The Forge: an Apprenticeship Perspective on Medical Education

The apprenticeship model is sometimes portrayed as an old fashioned, outmoded form of clinical teaching and learning. Does it still have a place in the modern curriculum?

 

All I know is a door into the dark.

Seamus Heaney, The Forge

In his poem, The Forge, Seamus Heaney shows us an intimate picture of a craftsman and his art: a hidden world of ringing iron and flying sparks. Initially, Heaney sees only rusty, abandoned iron and a closed door. The blacksmith emerges from the dark interior to talk to the schoolboy and a lasting relationship develops. A picture taken in later life shows the old blacksmith proudly cradling a photograph of the two of them. Heaney doesn’t idealise him—he sees the ‘hairs in his nose’—but his craft is still a fascinating mystery, something mythical, spiritual, sacramental:

The anvil must be somewhere in the centre,
Horned as a unicorn, at one end and square,
Set there immoveable: an altar
Where he expends himself in shape and music.

Seamus Heaney, The Forge

At the heart of the poem is their relationship, but also a sadness: for a dying art, and for another relationship, noticeable by its absence. The blacksmith shares his memories, of the forge as the glowing heart of the farming community, the street outside ‘a clatter of hooves’ where now there are only cars, flashing by. The absence becomes clear in the last lines of the poem:

Then grunts and goes in, with a slam and flick
To beat real iron out, to work the bellows.

Seamus Heaney, The Forge

He is alone in the forge. The tasks he returns to are those of a missing apprentice: first watching the master at work, entrusted with working the bellows to maintain the correct temperature; then graduating to the role of striker, wielding the heavy sledgehammer while the blacksmith holds the hot iron in the best position on the anvil, tapping with a small hammer to indicate the optimum point of impact.

Of course, Heaney is making an allusion to his own craft as a poet—hammering out real truth, alone in the dark—but perhaps also to his first desire, to follow in his father’s footsteps as an apprentice on the family farm: idolising his father, romanticising his craft, but never allowed to do more than stumble behind him, always feeling in the way; later, dismissing his ways as backward and foolish; and later still, regretting it.

I wanted to grow up and plough
To close one eye, stiffen my arm.
All I ever did was follow
In his broad shadow round the farm.

I was a nuisance, tripping, falling,
Yapping always. But today
It is my father who keeps stumbling
Behind me, and will not go away.

Seamus Heaney, Follower

When I look at medical education today, I too see, sometimes, both a sadness and an absence. I see it in the medical student who tells me she is going to spend less time on the wards, so that she can achieve even higher multiple choice exam scores. I see it in the the student who announces that he is going to refuse requests to help with routine ward work, as he already has those competencies signed off. And I see it in the disillusioned junior doctor, clocking in and clocking out of their shift: rudderless, rootless, and trapped on a meaningless treadmill.

Every generation has a tendency to become nostalgic about a golden age, to long for the ‘clatter of hooves’ once more, and to forget that those same streets were paved, not with gold, but with horse manure. My medical qualification was taken in Medicine and Surgery, and the curriculum mirrored the traditions of these two, originally separate occupations. The transmission of vast bodies of knowledge—occupying the academic high ground, the physicianly aspects of the course—was alloyed with an apprenticeship still recognisable from the days of the barber-surgeon guilds.

There were many limitations to that course; I’ve written about some of them in previous posts. The knowledge we spent so long memorising was often abstruse, and much of it proved easily—and safely—forgotten. We expended days, and nights, on the inpatient wards, in casualty, on labour ward, following, just in case there was an opportunity to get involved.

Certainly, at times we were made to feel ‘a nuisance, tripping, falling, yapping always’, but we also felt ourselves becoming part of the guild, contributing in real ways to clinical care. We took blood and sutured wounds, held retractors and wrote out forms, not to achieve a competency, but because the patient needed them, and our colleagues needed us. Over thirty years later I still remember, with gratitude, those clinicians who opened doors and drew me into that world, who invested trust and made me feel valued.

Unquestionably, doctors need to retain scientific knowledge, to develop skills and to reflect on their inner development: I have previously looked at Daniel Pratt’s Transmission, Developmental and Nurturing Perspectives on education, which help to address these needs. But much of medicine remains a craft practice situated in professional community, and we mustn’t neglect the vital role of apprenticeship.

My picture illustrates the key facets of an Apprenticeship Perspective. The most obvious difference from those previous models is that clinical apprenticeship is not learner centred; nor is it teacher centred: it is patient centred. Patients are the anvils on which we are shaped as we practice medicine.

For the patient, care comes from a broad circle of clinicians. Jean Lave and Étienne Wenger talk of a community of practice, within which craft work takes place. The apprentice starts outside this community, following, watching, memorising, but never a part of the work. The mentor—traditionally the master—is a gatekeeper, as are other members of the clinical team: it is only when they trust the apprentice enough to let them take on a useful role—legitimate peripheral participation—that the latter starts to become part of the community of practice, and their learning can really begin. This trust has to come out of ongoing relationship, developed over time.

In this model, learning itself is not something that occurs inside an individual; it grows within a community and flourishes in the relationships between its members; it is a journey towards the centre of that community, a gradual process of becoming.

The unstructured nature of the experience, the necessity of spending time in activity for which there is no predefined, explicit, immediate learning outcome, and the difficulty of measuring centripetal progress with an exam score, have all contributed to a general move away from apprenticeship as a suitable model for teaching and learning in the formal medical curriculum. But clinical apprenticeship is where our characters, as doctors, are forged – not in the classroom or the library, the simulation suite or online.

We need to continue to find ways to hold open the door into the inner realms of our clinical practice; to welcome in the learner as a legitimate, appreciated member of our clinical teams; to excite and sustain their wonder at that world within:

Inside, the hammered anvil’s short-pitched ring,
The unpredictable fantail of sparks
Or hiss when a new shoe toughens in water.

Seamus Heaney, The Forge

If we don’t, they will see only the rusting iron outside; they too will dismiss our ways as old and foolish; and I think we will all, later, have cause for regret.