OK, ok, I have missed by vocation as a tabloid subeditor, apprenticeship is not dead, it is just that it is not in rude health, and for much of undergraduate medicine it is irrelevant. Let me explain.

At the postgraduate level much, if not most learning is apprenticeship based. We rely on continued interaction between master and apprentice, and masters have a very good idea of what it is that the apprentices need to know. They can of course look at a syllabus, but mostly this is not necessary. And even though many masters are sub-specialised, they usually know quite a lot about what they do not know, and what the modern trainee needs to know. Often they are aware that the apprentice will be doing the master’s job in a couple of years or less. It is therefore mostly straightforward, and there is little need for formality. Of course there are lots of forces at work to try and eat away at this ancient method. That is why there are courses on teamwork at exactly the same time as teamwork is being destroyed (ditto for professionalism — I fear that once you make it explicit, it has kind of slipped through your fingers). I remember a hospital manager correcting a colleague who said that a junior doctor worked for a particular consultant; apparently junior doctors are ‘ward resources’ now. Like the furniture or the bedpans. The master pupil personal relationship is being supplemented or destroyed by tick-boxing, depending on your viewpoint.

For undergraduates I would argue that apprenticeship learning is the exception, rather than the norm, and that we would be better off not pretending otherwise. There are of course some exceptions, some final year attachments try very hard, but overall a number of factors mitigate against apprenticeship learning. Perhaps in some mythical past, students could acquire most of their knowledge by merely being on the ‘firm’ (note my antiquated terminology), but a host of factors make this approach problematic. Continuity of care is lacking; continued personal interaction with feedback lacking; most care is now delivered by specialists of one description of another; and most people who teach students are part-time teachers and part-time masters. The bond of common knowledge and goals has been broken; not uniformly, but more often than not. Masters within their narrow niches are unaware of what others have said or taught the novices. They are unaware of how one facet of medicine should build on what has gone before, and are therefore unable to integrate prior knowledge with the technical details of what they believe students need to know. Integration is a feature not of a curriculum, but of individual staff. Curriculums are usually meta objects, not of this world.
Apprentice learning is more fun, for both student and teacher, and is the only way to develop high level skills. For most domains of human expertise, there is no historical alternative. At the doctoral level, it is how we train academics. But at an undergraduate level, it is usually impossible. As Alice Gopnik remarked, if we want to become a chef, we stay in the kitchen; if you go to university, you spend 3 years sitting in ‘cracking eggs’ lectures. Apprenticeship doesn’t scale. We need something else, something better than we currently deliver.

Creating online courses from scratch is expensive and time-consuming. When universities try to do it themselves, the results can be erratic. Some online classes wind up being not much more than grainy videos of lectures and a collection of PowerPoint slides.

Slate

There was a time when universities had no natural predators. They roamed the intellectual savannah, their fight-or-flight response mechanism permanently turned off. Higher education ministers were another benign species doing what species have always done: consuming, reproducing and passing on. This was paradise before the snake; chicken before Colonel Sanders.

Christopher Bigsby in the THE

So, the GMC have decided to introduce a national licensing exam (‘passport to practice’). Their website says:

Medicine is an increasingly mobile profession, and we believe that a single national licensing examination would not only help to ensure that UK-trained graduates meet the required standards, but that international medical graduates seeking to practise here have been examined and evaluated to the same high level. Further work would be required on the position of doctors from the European Union.

Worthy of detailed  thought, but a number of points come to mind. First, the metaphor of a ‘passport’. What they describe  is a passport for non-UK persons, rather than UK medics. Second, within the EU we already have a medical ‘passport’. Indeed the last sentence of the above quote is, to say the least, strange. Are we seriously going to erect hurdles for UK citizens, but not say those of Holland or Germany who want to practice in the UK. And what of those of us who hold non-UK EU citizenship, but practice here. Medicine is indeed an increasingly mobile profession, and I think it needs to be much more so, but the logical follow through is that we need transnational standards or a series of reciprocal recognition treaties.

This strikes me more about the GMC trying to justify its own survival and, once again, expanding into domains where it has little genuine competence. What is the betting  it will be an MCQ paper? Certification close to graduation in medicine is fool’s gold. 

Are those of us who savour the irony of a British professor’s feeling the need to write “in a personal capacity” about academic freedom (Thomas Docherty, “Jobsworths and squatters”, Books, 2 October) allowing a sense of humour to habituate ourselves to the horrendous?

