The primary goal of clinical training is to develop competent, skilled practitioners who can and will continue to provide quality care. For decades, across almost every training site, clinical supervision has been considered "central to the development of skills" in psychiatry (1). The crucial supervisor/supervisee relationship has been described extensively in the literature (1–3), most often framed as a clinical apprenticeship of the novice to the master craftsman (4). The literature has examined this relationship from a variety of vantage-points, and detailed, informative developmental models have been described that map the trainees' progress as they evolve in supervision (1, 3, 5). Although these approaches to supervision offer many vital and developmentally-informed insights, their failure to directly incorporate adult-learning theory (ALT) (1, 6), despite a clear literature supporting its superiority, may lead to unforeseen limitations (6). The failure, common in traditional contexts, to promote personal ownership and continuous monitoring of learning, both key components of ALT, may impede trainees from developing the critical core competency of Practice-Based Learning and Improvement (PBLI), as outlined by the Accreditation Council of Graduate Medical Education (ACGME; Table 1) (7) and limit the effectiveness of clinical supervision. In this article, we describe the basic principles of ALT, reviewing the limitations of current supervisory practice from the ALT perspective. We then describe system insights gleaned from elements of the manufacturing process and integrate them into a model that enhances ALT-informed approaches to clinical supervision that can be utilized in all settings.
Effective adult learners are independent, self-motivated, and self-directed (8). Educators have shown the following elements and principles to be critically important across a wide range of contexts, in promoting optimal and effective adult learning (8–10).
The elements of adult learning (8, 9) comprise the following principles:
Simply put, adult learners need to be actively involved in the learning process from initial knowledge activation, to self-appraisal, setting goals, and developing mastery, through the evaluative process and the setting of future goals. It is this continuous, cyclical process that promotes effective and efficient learning.
Current Supervisory Practices
Ironically, despite the great educational importance attributed to clinical supervision, relatively few supervisors have formal training in the supervisory process (11). Riess and Herman (11) found that at a major teaching institution, fewer than 25% of their supervisors had training in supervision. MacDonald (1) described the many roles of supervisors, noting that "most psychiatrists are expected to supervise, whether they want to or have the skill" and that psychiatrists "are not taught to supervise; they are taught to treat and give therapy." Although "clinical supervision is probably the least investigated, discussed, and developed aspect of clinical education (12), most reports emphasize that relationship, acceptance, and guidance (2, 5) are key—acknowledging the importance of the learning process, but not addressing it.
According to Wilkes (13), clinical education is a "complex combination of systematic teaching and learning activities …how they learn is as important as what they learn, and understanding how they learn can contribute much to what they learn." The earlier-noted supervisory models define stages, components, and challenges of the work, but they do not incorporate key elements of how adult learning progresses. This under-addressing of how residents learn limits supervisory effectiveness. Although ALT-informed, case-based education has been integrated into preclinical medical education over the past two decades (14, 15) and more recently, with the addition of logbooks and elements of reflective practice into the clinical years, as well (16, 17), it has not become part of typical supervisory practice.
In most cases, residents are given the goals and objectives that represent program-specific elements for the rotation, as framed by the ACGME core competencies. These are seldom modified or personalized to more specifically inform the supervisory work. Rarely does the supervisory literature suggest in any manner that supervision should start with "activating prior knowledge" and then "cross-link" the residents' past experiences to the current learning demands. This could readily be accomplished by beginning the supervisory relationship with a detailed review of the residents' earlier work, clarifying what they have mastered and what they both want and need to do. Ironically, although most clinical supervision occurs in a highly individualized context, without the critically-needed initial appraisal and collaborative goal-setting, the actual teaching effort cannot be personalized; thus, a major opportunity for resident-specific learning that would improve the quality, efficiency, and usefulness of both the supervision and the resident's education is missed. With this traditional context, residents generally see goals and objectives as external criteria, imposed from above, by which they will be judged, thus relying on extrinsic motivation to promote learning. The opportunity to collaboratively set personal goals for learning that promote both the residents' level of responsibility and their intrinsic motivation are lost. This undermines their ownership of learning, turning the evaluative processes into "competency" fences to get over, rather than "competency" ladders to take residents to new heights. Resident learning is further compromised by the failure of most supervisors to regularly and collaboratively examine the ongoing educational process and progress, leaving it instead to the externally-mandated performance reviews. This misses the chance for "real-time" learning, collaboration, corrections, and confirmation that what is intended to be taught is, in fact, being taught and learned (18). It further undermines the adult learner's mandate for ongoing ownership of the assessment and direction of his or her education. These lost opportunities erode efforts at real quality-control and educational ownership and are contrary to the ACGME goals of promoting PBLI.
