Whatever happened toapprenticeshiplearning?Dr Gordon Caldwell, FRCP, Clinical Tutor, Worthing Hospital, Western Sussex HospitalsNHS Trust, Worthing, UK

SUMMARYBackground: I have been a clin-ical tutor for 10 years in Wor-thing Hospital, UK. During thistime I have seen an increasedemphasis on classroom teaching,assessments in controlled situa-tions and simulation, rather thanon apprenticeship learning

during well-supervised clinicalworking.Context: At the educational con-ference on ‘Learning without Leav-ing the Workplace’ hosted by myhospital, I had an opportunity topresent my reflections on appren-ticeship or situated learning. Thisarticle is a summary of that talk.

Implications: The relatively newmodel of ‘situated learning’offers an opportunity foracademics and clinicians torevitalise the apprenticeshipmodel of learning in, and beingstimulated by, the clinicalworkplace.

‘Situatedlearning’ offersan opportunity

to revitalise theapprenticeship

model

Food forthought

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INTRODUCTION

Is Apprenticeship Dead andBuried as a Useful Model forLearning to Master MedicalPractice?

In September 2009 our UKNational Health Service(NHS) trust ran an Educa-

tional Conference on the theme of‘Learning without Leaving theWorkplace’. I had to deliver thekeynote address on ‘Whateverhappened to apprenticeshiplearning?’, when the main speakerhad to cancel at short notice. Ihave rewritten my talk to distil mythinking about apprenticeshiplearning.

THE SUPPOSED DEATH OFAPPRENTICESHIPLEARNING

Apprenticeship learning has along history, dating back to atleast Greek and Roman times.1

Apprenticeship is concerned withlearning to simultaneously think,act and review, often in complex,uncertain and time-limited pro-cesses. The apprentice mastersupervises the apprentice byexplaining the work in hand,talking the apprentice throughthe processes and allowing theapprentice to take on ever morecomplex work, as he moves from‘novice’ to ‘expert’.2 Eventuallythe apprentice becomes a master,and is admitted to a community ofpractice such as the Goldsmiths,or in the world of medical practicebecomes a member of a RoyalCollege. The apprentice has thenbecome a master of his art, fullyconversant with the behavioursand ethics of his professionalcommunity.

Yet, I feel that many educa-tionalists in health care believethat apprenticeship is dead andburied as a useful model to mastermedical practice. When hospitalsare inspected as local educationalproviders (LEPs), the inspectionteams seem to focus on how muchclassroom teaching is delivered or

how many standardised assess-ments have been performed. Theemphasis is all on ‘protectedteaching time’, and not on ‘pro-tected supervised working time’and expertise gained throughexperience.

How did this come about? Isthe apprenticeship model aflawed model or a valuable modelthat was poorly executed? Iqualified in 1980 from King’sCollege Hospital Medical School,where apprenticeship was thelearning model. Students wereexpected to work up to 6 hours aday, in a ‘firm’, on the wards withpatients, and attended just onelecture at 5 PM. When I startedwork as a doctor, we wereexpected to clerk and managelarge numbers of acutely illpatients and to work long hours.The supervision was rather dis-tant, and I am sure that thelearning could have been accel-erated by closer contact with the‘apprentice masters’. I think dur-ing the last two decades of thetwentieth century and the firstdecade of the twenty-firstcentury, the pressures of clinicaltargets and working time limita-tions has reduced the level ofclose supervision of trainees bymaster clinicians. The success ofthe apprenticeship model wasundermined by a failure to pre-serve the close professional

relationship between the masterand the apprentice.

In addition, educationalistsand managers of education loveto measure outcomes and producevalid statistics of success. It isalmost as if some medical educa-tionalists believe that all medicalpractice can become standar-dised, reproducible and measur-able. Yet medical practice isundertaken in the midst ofuncertainty, in rapidly changingconditions, with limited data, andalways in the context of trying toprovide evidence-based medicaladvice and treatment to auniquely individual patient.Medical practitioners need to betrained to act in uncertainty andin the best interest of the indi-vidual human being presentingwith an illness. Objective stan-dardised clinical examinations(OSCEs), and even the new simu-lation suites, imply that there isone way to act in a given situa-tion, that medical practice ismerely following a set of instruc-tions or evidence-based guide-lines in a reproducibleenvironment. Combined togetherclassroom teaching, knowledgeexams, OSCEs and performanceassessments in simulation suitesare all reproducible, measurableand taken as valid indicators ofclinical expertise. Of course theyall have a place in learning to

Is theapprenticeshipmodel a flawedmodel or avaluable modelthat was poorlyexecuted?

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become a doctor. Simulation isuseful for the rehearsal ofuncommon events. However, oursimulation suites often seem to be‘idealisation suites’, with a perfectenvironment and a plethora offully qualified staff with all the kitto hand. Our simulation suitesshould mimic reality and preparestaff for the complex unpredict-able world of the realities ofmedical practice, where the out-come is never known until afterthe event.

Apprenticeship is in a criticalcondition because of the break-down of the professional rela-tionship between apprentice andmaster, and because of theemphasis on reliable measure-ments rather than the assessmentof expertise in the face ofuncertainty.

IS THERE ANY HOPE FORAPPRENTICESHIP?

