Death of the physician apprenticeBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2994 (Published 29 July 2009) Cite this as: BMJ 2009;339:b2994
- Katie Wynne, clinical lecturer
Times have changed. So must teaching, says Katie Wynne
All doctors have a duty to supervise, teach, and appraise trainees. For centuries this responsibility has been met by a traditional apprenticeship, dependent on trainees being available for long hours during which there was substantial clinical exposure and mentorship. However, working patterns have changed drastically following the implementation of the European Working Time Directive and the New Deal. Clinical service provision will undergo further restructuring to comply with the average 48 hours a week required in August 2009. The impact of this change on postgraduate training is likely to be considerable and will be further compounded if the overall length of medical training is shortened, as recommended by Modernising Medical Careers.
Moving away from the apprenticeship model
There is an urgent need to improve training opportunities without compromising service delivery. MMC: The Next Steps suggested that the apprenticeship model should not be abandoned but managed within the European Working Time Directive. A purely apprenticeship based model of training would be ineffective, however, once the length of clinical exposure and contact between trainers and trainees are limited. The impact of a nine hour shift rota that is compliant European Working Time Directive, as outlined in the Royal College of Physicians model for hospital medicine,1 has recently been evaluated for the first time.2 From a training perspective, doctors on the new rota reported “worse educational opportunities” and a “lack of time for interaction with the rest of the team with less chance of feedback on their performance.” This lack of supervision will inevitably be detrimental to training and ultimately compromise patient care.
Postgraduate medical training needs to evolve, but there are barriers to be overcome. Senior doctors are concerned about their time and availability and have doubts about changing existing teaching practice.3 Certainly, senior doctors have been asked to undertake extended roles as supervisors and assessors in addition to their existing workload, with only modest support and guidance. The use of workplace assessments and the e-portfolio provide an important opportunity for maintaining the mentor relationship. However, sufficient time is needed to facilitate formative feedback to ensure confidence in these tools. Workable solutions must be identified rapidly to maintain the standards of postgraduate training.
Developing new training strategies
Training at the hospital bedside and in outpatient clinics is a powerful method of teaching professional skills but can be perceived as time consuming and disruptive to patient care. Training opportunities can, however, be integrated into these existing clinical resources. Traditional clinical teaching methods, in which trainees present a case, allocate only a small proportion of time to learning and feedback. If clinicians can adopt more efficient models of trainee centred teaching, successful learning and appraisal can occur in a shorter time frame while remaining within the limits of a clinical environment (for a review of these models see Irby and Wilkerson4). For example, inexperienced trainees benefit from being given a task to complete during their observation of a clinical interaction, whereas more experienced trainees benefit from focusing on their specific learning needs. If clinical teaching can be successfully incorporated into and acknowledged as part of service provision, the progressive trend towards “undergraduate style” teaching, in which postgraduate curriculums are delivered through lectures and in small groups, might be reversed. Structured teaching requires junior doctors to attend fixed sessions, which uses important time resources and is often impractical in the context of shift rotas.
Physicians have not previously benefited from an explicit trainer role with a tailored job plan, a position that is well established in general practice. The development of a “physician trainer” role was suggested by the Tooke report and in Standards For Trainers, published by the Postgraduate Medical Education and Training Board. The Tooke report also recommended that training outcomes should be incorporated into performance ratings for local hospital trusts. The creation of Medical Education England5 will hopefully add political force to incentivise hospital trusts to integrate training provision as a part of clinical service delivery and, importantly, formalise resources for trainers.
The current changes to doctors’ working patterns necessitate a move away from traditional apprenticeships, as this paradigm lacks elements of supervision and feedback when trainer interaction is limited. Adopting clinically integrated, time efficient, learner centred models of training is therefore vital for maintaining standards of continuing postgraduate medical education. Any delay in modifying teaching practice risks compromising training for the next generation of hospital specialists.
Competing interests: None declared.