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Apprenticeship is a well established, traditional, and valued component of medical education.1,2 During internship and registrar years, doctors learn by applying their knowledge to real workplace problems in the context of professional practice. Learners start by observing clinical practitioners and are then given progressive responsibility.3 However, competing interests occur as the core activity of hospitals and primary care providers is patient care rather than clinical teaching.Time pressure, competing demands on staff from service, research, administration and teaching conspire to make the hospital a highly unstructured and complex learning environment.1 Learning is often driven by the day-to-day demands of the workplace where learning opportunities and supervision may not have first priority.4,5 Despite these challenges apprenticeship remains an important component of postgraduate and undergraduate medical education.2This paper considers and describes the attributes and behaviours of a good apprentice in the light of current research. We adopt a view of the apprentice as an active participant moving into a social learning environment requiring participation and active engagement in the clinical team, and the professional medical community.6-8It answers the following questions: What are the key elements of apprenticeship? What can an intern or registrar do to assist their own learning and development? What is apprenticeship?The basic notion of apprenticeship is showing the apprentice how to do the work and helping the apprentice to do it. In this article, we have drawn on two conceptual models we see as suited to modern healthcare environments: apprenticeship as situated in a community of practice and cognitive apprenticeship. These two models are not mutually exclusive.Apprenticeship within a community of practiceLave and Wenger9 argue that, for new practitioners, learning begins by practising clegitimatelyd on the periphery of a community. Initially newcomers to a workplace assume a relatively passive role and watch what is happening (at the periphery). Provided such newcomers feel entitled to be attendant (legitimate), much significant learning can occur as they become more involved in the activities of the workplace and assume more responsibility. Through this process, newcomers learn about the practice of the community by being situated within it and receiving guidance from its established members. We see this well embedded within the way vocational medical colleges admit, support, teach and provide ongoing education for their members. cThe community of practiced is defined as; cGroups of people informally bound together by shared expertise and passion for a joint enterprised.9 (p. 139)Communities of practice are a way practitioners can share and gain practice knowledge. As a learner becomes more engaged in the learning workplace, increasing interactions will occur with other members of that community. It is these interactions that promote good apprenticeship learning. By the sharing of stories and discussing problems, practitioners can reflect on experiences and receive feedback from other members of the group on their shared passion or subject. This sharing leads to new ways of cdoingd, and so creates a cyclical learning pattern that is driven by practitioners themselves. Wenger 10 theorises that meaning is continually negotiated and renegotiated through the processes of participation, the active experience of ongoing practice and the use and development of shared tools (e.g. case notes, ward rounds).Cognitive apprenticeshipIn cognitive apprenticeship, one needs to deliberately bring the thinking to the surface, to make it visible. The experts thinking must be made visible to the novice just as the novices thinking must be made visible to the expert. In the cognitive professions, such as medicine, learners benefit from insight into the cognitive processes underlying expert performance; it can make it easier for them to reproduce certain procedures on their own.11As novice learners share their thoughts and reasoning, expert clinicians can listen in order to diagnose errors in reasoning and defective analysis or synthesis of patient information. Making explicit the generally tacit cognitive processes of experts can elucidate complex task performance and help students in observing, enacting and practicing such tasks.12 This requires both the teacher and learner to cthink aloudd. For example, this might mean not just asking for the problems/diagnoses but also asking how these were arrived at.What can an intern or registrar do to assist their own learning and development?Considering these two conceptual models of apprenticeship allows us to describe the behaviours and attributes of a good apprentice. We have selected four themes in the current literature to describe the good apprentice and we present these as tips to students and teachers: engagement; managing uncertainty in decision making; learning from practice and maximising feedback; and adopting an ethical and moral commitment to patient safety.EngagementEngagement and participation have key roles in workplace learning. It is essential to the ccommunity of practiced style of learning. Clinical workplaces can enhance effective learning through encouraging or inviting newcomers to engage in interactions with peers and practitioners that are more experienced, encouraging newcomers to participate fully as a member of the healthcare team.7,13 This benefits the learner as well as the entire healthcare team.Key components of this engagement are listed in Box 1. It is important to note also that learning occurs from a wider healthcare team than one might initially think. The healthcare team includes, but is not limited to, a more experienced supervisor, the inter-professional team delivering care, the patient and their family, the more expert medical practitioners, and the relationships inherent in the clinical environment. Learning is participatory and knowledge is built within the clinical team as the community of practice that provide patient care and the medical colleges as those that support the novice practitioner Box 1. Key messages for engagement and participation Get involved by building relationships Be willing; take all opportunities to be involved. Look for things to do, do not stand back, offer to do things, accept all invitations to be involved in patient care. Be proactive, show enthusiasm Bring a sense of urgency and enthusiasm to your work and others will notice you and respond. Ask questions and develop an attitude of enquiry. Be an active learner Look up information, read around cases, attend case meetings and contribute even in small ways. Offer suggestions and do not be afraid of being wrong. Talk through your decision making process with your peers and supervisors, check that the way you are solving problems is effective. Ask questions all the time and of everybody. Managing uncertainty in decision makingGood decisions require underpinning knowledge and skills but also require a diagnostic approach i.e. a way of thinking about problems which is not innate, but needs to be learnt. Diagnostic skills are often acquired subconsciously but there is growing literature that explains how this occurs. Clinical decision making arises within the context of varying needs of patients, who do not necessarily present as ctextbook casesd. Therefore clinical decision making requires the development of judgment in applying knowledge to