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

Abstract

Abstract: 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 doctor-mentor. 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 “old-timers”.
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.