An “apprentice” is someone who works for a fully qualified individual for the purpose of learning a trade. Although the term has taken on a somewhat negative connotation of semi-indentured servitude, the word itself, interestingly, shares entomologic roots with French verb apprendre (to learn), and the Latin apprehendere (to “grasp” or understand). It would seem then that apprenticeships are intended to be primarily educational endeavors.
Apprenticeships served admirably as the original model of medical education. Eager and bright young people who wished to become doctors would enter the service of an established practitioner, in the same way that aspiring masons or carpenters would engage training from masters of those trades. The apprenticeship provided, in addition to instruction in fundamental knowledge and skills, on-the-job, supervised practice training. Presumably, the level of responsibility and independence of the learner increased progressively over the period of training but, in fact, the contractual arrangements, terms of service and educational program were entirely at the whim of the “master” without consistent standards or regulation. At the end of the agreed-to term of service, the learner would receive the endorsement of the teacher and, after submitting to whatever regulatory process might exist, enter independent practice.
Our Clinical Clerkships and Residency programs are modern day vestiges of the apprenticeship model, the major points of departure being the organizational (school-based) rather than individual focus, and considerably expanded, highly defined and rigorously regulated educational expectations. However, the delicate interlacing of the two fundamental components-education and supervised clinical practice-remains the core, defining characteristic. As those two elements combine (as illustrated in the diagram below),three domains of activity are defined.
The purely educational activities consist of scheduled rounds, conferences, academic days, assessments and various other structured events. Learners are either expected or required to attend. Together, these events provide an established “protected” learning curriculum. These events are deliberately, completely separated from clinical service in order to ensure opportunities exist for the requisite learning.
There are also activities where clinical service and education overlap and occur simultaneously. These consist of clinical activities where learners and teaching faculty work together in the delivery of care, such as clinics, operating rooms, procedural suites and emergency departments. In these settings, the learner is directly supervised, is involved in care delivery to the extent their training and acquired skills allows, and receives instruction ‘on the fly’. The “curriculum” is defined not by a pre-determined schedule, but by the issues presented by the patients receiving care.
This leaves a third component of clinical service that can be considered either indirectly supervised, or independently provided. This consists of activities appropriate to the learner’s qualification and can be considered the “scope of practice” at that point in his or her training. Examples vary considerably, but could consist of ordering basic investigations, prescribing, charting, minor procedures, and patient assessments. As learners progress in training, their “scope of practice” escalates accordingly. This more distinctly service role is recognized officially in the residents’ hospital or practice privileges, provision of payment for service, and development of professional organizations such as PARO which recognize residents as service providers and work to protect that role.
To extend the illustration above, the spheres progressively diverge until, at the end of training, they separate completely as the learner assumes independent practice and, with it, complete responsibility for both their clinical and educational activities. The latter is, in fact, an expression of professional identity.
The balance between these two domains and three spheres of activity within medical training has been, and remains, contentious and a point of competitive tension. The need to vigorously protect the educational components of residency training has been very appropriately promoted through the development and protection of core curriculum within training programs and mandated by accreditation standards. The need to put limits on the clinical role has also been recognized and effectively enforced through accreditation and professional organizations that advocate for their members by, historically, promoting protection of purely educational endeavours above purely clinical service activities. The move to more competency-based models of residency education brings many potential advantages, but by formalizing and emphasizing educational processes, may further sideline the clinical service role.
It could certainly be argued that we’ve passed a tipping point where our emphasis on protection of educational activities has diminished the value of clinical service and portrayed to our learner the impression that avoidance is somehow virtuous. This would be appropriate if clinical service had no educational value and was simply a distraction from “pure” learning experiences. But is this the case? Is there an educational price to be paid for reduced clinical service experiences during training? Is it reasonable to consider residency as a “job” in and of itself with expectations of service independent of direct educational context? Expressing the issue another way: is there, in fact, educational value in the provision of clinical service? Some compelling arguments can be made:
The practice of medicine is much greater than the sum of the educational components. It is a complex interplay of scientific knowledge, specific technical skills, and an ability to understand and relate to the individual human situations in all their variety and complexity. There is something about engaging these situations individually that is far beyond what can be attained in any classroom or even directly supervised situation. The ability to do so in a nonetheless safe setting, with understood limits and readily available help is the core educational value of clinical service delivery.
Personal growth and development of professional identity. People in any human endeavour learn by engaging personal challenges and confronting adversity. This is certainly true of developing physicians. In medical school, it begins with the first time a student has a one-on-one encounter with a patient. It progresses steadily through training, but whether it is performing a minor procedure, an assessment in clinic or attending to a distressed patient with an urgent problem, these are all opportunities to grow as providers in a protected and supervised setting where optimal patient care is not only assured, but likely enhanced. This provides training physicians the opportunity to not only learn clinical medicine, but also about their own individual strengths and weaknesses in a way that can’t be reproduced in any artificial educational setting. That self-awareness is essential to professional development and critical to career decisions. Strong personal preferences or deficiencies should be identified and addressed during training, not after graduation to independent practice.
Our patients are our best teachers. Great physicians learn from every patient encounter, no matter how apparently straightforward or routine. This is the basis of lifelong learning. If the practice of valuing and learning from every patient encounter is not engaged and refined progressively during training, will it be developed in independent practice?
Valuing clinical service as a privilege, not a chore. The core mission of Medicine, and of physicians, is the provision of clinical service to our patients. To them, there is no “scut work”. If we don’t value clinical service as an educational community, what message are we sending to our learners? Are they graduating to a career of uninspiring and boring chores? In an educational sense, the development of clinical competence and increasing independence should be recognized, highly valued and accompanied by increasing status and prestige.
Pragmatically, there already exists a contractual definition of residency as a “job” with compensation and obligations. Rather than live in denial of this reality, we might be better advised to engage the balance between those obligations and educational development in a thoughtful way ensuring the optimal expression and value of both aspects.
Finally, we must recognize that this is no longer a theoretical discussion or abstract educational concept. Clinical care is becoming more, not less, demanding within our schools, outpatient clinical settings and academic teaching hospitals. Education and clinical service delivery are on a collision course that can only be averted by recognizing that these two aspects of medical education are individually necessary and mutually interdependent. Both must be preserved. We must recognize this essential duality, particularly as we go about developing newer models for both undergraduate and postgraduate education.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education