specific cases. Judith Bowen15 offers a process an apprentice can utilise when making decisions about a clinical problem. (Figure1). Decisions will be influenced by knowledge already acquired, the context in which the decision making occurs and past experience. Taking the history, gathering data, accurate problem representation and generating the problem are skills usually well developed by graduation from medical school. The difficult step for the apprentice can be matching their hypotheses to an 8illness script. An illness script is how more experienced clinicians store diseases, conditions or syndromes. Matching the problem representation against the illness script enables recall of knowledge and appropriate matching - hence diagnosis. Apprentices usually have limited knowledge and prior experience to draw on and will therefore need to discuss diagnostic reasoning with senior colleagues and frequently consult medical texts. Figure 1. Diagnostic Reasoning Process 3 from Bowen 14 When interacting with a supervisor, a good apprentice should provide a differential diagnosis, including ranking why some diagnoses are more probable than others. To aid learning, the apprentice should be able to highlight which key features of the history, examination and investigations support the favoured diagnoses, and be willing to debate these with their supervisor. To develop good clinical decision making the good apprentice should be prepared to be active rather than a passive receiver of information. Fish and de Cossart15 provide some guidance for those new to clinical reasoning based on their research within the surgical education programme in the United Kingdom (Box 2). Box 2. Guide to clinical diagnostic reasoning (Adapted from Fish & de Cossart15) Prioritise tasks, focus on the decision in hand, and be willing to reconsider the order of their tasks View the problem from a distance, look for inconsistencies Welcome uncertainty, recognise the inevitability of complexity Do not ignore or leave to one side those elements that do not fit ones developing decision Think carefully about the significance of all elements Look at the patient as a whole Do not rush to identify resemblances between this case and others Be willing to ask for another opinion Learning from practice and maximising feedbackAn independent practitioner, as well as good apprentice, should continually reflect on practice in order to ensure ongoing development as an effective practitioner. Schon,16 Kolb,17 and Boud18 have described processes by which professionals learn from practice (experiential learning and reflection). It is the reflection on experience and the problem solving that occurs alongside experience that creates what Ken Cox19 describes as cworking knowledged. Cox19 describes learning cdoctoringd as involving: the exploration of clinical working knowledge, practical skills and responsible behavior to learn how clinical experience builds judgment, expertise and eventually wisdom in the specific context of the patient. (p. 768) Reflection can be a retrospective activity after the process (on-action), reflecting as you are doing it (in-action), and/or reflecting forward (for-action), which is anticipatory, thinking about what might happen, planning for the future, and how it can be improved.20 Whilst reflection requires self-evaluation, the use of peer and supervisor feedback is required to accurately self assess ones level of competence and to gain insight. Insight is not innate but can only be learnt when there is recognition of congruence or discrepancies between ones self assessment and the assessments of others. If feedback from others is not forthcoming, or if there is insufficient reflection on which to build self-assessment, then insight will be lacking. Feedback is important to aid reflection and also practical development but it is not the sole responsibility of the supervisor or other members of the health care team. Many articles focus on the role of supervisor as the giver of feedback (for example, Ende, Pendleton, Silverman) underplaying the importance of the active role of the receiver (the apprentice).21323 The good apprentice will identify deficits or areas for improvement and seek feedback from more experienced practitioners in order to confirm these deficiencies. They will accept and value feedback from multiple sources within their community of practice, reflect on their practice and the feedback they receive and use it to plan their own learning. For new or uncertain areas of practice, the apprentice should take the responsibility of asking more senior colleagues chow you might do it?d 24 Box 3. Suggestions for obtaining feedback (Adapted from Teunissen & Dornan24) Challenge yourself , seek feedback, but remember If you are inexperienced, get instructions first. Think first about the areas you already know are satisfactory, and areas that you know are not. Check if your supervisors agrees with this Think about areas that you are uncertain of, and pose these as questions to your supervisor. Seek answers to the following three questions. Where am I going? How am I getting there? What next? Get feedback directed at: the task, processes needed to understand the task and how you can monitor your own performance on the task An ethical and moral commitment to patient safetyThe good apprentice holds the patient central to all decisions for learning and delivery of care and is constantly looking to improve both their patients health and the health of the system as a whole. 25 Part of ensuring patient safety is the necessity for practitioners to have excellent communication skills and competence in communicating risk.25327 Box 4 provides some practical tips. Box 4. Patient safety tips Know your limitations and be honest about these with your supervisor. Reflect on your practice and its implications for patient safety. Recognise when you are overwhelmed by your caseload and its complexity; seek help early. Consult widely and utilise the wider health care team and systems to assist you. Recognise serious illness and the deteriorating patient; seek help early Communicate clearly and comprehensively at all times but especially with phone consultations. Maintain a life-work balance; seek to build personal and professional resilience and develop strategies to manage stress. Summary We see the good apprentice as an active participant.9 It is engagement with the team (through conversation and dialogue) that aids the passage from observer to involvement with the clinical team and wider inter-professional and medical community.15 The good apprentice is proactive making the most of the formal and informal learning opportunities available within the workplace. The apprentice doctor demonstrates commitment to the medical and inter-professional teams in which they work by acknowledging team members, sharing within the team respecting the diversity of members within the team and respect for each of these members. It is the conversations, the questions/answers and hearing more experienced practitioners cthinking aloudd that helps the new practitioner improve their skills in clinical reasoning. It is the dialogue, the language and the behaviours that give the experience meaning. While it is possible to learn by cdoing the jobd it is not easy to do this alone and there is evidence that the quality of supervision is the most significant factor in the clinical learning environment. A subsequent article in this series focuses on supervisors practices that encourage participation and learning.