John Holford in the THE

One of the major challenges in clinical medicine is to delineate what knowledge can be formalised and what remains tacit. In general I believe we underestimate the latter. I like this example from a Nature editorial:

[tacit] know-how that can be passed on only through direct contact, and not by written or verbal instruction. How to ride a bicycle is a classic case. How to make an atomic bomb is a less-well-known example: all the instructions to build a nuclear weapon may be there on the Internet, but the ‘been there, done that’ personal experience is not. Indeed, security analysts have suggested that the lack of active testing and consequent erosion of nuclear-weapon tacit knowledge is leading to the “uninvention” of the bomb, and reduced credibility of the nuclear deterrent.

 In spite of the extra instruction that the on-campus students had, Figure 6 shows no evidence of positive, weekly relative improvement of our on-campus students compared with our online students.

A key paper comparing online with on campus.

The FT runs a story about a 18 year old Polish schoolgirl who has—whilst still at school — has come up with a way to target doxorubicin to tumour cells (the drug is attached to gold nano particles, within nano fibres, used in surgery). The work was done as part of a summer fellowship at the University of Warsaw. The article says that the Marie Curie Institute in Warsaw is giving her space to continue the work. The article ends:

Ms Jurek, who has still one more year of high school to complete not to mention university, has ambitions beyond the lab. In particular, she would like to develop her own product and set up a company to manufacture and sell her cancer treatment at an affordable price. “I don’t want to write scientific papers and hope for someone with means to pick up my research and invest in it. I want to have the means to apply the research myself,” she says. 

How the world changes — and can change. I wonder if silicon can make it in biology.

Its always a cheap shot (but true, nonetheless) to respond to students who say their medical school is better than most other medical schools, with the question “Have you been any other medial school?”. They may have some data, or have spoken to students from elsewhere, but most of the time I think it reflects the standard psychological bias we all suffer from. I am so glad I did dermatology rather than cardiology… (I am, I will add). And so on.
There is of course another bias, and that it to imagine that the grass is always greener else where. I certainly am guilty in this respect. I was always critical of my undergraduate medical degree at Newcastle, but with time I think I judged some of it too harshly. I am not referring to the fact that 10% of the clinical teaching sessions were no-shows by teaching staff who showed no interest in students. There were real problems, and there still are at most UK medical schools. I am just saying there were some good things. Let me describe two.
In the first two clinical years (years 3 and 4), Wednesday afternoons were sports afternoons. Or not, depending on your preferences — but there was no timetabled teaching. Wednesday mornings were devoted to a ‘special study research project’. This was highly informal, in that you decided whether you wanted to do it or not, and there was no formal structure to it, and of course, no exam. It didn’t count in terms of marks for any formal assessment. I doubt it has survived in this form, but as I look back now, I marvel at how farsighted the people were who planned it this way. If you didn’t want to do one or, like most research, it went nowhere, you just stopped it. You could stay in bed, or go to the library. Terrific. For me of course, it was how I met Sam Shuster, and that meeting determined the rest of my professional career.

The second thing, was the nature of the intercalated degree. Unlike many of the Scottish schools at least, the BMedSci was a bespoke course, built bottom up with the goal of providing training in medical science, not of allowing students to join other non-medical BSc courses. You could do it after year 2 or year 4. The idea being that being able to do it after you had clinical exposure, would encourage people to do clinical science projects. So, most students still wanted to become budding T cell immunologists (‘thymologists’ we called them) but people like me could tackle clinical problems (if they wished).
The degree was unmistakably a research degree. There was an intensive three month introduction, with my syllabus including med stats, epidemiology, health economics, and computing. The class size for all of this bar the stats was n=2 (for statistics it was n=12). Teaching was in a  lecturer’s offices over coffee. After the 3 month intensive course you were left to get on with your work for the remaining 9 months, with only 2 seminars to present, and a written individually bespoke exam, and a full length doctoral thesis to write. I forget the exact break down of marks, but over 70% were dependent on the thesis, which was examined by an external and internal, and included a viva. The degree was marketed (not the right word) to not just high fliers, but as an escape valve for those who found much of undergraduate medicine crushingly boring. This post is a way of saying thank you, and also a marker of how higher education has changed.

On why you might prefer med school to vet school. Philip Greenspun. Or not.