Manufacturing Systems, Insights, and Learning
Manufacturers (at their best) all strive for cost-efficiency while producing the best product possible. Supervisors (educators) strive for cost-efficiency (time, effort) while producing the most competent resident possible. For both, effective and efficient efforts that yield optimal quality are sought. Although all manufacturers focus on quality-control and efficiency, the differences among manufacturing management systems offer useful insights for educators (19, 20). Many traditional manufacturers, and, by analogy, educators, utilize what is described as a top-down, "push" system of production. In business, this means that, well in advance, "upper management" (educationally, ACGME, training committees, etc..), with all due diligence, set the best estimates of labor, materials, and anticipated consumer need. These estimates "push" a down-stream flow of production goals, materials, labor, and, ultimately, product. Real-time emerging production problems, variations in individual worker (or resident) skills, needs, or productivity, and consumer demand are not factored in. From the corporate perspective, without the appropriate real-time feedback loops, excess "capital" (by analogy, teaching time and effort) is tied up in anticipated supplies and production lines, but not keyed to actual worker performance, productivity, or consumer demand. This leads to a system that is both inherently inefficient and limited in quality-control. From the worker's (or resident's) perspective, this top-down, "push" approach, fosters a personal "disconnect," minimizing any individual input or ownership for productivity (education). Problems with production, quality-control, and emerging issues are experienced as externally determined. The worker's (or resident's) roles as responsible adults are undercut, and there is little sense of personal efficacy, which encourages the passivity that is a frequent complaint of management (and educators), and undermines active collaboration.
Alternative manufacturing systems exist (21), with the Toyota Motor Company (Toyota) as the lead example of "pull" manufacturing. The "pull" system starts with management's setting the initial goals and parameters and then implementing an ongoing feedback loop, matching production-line management to individual worker experience, and productivity to customer demand. Real-time monitoring of the production process, product quality, and consumer demand are then used to "pull" or trigger data-driven adjustments in supplies, labor, and work process, thus matching actual need. Workers are empowered to have personal responsibility for monitoring their productivity and their product, signaling needed adjustments through what is called the Kanban (card) system. This approach effectively optimizes the utilization of resources and productivity as it strives for continuous improvement by matching; supplies, work processes, production, and product demand, all in real time (21). It encourages both labor and management's responsibility for solutions, promoting collaboration. It is the combination of fostering tangible personal responsibility and providing systemic support that are deemed crucial. This Total Quality Management (TQM) approach has been identified as an integral part of Toyota's (and many others) success (21). The educational equivalent would be a system that monitors the trainee and context (production conditions) to develop explicit production (educational) goals for each resident on each rotation, coupled with the real-time, collaborative monitoring needed to "pull" the teaching resources (supplies/labor) to ensure a quality product (a competent trainee). "Pull" manufacturing, in contrast to "push" manufacturing, is a systemic approach that embraces the core principles of adult-learning in its approach to workers. It activates their prior learning and then cross-links it to the task at hand by utilizing their individual competencies to optimize the current production process. It fosters personal responsibility for productivity (intrinsic motivation) as adult-learners actively monitor and correct the ongoing process, ultimately minimizing the need for external supervision (teachers).
ALT and Manufacturing Principles in Supervision
By analogy, supervisors could adapt this ALT-informed, "pull" management system to the education of residents. It would begin with "management" (training directors and committees) setting broad goals and parameters that encompass the core national competencies and those of the specific program/rotation into a dynamic document. At the beginning of each rotation, the supervisor and supervisee would review the trainee's progress to-date, along with the program/rotation goals. Building upon the trainee's prior experiences, knowledge, skills, interests, and needs, the trainee/supervisor pair collaboratively would set a trainee-specific supervisory learning plan with individualized objectives and parameters that are consistent with both their needs and the program's needs (22). This approach embraces and takes advantage of the individualized nature of psychiatric supervision. This collaborative approach cross-links the trainee's earlier experiences to the tasks at hand, and encourages active supervisee buy-in and ownership, thus fostering intrinsic motivation. Consistent with TQM, the process and progress should be actively monitored, and real-time corrections should be made as indicated. This approach is described in detail in the educational Kanban (22), which recommends that the document be kept electronically, as part of the trainee's personal record, and should never be entered into their permanent file. Having the adult-learner keep the files both encourages ownership (intrinsic motivation) and lessens the inherent tension between honesty in self-reflection and being evaluated (1, 22).