Summary

Abstract

This paper targets both current apprentices and their supervisors drawing on current research to answer the following questions. What is apprenticeship and what are the key elements? What is a good apprentice and what can an intern or registrar do to assist their own learning and development? It takes a pragmatic approach and seeks to assist apprentices and their supervisors by attending closely to what is practicable, realistic, expedient and convenient; articulating this and laying it out as clearly as possible.

Aim

Method

Results

Conclusion

Author Information

Dale Sheehan, Clinical Teaching Coordinator, Health Sciences University of Canterbury & Medical Education Coordinator, Medical Education and Training Unit, Canterbury District Health Board; Warwick Bagg, Associate Dean (Medical Programme), Director Medical, Programme Directorate, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland; Wayne de Beer, Director of Clinical Training, Waikato Clinical School, School of Medicine, University of Auckland; Stephen Child, Director of Clinical Training / Physician Consultant, Clinical Education and Training Unit, Auckland District Health Board, Auckland; Wayne Hazell, Head of Emergency Medicine Education & Research Emergency Care, Middlemore Hospital, Counties Manukau District Health Board, Auckland; Joy Rudland, Director Faculty Educational Unit, Faculty Education Unit, University of Otago, Christchurch; Tim J Wilkinson, Associate Dean (Medical Education), Faculty of Medicine, University of Otago, Christchurch