In the early 1990s two ethnogra-phers, Jean Lave and EtienneWenger, described a learningmodel called ‘situated learning’and published ‘Situated Learning,Legitimate Peripheral Participa-tion’.3 Like many controversialand radical documents, it is veryshort. The closest it comes tohealth care practice is a descrip-tion of hereditary midwiferypractice in South America. Theirbook contains radical thinking,even suggesting that all welearn at school is ‘how to doschool’.

Lave and Wenger describe hownovices or apprentices are firstgiven small tasks with limitedresponsibility, and then tasks ofincreasing complexity andresponsibility until they becomefull members of a ‘community ofpractice’.4 The daughters of themidwives are given small and thenincreasingly complex tasks toeventually become full ‘partici-pant’ members of the ‘communityof practice’ of midwifery. Thecommunity has its rules, customs,

culture and ethics, which arelearned through experience. Muchof the learning comes from sto-rytelling, observation and beingimmersed in supervised experi-ence, with increasing responsi-bility. Storytelling has been astrong tradition in medical learn-ing, but these days the educa-tionalists tell us that a goodstory, well told, is not enough:they say that every learningexperience must have a setlearning objective, and evaluationis only measured against thatobjective. Imagine how dull sto-ries in films, novels and playswould be if the author had to havea learning objective for everystory! Yet films, books and playsteach us of the ambiguity, com-plexity and oddity of humanbehaviours, which are reflected inthe ambiguity, complexity andoddity of clinical practice.

This model of situated learn-ing has interested me, because init I recognise much of the waythat I learned medical practice. InOxford University my first lessonwas not academic concepts, it wasdissection of the cadaver. Themessage in retrospect was clear,medical practice is ‘hands on’,complicated, confusing, dirty, toan extent smelly and challenging.This is the stuff that life anddeath are made of. It was this‘hands-on’ experience that drovemy search, guided by my tutors,for understanding and attemptsto master medical practice. Muchof my learning has been stimu-lated by the patients that I havemet, and my need to understandtheir illnesses and treatments. Iwas also given small tasks withresponsibility, like taking blood,and then increasingly complextasks. My learning was driven bymy lack of understanding of whatI saw in front of me. Eventually Ibecame a doctor – a member ofthe ‘community of practice’ ofmedicine, and later a member andfellow of the community of theRoyal College of Physicians. I ama participant member of the

community of practice of healthcare, with all its complexity,errors, ambiguities and oddities,codes of behaviour, culture, eth-ics and achievements.

As a clinical teacher, I can nowsee that I am not just teachingindividuals to pass exams, I amcontributing to developing thenext generation of a community ofpractice of doctors.

This model of situated learn-ing is apprenticeship learning,and can draw clinicians and edu-cationalists together again.

My only concern about situ-ated learning is that it isdescribed as a rather passiveprocess, of learning by listeningto stories, by observation and byexperience: i.e. learning by‘osmosis’. It could be a very slowprocess. What we need to developin medicine is ‘activated’ or‘accelerated’ situated learning,5

where the apprentice mastercan speed up the learningprocess.

For example, no one evertaught me how to do a wardround. I observed good and badrounds, and slowly developed myrounds. In the last 18 months Ihave developed an active processthat can teach a foundation doc-tor, or even a medical student,how to do a comprehensive sys-tematic ward round by the processof legitimate peripheral partici-pation. I allow the junior to ‘lead’the round under my supervisionand guidance, and provide‘assessment for learning’ withformative feedback.6 The processalso improves the reliability,quality and safety of my rounds tothe benefit of the patients. Juniordoctors start to learn in 8 weekswhat took me many years oflearning by osmosis.

Whatever happened toapprenticeship learning in medi-cine? We allowed an erosion ofthe professional learning

Simulationsuites shouldmimic reality

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relationship between the appren-tice and the master. We wereseduced by the measurable andreproducible. We allowed appren-ticeship to slip into a criticalstate. Lave and Wenger’s modelfor ‘situated learning’ offers us alifeline to join clinicians, educa-tionalists and our apprenticestogether, so that they will becomefully participant professionalmembers of the community ofpractice of medicine.

REFERENCES

1. Miles S. The Hippocratic Oath and the

Ethics of Medicine. Oxford: Oxford

University Press; 2005.

2. Benner S. From Novice to Expert.

Excellence and Power in Clinical Nurs-

ing Practice. New Jersey: Prentice

Hall; 2000.

3. Lave J, Wenger E. Situated Learning

Legitimate Peripheral Participation.

Cambridge: Cambridge University

Press; 1991.

4. Wenger E. Communities of Practice

Learning Meaning and Identity.

Cambridge: Cambridge University

Press; 1999.

5. Smith A. Accelerated Learning in

Practice Brain-based methods for

Accelerating Motivation and Achieve-

ment. Stafford: Network Continuum

Education; 1998.

6. Black P, Harrison C, Lee C, Marshall B,

William D. Assessment for Learning

Putting it into Practice. Maidenhead:

Open University Press; 2003.

Corresponding author’s contact details: Dr Gordon Caldwell, Diabetes Centre, Worthing Hospital, Worthing, BN11 2DH, UK. E-mail: gordon.caldwell@wsht.nhs.uk

Funding: None.

Conflict of interest: None.

Ethical approval: Not required.

‘Situatedlearning’ offersus a lifeline tojoin clinicians,educationalistsand ourapprenticestogether

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