The resident-owned learning plan (22) becomes the core of ALT-based supervision, providing trainees with specific objectives that are continuously monitored and updated. It is grounded in and consistent with both ALT and "pull" systems of quality management. The supervisor can further the process by incorporating ongoing elements, informed by ALT and manufacturing, into their day-to-day interactions by promoting critical thinking, self-reflection, and real-time, ongoing assessment.
The following suggested questions can be used in part or as a whole, depending on the context, to promote this, the goal being the residents' incorporating this framework, whether at the bedside or in the psychotherapy hour, as a way of enhancing their understanding, learning, and competence. Suggested questions before the patient encounter include the following: 1) What is your formulation of patient/problem or systems issue? 2) What is your plan for the encounter; what do you hope to accomplish? 3) Have you seen similar situations before, and are there relevant alternative understandings or plans for this patient/problem? 4) How does your theoretical framework inform your formulation and your plan? 5) What is the state of your alliance with the patient/family or system? 6) Given the above, how could this plan be implemented? (I concretely suggest that residents view the encounter with the formulation/plan, on one hand, and the alliance, on the other, as they proceed in all clinical contexts.)
After the patient encounter (independently or in supervision) the process can be continued with the following questions: 1) Did what transpired match your understanding? 2) At critical points, how did your understanding inform your actions? 3) What are the alternative formulations/actions and the pros and cons of each? 4) What was the impact of the patient on you, and you on the patient? 5) Are there previous patient/personal experiences that influence your understanding or actions? 6) If there were unexpected elements, how do you account for them? 7) Did the encounter modify your understanding or plan; what is next?
The final elements of incorporating ALT into supervision would be in the on-going monitoring of progress and the resetting of resident-specific goals. TQM-informed approaches depend on both ongoing informal and formal monitoring. The questions suggested above can aid in the informal, on-going monitoring, both in supervision and by the residents on their own. Formally, at regular (monthly suggested) supervisory meetings, the residents would update their self-appraisal in detail, with the supervisor adding his or her feedback, the ensuing discussion leading to the establishment of new collaborative goals. This approach, as informed by ALT and "pull" management, emphasizes the process, and asks the residents to actively increase their responsibility for their learning agenda and education. This is consistent with all elements of the ACGME core competencies, particularly the one of PBLI.
Although the benefits of ALT and "pull" manufacturing management-informed approaches to supervision have been outlined, there are several anticipated areas of likely "push-back." The first would be the issue of time for the collaborative goal-setting, monitoring progress, and revising the educational plan. Much of this is already embedded in the current, labor-intensive patterns of individual supervision, and, in practice, even the formal monthly review has, in almost all cases, taken appreciably less than half of a supervisory hour. Any possible increases in time or effort would be more than compensated for by the inherent efficiency of resident-specific teaching and learning. Additionally initiating and maintaining an active dialogue about learning will be foreign to some trainees and faculty. Elements of adult-learning, setting collaborative goals, and the ongoing dialogue will require start-up training for trainees and staff. These sessions serve the dual purpose of training for the new elements of this approach and laying the much-needed educational foundation for supervisors that others have noted is lacking (1, 11). For some faculty, there may be the acknowledged or unacknowledged loss of the more-traditional hierarchical supervisory model. The exchange of power and control for growth and autonomy is a challenge that every educator and mentor must ultimately face. For some residents, the challenge will be giving up the more passive learning modes that may, at times, be all-too-comfortable. The efficiency, effectiveness, and growth-promotion of ALT-informed, "pull"-style learning are anticipated to be more than sufficient to counterbalance these factors over time. Finally, although ALT/TQM-informed approaches continuously monitor and promote competence, the need for summative documentation to meet ACGME standards will remain. However, if this approach to resident education parallels worker experience, challenges will be addressed collaboratively in real-time, making reviews and the educational process, including evaluations, more constructive and less adversarial.
Current supervisory practices can be revised to include principles of ALT and "pull" manufacturing systems that can enhance resident education. The critical first element is in the supervisory frame-shift; setting ALT and manufacturing-informed, individualized goals and agendas. The second critical element is applying, both formally and informally, TQM-style, ALT-informed management to monitor the resident's educational progress. By modifying supervision to include these principles, educators can improve the efficiency and effectiveness of their teaching and promote the growth, learning, and autonomy of residents.