Medical apprenticeship is dead.

by reestheskin on 16/10/2014

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OK, ok, I have missed by vocation as a tabloid subeditor, apprenticeship is not dead, it is just that it is not in rude health, and for much of undergraduate medicine it is irrelevant. Let me explain.

At the postgraduate level much, if not most learning is apprenticeship based. We rely on continued interaction between master and apprentice, and masters have a very good idea of what it is that the apprentices need to know. They can of course look at a syllabus, but mostly this is not necessary. And even though many masters are sub-specialised, they usually know quite a lot about what they do not know, and what the modern trainee needs to know. Often they are aware that the apprentice will be doing the master’s job in a couple of years or less. It is therefore mostly straightforward, and there is little need for formality. Of course there are lots of forces at work to try and eat away at this ancient method. That is why there are courses on teamwork at exactly the same time as teamwork is being destroyed (ditto for professionalism — I fear that once you make it explicit, it has kind of slipped through your fingers). I remember a hospital manager correcting a colleague who said that a junior doctor worked for a particular consultant; apparently junior doctors are ‘ward resources’ now. Like the furniture or the bedpans. The master pupil personal relationship is being supplemented or destroyed by tick-boxing, depending on your viewpoint.

For undergraduates I would argue that apprenticeship learning is the exception, rather than the norm, and that we would be better off not pretending otherwise. There are of course some exceptions, some final year attachments try very hard, but overall a number of factors mitigate against apprenticeship learning. Perhaps in some mythical past, students could acquire most of their knowledge by merely being on the ‘firm’ (note my antiquated terminology), but a host of factors make this approach problematic. Continuity of care is lacking; continued personal interaction with feedback lacking; most care is now delivered by specialists of one description of another; and most people who teach students are part-time teachers and part-time masters. The bond of common knowledge and goals has been broken; not uniformly, but more often than not. Masters within their narrow niches are unaware of what others have said or taught the novices. They are unaware of how one facet of medicine should build on what has gone before, and are therefore unable to integrate prior knowledge with the technical details of what they believe students need to know. Integration is a feature not of a curriculum, but of individual staff. Curriculums are usually meta objects, not of this world.
Apprentice learning is more fun, for both student and teacher, and is the only way to develop high level skills. For most domains of human expertise, there is no historical alternative. At the doctoral level, it is how we train academics. But at an undergraduate level, it is usually impossible. As Alice Gopnik remarked, if we want to become a chef, we stay in the kitchen; if you go to university, you spend 3 years sitting in ‘cracking eggs’ lectures. Apprenticeship doesn’t scale. We need something else, something better than we currently deliver.

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