Acknowledgements

Correspondence

Dale Sheehan, Medical Education and Training Unit, Canterbury District Health Board, LGF Parkside, Christchurch Hospital, Private Bag, Christchurch, New Zealand. Fax: +64 (0)3 3437731

Correspondence Email

dale.sheehan@cdhb.govt.nz

Competing Interests

None known.

Spencer JA, Jordan RK. Learner centered approaches in medical education. BMJ. 1999;318(7193):1280-83.Medical Training Board. Foundations of Excellence: Building infra structure for medical education and training. Wellington. Ministry of Health; 2009.Stalmeijer RE, Dolmans DJ, Wolfhagen HA, et al. The development of an instrument for evaluating clinical teachers: involving stakeholders to determine content validity. Med. Teach. 2008;30:8;e272-77.Collins A, Brown JS, Newman SE. Cognitive apprenticeship: teaching the crafts of reading, writing and mathematics. In L.B. Resnick, (ed) Knowledge, learning and instruction, essays in honour of Robert Glaser. Hillsdale, NJ: Erlbaum & Associates. 1989, p453-94.Dornan T. Experience based learning. Learning clinical medicine in workplaces. Dissertation, Maastricht University, Maastricht; 2006Van der Hem-Stokroos HH, Daelmans HEM, et al. A qualitative study of Constructive clinical learning experiences. Med Teach. 2003;25(2):120-6.Sheehan D, Wilkinson TJ, Billett S. Interns participation and learning in clinical environments in a New Zealand hospital. Acad Med. 2005;80(3):302-8.Teunissen P, Boor K, Scherpbier A, et al. Attending doctors perspectives on how residence learn. Med Educ. 2007;41(11):1050-58.Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge University Press; 1991.Wenger E. Communities of Practice: learning, meaning and identity: Cambridge. Cambridge University Press; 1998.Taylor TK, Care WD. Nursing education as cognitive apprenticeship: A framework for clinical education. Nurse Education. 1999;24(94):31-36.Sternberg RJ, Hoorvath JA. (Eds) Tacit knowledge in professional practice. Researcher and practitioner perspectives. Mahwah. New Jersey: Lawrence Erlbaum Associates Inc; 1999.Sheehan D, Wilkinson TJ. Applying theory to practice to train supervisors for the future. Poster ANZAME Conference Sydney, Australia. July, 2008.Bowen J. Diagnostic Reasoning Process. N Engl J Med. 2006;355:2217-25.Fish D, de Cossart L. Developing the wise doctor: A resource for trainers and trainees in MMC. The Royal Society of Medicine Press Ltd; 2007.Schon DA. The Reflective Practitioner. How Professionals Think in Action. New York: Basic Books; 1983.Kolb DA. Experiential learning: Experience as the source of learning and development. Englewood-Cliffs, NJ: Prentice-Hall; 1984.Boud D. Appreciating Adults Learning: Ipswich Book Co. Ltd; 1994.Cox K. What is included in Clinical Competence. The Medical Journal of Australia. 1988;148(4):25-27.Killion J, Todnem G. A process for personal theory building. Educ Leadersh. 1991;48:14-16Silverman JD, Kurtz SM, Draper J. The Calgary-Cambridge approach analysis of consultation. Educ Gen Pract. 1996;7:288-99.Pendleton D, Scofield T, Tate P, Havelock P. The consultation: an approach to learning and teaching. Oxford: Oxford University Press; 1984.Ende J. Feedback in clinical medical education. JAMA. 1983;Volume 250(6):777-81.Teunissen PW, Doran T. The competent novice lifelong learning at work BMJ;2008;336:667-69.Australian Council for Safety and Quality in Healthcare. National Patient Safety Education Framework.http://www.safetyandquality.gov.au/internet/safety/publishing.nsfAlaszewski A, Horlick-Jones T. How can doctors communicate information about risk more effectively? BMJ:2003;327:728-31.Paling J. Strategies to help patients understand risks. BMJ. 2003;327:745-48.

