountered him as a student or a registrar.  They have often commented that he takes the trouble to keep in touch with them well beyond their completion of training.  Because I respect him enormously I threw it back to him and asked him to jot down half a dozen points about being a role model. I think these comments also include (conceptually)  aspects of mentoring.  Here they are (grouped in sections):

Ten points of mentoring and role-modelling:

Self awareness

  1. Be aware of being a role model (it happens whatever we do). By this I mean we need to be conscious of our actions at all times, particularly in the presence of registrars and not only in our dealings with them directly but in the way we interact with practice staff and nurses as well as colleagues and contacts beyond the practice environment. Registrars are absorbing much of this behaviour consciously and unconsciously and will model themselves on it or use it as a lesson in how not to behave.
  2. Be willing to accept and acknowledge your own limitations as a doctor and a supervisor

The supervisor’s approach to the registrar (mentor role)

3. Demonstrate interest and get to know the registrar as a person. Without being intrusive, it is so important to learn about and understand the registrar in the context of their world. It is particularly important, for instance, to try and learn where overseas trained doctors have come from and where they wish to take their careers in the future. The other group that comes to mind are those female practitioners who may lack confidence, despite often being outstanding practitioners and whom I have observed, over the last thirty years, to go on to achieve excellent Fellowship exam results.  

4. Encourage registrars, demonstrate confidence in them and take time to support them. It is invaluable.

5. Be sensitive to the registrar’s needs. This moves into a more pastoral role.   Be aware of their moods and state of mind, providing pastoral support when it is needed. Sometimes registrars can become a little lost in the morass of practice and picking up on this and enquiring about their needs and their concerns can be crucial. It is not all about education!

Specific attributes and attitudes that are worth consciously modelling

6. Enthusiasm for general practice – enthusiasm is contagious. By modelling our own enthusiasm for the role of a GP and the privileged entree into people’s personal lives, our registrars develop similar attitudes. The opposite is also true.

7. A positive response in challenging situations – especially when things go a little pear shaped clinically as they sometimes do.

8. A sense of lifelong learning can be promoted. It is not all about the Fellowship exam. Model your own learning for them and demonstrate the fact that you are constantly learning and open to this.

9. Collegiality – with the registrar

  • Acknowledge your own limitations as doctor and supervisor
  • Encourage questioning and accept criticism and constructive suggestions Encourage questioning – especially of you as a supervisor. We are all in this profession together and should not be afraid to accept criticism and constructive suggestions so that it becomes a two-way process.

10. Collegiality – with other doctors and health professionals. Too much of medicine is based on putting our colleagues down instead of understanding where they are coming from. Doing this with our senior colleagues can model behaviour for our registrars.

walking-together  Mentoring can be described as “a personal process that combines role modelling, apprenticeship and nurturing”. The article, True Mentorship in Medicine, describes some qualities of good mentors: “they exude genuine and infectious enthusiasm; they modify their teaching strategies according to learners’ needs; they consistently reflect on their roles; they have excellent interpersonal skills; and they are knowledgeable. These qualities act synergistically to create non-threatening learning environments……..Learning is not about obtaining good evaluations; it is part of the overarching goal of becoming a better physician. The atmosphere generated by a good mentor promotes self-esteem and the importance of lifelong learning…..Mentors, in addition to teaching through words and deeds, show us care and respect and empower us to confidently approach the myriad complications inherent to the human In the end, we must repay our gratitude to our mentors by providing excellent patient care and evolving into effective role models ourselves.”

I think this echoes what John demonstrates and what he has so clearly described above.


Another lengthier and more academic look at the process is found (for those interested) at