“Too busy to think, too tired to learn” - the attrition of the apprenticeship model of surgical training in the United Kingdom

This article examines the notion of apprenticeship as experienced by trainee surgeons within the modern NHS, and attempts to demonstrate some unintended consequences of managerial target setting upon the training process. It argues that this situation is made more critical by the lack of explicit standards and curriculum by which trainees may assess their progress, and also that the potential grafting of behaviourist competence-based training models onto older notions of apprenticeship will be inadequate to meet the need for an holistic account of the development of professional practice. Alternative theoretical perspectives are examined, in particular social accounts of shared and collaborative expertise such as Lave and Wenger’s “community of practice” and Vygotsky’s thinking on the “zone of proximal development” with its emphasis on a highly active pedagogic role for both mentor and peers. A parallel is also suggested with Leder’s work on therapeutic discourse, in the sense that both patient and trainee actively construct shared interpretative modes with the doctormentor. These accounts challenge the traditional model of medical education which assumes a linear hierarchy of learning, effectively ignoring the cyclic nature of surgical development, and the mutual learning needs of “new comers” and “oldtimers”. In order to initiate the modelling of surgical development, it is suggested that: • a dynamic and non-linear view of progress is required; • the link between formal structured training and opportunistic learning “on the job” is crucial; • assessment strategies are needed that promote, rather than hinder, the learning that derives from reflective practice. Introduction: Apprenticeship in the modern NHS Surgery is a craft-based profession in which learning has typically taken the form of apprenticeship, reinterpreted for modern times as “hospital-based clerkship” (Federated Council for Internal Medicine, 1997, p.179). This model of apprenticeship assumes a lengthy induction, during which learning takes place through observing and doing while simultaneously providing a service, under the “Too busy to think, too tired to learn” the attrition of the apprenticeship model of surgical training in the United Kingdom 47 supervision of experienced practitioners. However, current pressures to meet waiting list “targets” set by NHS management are eroding the time available for teaching and learning. This is exacerbated by the fact that, to date, both clinical standards and curriculum have been implicit, embedded in practice. Trainees now encounter three significant obstacles: • explicit standards and curriculum, against which trainees may assess their progress, do not as yet exist; • even the implicit (and accordingly problematic) standards and curriculum of traditional apprenticeship are now less accessible, because of time constraints; • traditional methods of supervision have not been replaced or reinterpreted and there are accordingly less opportunities for reflection and feedback. Target pressures, therefore, are likely to have unintended consequences, in that they are undermining practitioners’ initial professional development, which in turn will impact upon service not only in terms of throughput, but also of quality of patient care. It is relevant that of the thirteen priority issues that the General Medical Council (GMC) identified as arising out of the cases of those children who died while receiving complex heart surgery at the Bristol Royal Infirmary between 1984 and 1995 (Smith, 1998, p.1917) the first concerned “the need for more clearly understood clinical standards” and the second “how competence and technical expertise are assessed and evaluated”. Essentially the medical profession is now in the position of having simultaneously, and for the first time, to define clinical standards explicitly, and to articulate a curriculum that addresses those standards. At the same time the profession is faced with increasing centralisation of control via government agencies of activities that to date have been considered to lie within the remit of self regulation. New agencies such as the Medical Education and Standards Board, the Commission for Health Improvement, and the National Clinical Assessment Authority look set to pursue a range of regulatory activities utilising their own resources, with only limited involvement from the profession.