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Apprenticeship is a well established, traditional, and valued component of medical education.1,2 During internship and registrar years, doctors learn by applying their knowledge to real workplace problems in the context of professional practice. Learners start by observing clinical practitioners and are then given progressive responsibility.3 However, competing interests occur as the core activity of hospitals and primary care providers is patient care rather than clinical teaching.Time pressure, competing demands on staff from service, research, administration and teaching conspire to make the hospital a highly unstructured and complex learning environment.1 Learning is often driven by the day-to-day demands of the workplace where learning opportunities and supervision may not have first priority.4,5 Despite these challenges apprenticeship remains an important component of postgraduate and undergraduate medical education.2This paper considers and describes the attributes and behaviours of a good apprentice in the light of current research. We adopt a view of the apprentice as an active participant moving into a social learning environment requiring participation and active engagement in the clinical team, and the professional medical community.6-8It answers the following questions: What are the key elements of apprenticeship? What can an intern or registrar do to assist their own learning and development? What is apprenticeship?The basic notion of apprenticeship is showing the apprentice how to do the work and helping the apprentice to do it. In this article, we have drawn on two conceptual models we see as suited to modern healthcare environments: apprenticeship as situated in a community of practice and cognitive apprenticeship. These two models are not mutually exclusive.Apprenticeship within a community of practiceLave and Wenger9 argue that, for new practitioners, learning begins by practising clegitimatelyd on the periphery of a community. Initially newcomers to a workplace assume a relatively passive role and watch what is happening (at the periphery). Provided such newcomers feel entitled to be attendant (legitimate), much significant learning can occur as they become more involved in the activities of the workplace and assume more responsibility. Through this process, newcomers learn about the practice of the community by being situated within it and receiving guidance from its established members. We see this well embedded within the way vocational medical colleges admit, support, teach and provide ongoing education for their members. cThe community of practiced is defined as; cGroups of people informally bound together by shared expertise and passion for a joint enterprised.9 (p. 139)Communities of practice are a way practitioners can share and gain practice knowledge. As a learner becomes more engaged in the learning workplace, increasing interactions will occur with other members of that community. It is these interactions that promote good apprenticeship learning. By the sharing of stories and discussing problems, practitioners can reflect on experiences and receive feedback from other members of the group on their shared passion or subject. This sharing leads to new ways of cdoingd, and so creates a cyclical learning pattern that is driven by practitioners themselves. Wenger 10 theorises that meaning is continually negotiated and renegotiated through the processes of participation, the active experience of ongoing practice and the use and development of shared tools (e.g. case notes, ward rounds).Cognitive apprenticeshipIn cognitive apprenticeship, one needs to deliberately bring the thinking to the surface, to make it visible. The experts thinking must be made visible to the novice just as the novices thinking must be made visible to the expert. In the cognitive professions, such as medicine, learners benefit from insight into the cognitive processes underlying expert performance; it can make it easier for them to reproduce certain procedures on their own.11As novice learners share their thoughts and reasoning, expert clinicians can listen in order to diagnose errors in reasoning and defective analysis or synthesis of patient information. Making explicit the generally tacit cognitive processes of experts can elucidate complex task performance and help students in observing, enacting and practicing such tasks.12 This requires both the teacher and learner to cthink aloudd. For example, this might mean not just asking for the problems/diagnoses but also asking how these were arrived at.What can an intern or registrar do to assist their own learning and development?Considering these two conceptual models of apprenticeship allows us to describe the behaviours and attributes of a good apprentice. We have selected four themes in the current literature to describe the good apprentice and we present these as tips to students and teachers: engagement; managing uncertainty in decision making; learning from practice and maximising feedback; and adopting an ethical and moral commitment to patient safety.EngagementEngagement and participation have key roles in workplace learning. It is essential to the ccommunity of practiced style of learning. Clinical workplaces can enhance effective learning through encouraging or inviting newcomers