In a previous blog on WPBA, I observed there
has been a culture shift in postgraduate medical education, from that of a time-served apprenticeship, to one of time-measured training. This observation
arises from my doctoral research part of which involved an analysis of 20 years
of policy relating to the training of doctors. I was interested in tracing the
ways in which NHS and postgraduate training reform had ‘dismantled’ medical
apprenticeship. My analysis led me to observe a gradual decoupling of ‘working’
and ‘training’. at least conceptually. To explain…
Historically, in a time-served apprenticeship, work was the curriculum for medical
training; through engaging in increasingly complex work activity doctors made
transitions to greater levels of responsibility. Supported by their ‘firms’, to
greater or lesser extent, transitions were made on the basis of readiness to
progress, in the eyes of those closest to their work activity. There are close
parallels here with Lave and Wenger’s (1991) accounts of communities of practice,
where newcomers to a community are invited to engage in the shared work of the
communities they join. The goal of training, in this case, is full participation
in the work of the community.
In more recent years, we have witnessed the
move to a national curriculum for postgraduate training, expressed in terms of
competences to be acquired, or outcomes to be evidenced. The modernized time-measured
curriculum for medical education stipulates much more closely the anticipated
length of time for each stage of training; those who do not progress at a
predetermined point are at risk of being seen as ‘failing’. The tension here of
course, is that certain posts may afford greater opportunities to learn than
others, simply in terms of the scope and amount of ‘suitable’ work available.
Failure to progress may be a failure of the workplace to support the
development of the trainee. The ultimate goal of any stage of training is
expressed here in terms of ‘sign off’; doctors in training have demonstrated the
acquisition of pre-determined outcomes, competences, knowledge, skill or
attitudes, however these are expressed. Those familiar with Sfard’s (1998) account of two metaphors for learning might see time-served apprenticeship in
terms of ‘learning-as-participation’ and time-measured training as
‘learning-as-acquisition’.
Does this distinction matter, other than
conceptually? I think it does. I believe that the postgraduate medical training
curriculum introduced over the past 5 or 6 years got ‘lost in translation’.
Ultimately, doctors, whatever stage they are in their career, learn through
working: work is the curriculum. The challenge is ensuring that the amount,
range and complexity of work activity undertaken is both within the trainee’s
capability and stretches them to be more capable. One way to do that is to
develop a curriculum map, that captures where they have been, where they are
going and where they might go next. In this way, it is possible to make
explicit and surface up the learning that arises while working and to make
adjustments, where needed, to offer a richer learning journey (to keep the
mapping metaphor going). The map does not need to be too prescriptive; there
are, after all, many possible routes to the same destination. Some trainers
have a natural sense of direction, have walked the journey with trainees on
many occasions and only need check in, from time to time, to make sure they are
both still on track. Others may prefer to plan the itinerary much more tightly,
checking in on a regular basis that all is going according to plan. This kind of
mapping process, overlaid on the workplace, had real potential to guide
training. Unfortunately, the associated mechanics of the new curriculum models,
workplace based assessments, compulsory ‘reflections’, log books, portfolios
etc got in the way. These new ‘souvenirs’ from the journey too readily became
the journey. 'Trainer-trainee' relationships became enacted through these tools
of curriculum engagement. The training curriculum moved from being the trainees
work, to additional work for the doctor in training.
So where next for postgraduate medical
education? I take some comfort in the revised foundation curriculum, although I
believe it has some way to go.
The move away from competences is
encouraging, although the scuttle back to the security of outcomes statements
is, for me at least, a missed opportunity. I think the discourse around EPAs
(entrustable professional activities) is worth extending. It is much more
meaningful to think in terms of what you are confident in delegating to a more
junior colleague, than relying on the competences they have once demonstrated.
The move away from workplace based
assessments to supervised learning events, conceptually at least, is also
promising. The value of having a more knowledgeable other (in Vygotsky’s terms)
observing your work and engaging in a meaningful dialogue about it has rich
learning potential. I am not sure we need the forms to evidence these
conversations have happened, but that is a topic for another blog perhaps.
Finally, the new curriculum revives 'the
firm', placing much more emphasis on the professional wisdom of clinical
supervisors, educational supervisors and the clinical team in terms of guidance,
support and decisions about readiness to progress.
