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 1^st 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!