Thursday, 2 August 2012

Apprenticeship: a rose-tinted view?

Commenting on my last blog, Kirsty asked whether ‘we hold a rose tinted view of apprenticeship’? 

It is a question that struck a chord, having been asked something very similar in my doctoral viva; on both occasions I have tried to adopt a critical stance to the idea of apprenticeship. Part of that stance involves engagement with the implied rationale for the move towards structured, competency-based training systems in postgraduate medical education, under the heading of Modernising Medical Careers. This leads me to explore a series of propositions about medical apprenticeship. 

Apprenticeship was too risky.

A dominant discourse in both undergraduate and postgraduate medical education, is that of patient safety. The most recent (2009) edition of Tomorrow’s Doctors (TD), for example, highlights the responsibility of medical schools in ensuring that patients are not put at risk by being involved in medical education. Patient safety is the first domain of this new version of TD; it was barely mentioned in the first. I observe increasingly risk-averse training practices being adopted (such as simulation), and listen to doctors who are increasingly anxious about delegating medical work to medical students or others. Medical colleagues (of a certain age) talk about ‘being thrown in at the deep-end’ and share vivid stories of early near-misses. All this might lead you to think that apprenticeship systems of the past were inherently more risky than those we adopt now. Yet, I watched with interest the 1st of August twitter feed yesterday, as comments from new and transitioning doctors echoed anxieties of the past. The inherent contradiction here is, of course, that risk-averse practices restrict learning opportunities, thereby increasing risks to patients. 

Was apprenticeship really inherently more risky?

 Apprenticeship is open to abuse of power.

Apprenticeship is often, unfairly in my view, coupled to accounts of teaching-by-humiliation, as if the two were integrally related. Strongly hierarchical systems amplify power differentials; senior doctors had considerable leverage over important decisions about progression to greater levels of medical responsibility in the past. These decisions are perhaps more transparent now; certainly the evidencing of decisions is more visible. The ‘lost tribes’ of Senior House Officers were put forward as part of the rationale for modernizing medical careers. Inequitable gender distributions across particular specialties, limited access to part-time training, under-representation of particular socio-economic groupings in medicine each suggest there have been inequitable training practices historically. An apparent silencing of the patient’s voice in medical education, (with patients seen as an exemplar of rather than an expert in their own condition) is another reason to rethink training practices of old. Prof Alan Bleakley talks, with passion, about the need to democratize medical education.

I wonder the extent to which new medical education and training practices move the profession towards this goal?

Apprenticeship is financially unsustainable.

Over the past three decades we have witness significant form throughout the public sector, based on financial imperatives. The three e’s of new managerialism, ‘economy, efficiency and effectiveness’ have driven much of this reform, shaping the ways in which healthcare is organized and delivered. Apprenticeship into the medical profession is a lengthy, resource demanding process, involving significant investment of time and energies. 

"The apprenticeship model, long the bedrock of our training in the past remains important but now needs to be set within efficiently managed, quality assured training Programmes compatible with the Working Time Directive." Modernising Medical Careers: the Next Steps (2004) 

Should new managerialist principles replace sound educational thinking when designing medical curriculum?

Apprenticeship fails on learning grounds?

In adopting a critical stance, it is clear, to me at least, that apprenticeship is costly in terms of human and financial resource. I recognize that apprenticeship practices were distorted by the playing-out of power differentials, leading to inequitable training practices. I fail to be convinced, that apprenticeship systems were inherently more risky than those we adopt now. Indeed, I grow increasingly concerned about the amount of hands-on experience gained and the increasingly narrow range of work activity undertaken by medical students and doctors in training. But did apprenticeship fail on learning grounds? I am not sure it did and I have found few accounts critiquing apprenticeship in the learning literatures. Medicine has a rich cultural inheritance in apprenticeship. A reformed NHS may make it increasingly difficult to sustain, but there is merit, in my mind at least, in taking time to re-think and develop a new form of medical apprenticeship. 

Rose-tinted? Perhaps!


  1. The value of blogs and resulting discourse is in exploring a theme which is presented, view or reflected on in a way the reader may not have have done. Therefore congratulation again for delving into a topic of relevance and importance. Apprenticeship in medicine has not been a focus of regular discussion (a quick search through google, google scholar and medline doesn't really find anything in 2011/2012) and my personal view is that in the UK the general feeling is that is no longer exists in its traditional sense.

    Therefore this is an important discussion to have, but I would argue Clare, that you haven't really defined what apprenticeship means to you? I suspect there is a large spectrum of interpretation but I don't have defining literature to hand and I am sure there are numerous theses on the subject. My personal view is that it is learning in the workplace with implied supervision by an expert. And this where I think currently we have a problem as there is lack of contact time between trainee and trainer with reduced learning opportunities and potentially unsafe practice [see Collins and Temple reports but I don't believe EWTD plays as much a part in this as others will do]

    For all its faults (ludicrous hours, learning by humiliation, practicing on patients) medical education in the past may have been salvaged by the apprentice model where at least there was focused contact with a few key experts.

    I would add that I don't believe simulation is 'risk adverse' behaviour as long as it is not used as a substitute for rather than an addition to improving clinical and leadership skills.

    We may well view apprenticeship through rose tinted spectacles but thats probably because we are pining for the opportunity to be educated in a safe but expert fashion.

    [the only journal i found of relevance in my quick review ! ]

    1. Thanks Damian, I think this a generous response to the ideas hatching in the blog. Can't believe I made the rooky error of failing to identify my terms and assuming a shared starting position. I have provided my definition of apprenticeship in the blog posting that follows this one. Thanks for the stimulus.
      There is much to debate, and too much in one blog here (part of the learning for me, about how to develop a scholarship of blogging). I am being deliberately provocative about medical simulation, as I think it is a great educational tool, poorly used. For me, simulation will be at its most powerful when we bring together actual teams (rather than proxy teams) to replay aspects of everyday work experience, to reconsider how it is working, or otherwise, and develop alternative /new responses. I think it is in the human factors domain that it will have most power.
      Thanks again for engaging with the blog - I am enjoying our dialogue enormously :)

  2. I agree with Damian, one needs to define what one means by an 'apprenticeship' before one starts to open up this can of worms!

    Apprenticeships are highly varied and it is hard to generalise.

    I think bits of the old system were good and an over reliance on competency based methods at the expense of experience is one of the big big negatives in modern medical training.

    The point I would make is that experience is vital. A lot of the competency based portfolios and assessments try to pretend that time and experience do not matter, they pretend that ticking a few boxes across a curriculum makes one an adequate or 'comepetent' doctor.

    Experience, time and training exposure are all crucial elements to good medical training, of course they overlap and blend together at times.

    A lot that is wrong with medical training today (too few hours, poor regulation leading to poor training content in many so called 'training jobs', conflicts of interest in regulation that allow poor training to continue) is resulting in trainees not getting enough good experience and exposure.

    The GMC's competency based fundamentalism is a sticky plaster over this gaping purulent wound.

    Common sense has been chucked out the window and no wonder trainees are frustrated.

    1. Hi Ben
      As I have said to Damian above, thanks for spotting the rooky error of failing to define terms. I have now done that in another posting - thanks :)
      I agree with the standpoint that work experiences are fundamental to development of practice, that working, is in this sense, the curriculum for training. I agree too that current practices are restrictive, in that they may fail to offer sufficient exposure to a suitably diverse range of work activity, without 'continuity of care' for the doctor in training i.e. a stable, supportive work team who can help turn those experiences into rich stimulus for further development. I think we speak a similar language on this one!
      Thanks for being generous with your time and thoughts on this one

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