The demise of 'the firm': implications for undergraduate apprenticeship learning in medicine Seminar

Concerns about the current state of junior doctor training in the UK are well documented. A recent report states that “the main problems are lack of confidence and competence in clinical-decision making, clinical procedures and prescribing in practical situations, lack of understanding of the NHS and how it works and standards of professionalism” (Skills for health, 2009).

Our research approach posited that the ‘demise of the firm’ lay at the heart of the matter (‘the firm’ denotes the site and mechanism through which apprenticeship style teaching was delivered within clinical settings in Britain). Despite its centrality, the concept of the firm has remained underexplored within the medical education literature. Our research asked: What was the firm and how has it changed? Of particular concern was the way in which firms encompassed the teaching of undergraduates.

The European Working Time Directive, in conjunction with the changes to junior doctor training (Modernising Medical Careers, etc.) have undermined firm structures. Some specialties are struggling to maintain its functions, but shift-working is currently delivering the final blow. The ‘absence’ of junior doctors has resulted in a loss of continuity not only for patients but also for undergraduates and thus fundamentally undermines apprenticeship-style learning. Additional pressures on undergraduate education result from the increasing sub-specialisation, the privatisation of routine care and the re-distribution of tasks across health care professions.

Undergraduates have lost their single access point, mentor and guide on the wards. Structured teaching sessions are set up to ensure students receive training, but it further removes them from everyday clinical practice. On shorter attachments, ever larger teams remain impenetrable. The increasing numbers of subspecialties further hinder mutually satisfying teaching relationships. In this context undergraduates struggle to demonstrate their interest, engagement and willingness to get stuck in; they are effectively sidelined and increasingly excluded from participation.

As clinicians and deaneries are scrambling to prop up junior doctor training without the firm, the implications for undergraduate education remain in the blind spot.