to engage in interactions with peers and practitioners that are more experienced, encouraging newcomers to participate fully as a member of the healthcare team.7,13 This benefits the learner as well as the entire healthcare team.Key components of this engagement are listed in Box 1. It is important to note also that learning occurs from a wider healthcare team than one might initially think. The healthcare team includes, but is not limited to, a more experienced supervisor, the inter-professional team delivering care, the patient and their family, the more expert medical practitioners, and the relationships inherent in the clinical environment. Learning is participatory and knowledge is built within the clinical team as the community of practice that provide patient care and the medical colleges as those that support the novice practitioner Box 1. Key messages for engagement and participation Get involved by building relationships Be willing; take all opportunities to be involved. Look for things to do, do not stand back, offer to do things, accept all invitations to be involved in patient care. Be proactive, show enthusiasm Bring a sense of urgency and enthusiasm to your work and others will notice you and respond. Ask questions and develop an attitude of enquiry. Be an active learner Look up information, read around cases, attend case meetings and contribute even in small ways. Offer suggestions and do not be afraid of being wrong. Talk through your decision making process with your peers and supervisors, check that the way you are solving problems is effective. Ask questions all the time and of everybody. Managing uncertainty in decision makingGood decisions require underpinning knowledge and skills but also require a diagnostic approach i.e. a way of thinking about problems which is not innate, but needs to be learnt. Diagnostic skills are often acquired subconsciously but there is growing literature that explains how this occurs. Clinical decision making arises within the context of varying needs of patients, who do not necessarily present as ctextbook casesd. Therefore clinical decision making requires the development of judgment in applying knowledge to specific cases. Judith Bowen15 offers a process an apprentice can utilise when making decisions about a clinical problem. (Figure1). Decisions will be influenced by knowledge already acquired, the context in which the decision making occurs and past experience. Taking the history, gathering data, accurate problem representation and generating the problem are skills usually well developed by graduation from medical school. The difficult step for the apprentice can be matching their hypotheses to an 8illness script. An illness script is how more experienced clinicians store diseases, conditions or syndromes. Matching the problem representation against the illness script enables recall of knowledge and appropriate matching - hence diagnosis. Apprentices usually have limited knowledge and prior experience to draw on and will therefore need to discuss diagnostic reasoning with senior colleagues and frequently consult medical texts. Figure 1. Diagnostic Reasoning Process 3 from Bowen 14 When interacting with a supervisor, a good apprentice should provide a differential diagnosis, including ranking why some diagnoses are more probable than others. To aid learning, the apprentice should be able to highlight which key features of the history, examination and investigations support the favoured diagnoses, and be willing to debate these with their supervisor. To develop good clinical decision making the good apprentice should be prepared to be active rather than a passive receiver of information. Fish and de Cossart15 provide some guidance for those new to clinical reasoning based on their research within the surgical education programme in the United Kingdom (Box 2). Box 2. Guide to clinical diagnostic reasoning (Adapted from Fish & de Cossart15) Prioritise tasks, focus on the decision in hand, and be willing to reconsider the order of their tasks View the problem from a distance, look for inconsistencies Welcome uncertainty, recognise the inevitability of complexity Do not ignore or leave to one side those elements that do not fit ones developing decision Think carefully about the significance of all elements Look at the patient as a whole Do not rush to identify resemblances between this case and others Be willing to ask for another opinion Learning from practice and maximising feedbackAn independent practitioner, as well as good apprentice, should continually reflect on practice in order to ensure ongoing development as an effective practitioner. Schon,16 Kolb,17 and Boud18 have described processes by which professionals learn from practice (experiential learning and reflection). It is the reflection on experience and the problem solving that occurs alongside experience that creates what Ken Cox19 describes as cworking knowledged. Cox19 describes learning cdoctoringd as involving: the exploration of clinical working knowledge, practical skills and responsible behavior to learn how clinical experience builds judgment, expertise and eventually wisdom in the specific context of the patient. (p. 768) Reflection can be a retrospective activity after the process (on-action), reflecting as you are doing it (in-action), and/or reflecting forward (for-action), which is anticipatory, thinking about what might happen, planning for the future, and how it can be improved.20 Whilst reflection requires self-evaluation, the use of peer and supervisor feedback is required to accurately self assess ones level of competence and to gain insight. Insight is not innate but can only be learnt when there is recognition of congruence or discrepancies between ones self assessment and the assessments of others. If feedback from others is not forthcoming, or if there is insufficient reflection on which to build self-assessment, then insight will be lacking. Feedback is important to aid reflection and also practical development but it is not the sole responsibility of the supervisor or other members of the health care team. Many articles focus on the role of supervisor as the giver of feedback (for example, Ende, Pendleton, Silverman) underplaying the importance of the active role of the receiver (the apprentice).21323 The good apprentice will identify deficits or areas for improvement and seek feedback from more experienced practitioners in order to confirm these deficiencies. They will accept and value feedback from multiple sources within their community of practice, reflect on their practice and the feedback they receive and use it to plan their own learning. For new or uncertain areas of practice, the apprentice should take the responsibility of asking more senior colleagues chow you might do it?d 24 Box 3. Suggestions for obtaining feedback (Adapted from Teunissen & Dornan24) Challenge yourself , seek feedback, but remember If you are inexperienced, get instructions first. Think first about the areas you already know are satisfactory, and areas that you know are not. Check if your supervisors agrees with this Think about areas that you are uncertain of, and pose these as questions to your supervisor. Seek answers to the following three questions. Where am I going? How am I getting there? What next? Get feedback directed at: the task, processes needed to understand the task and how you can monitor your own performance on the task An ethical and moral commitment to patient safetyThe good apprentice holds the patient central to all decisions for learning and delivery of care and is constantly looking to improve both their patients health and the health of the system as a whole. 25 Part of ensuring patient safety is the necessity for practitioners to have excellent communication skills and competence in communicating risk.25327 Box 4 provides some practical tips. Box 4. Patient safety tips Know your limitations and be honest about these with your supervisor. Reflect on your practice and its implications for patient safety. Recognise when you are overwhelmed by your caseload and its complexity; seek help early. Consult widely and utilise the wider health care team and systems to assist you. Recognise serious illness and the deteriorating patient; seek help early Communicate clearly and comprehensively at all times but especially with phone consultations. Maintain a life-work balance; seek to build personal and professional resilience and develop strategies to manage stress. Summary We see the good apprentice as an active participant.9 It is engagement with the team (through conversation and dialogue) that aids the passage from observer to involvement with the clinical team and wider inter-professional and medical community.15 The good apprentice is proactive making the most of the formal and informal learning opportunities available within the workplace. The apprentice doctor demonstrates commitment to the medical and inter-professional teams in which they work by acknowledging team members, sharing within the team respecting the diversity of members within the team and respect for each of these members. It is the conversations, the questions/answers and hearing more experienced practitioners cthinking aloudd that helps the new practitioner improve their skills in clinical reasoning. It is the dialogue, the language and the behaviours that give the experience meaning. While it is possible to learn by cdoing the jobd it is not easy to do this alone and there is evidence that the quality of supervision is the most significant factor in the clinical learning environment. A subsequent article in this series focuses on supervisors practices that encourage participation and learning.

Summary

Abstract

This paper targets both current apprentices and their supervisors drawing on current research to answer the following questions. What is apprenticeship and what are the key elements? What is a good apprentice and what can an intern or registrar do to assist their own learning and development? It takes a pragmatic approach and seeks to assist apprentices and their supervisors by attending closely to what is practicable, realistic, expedient and convenient; articulating this and laying it out as clearly as possible.

Aim

Method

Results

Conclusion

Author Information

Dale Sheehan, Clinical Teaching Coordinator, Health Sciences University of Canterbury & Medical Education Coordinator, Medical Education and Training Unit, Canterbury District Health Board; Warwick Bagg, Associate Dean (Medical Programme), Director Medical, Programme Directorate, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland; Wayne de Beer, Director of Clinical Training, Waikato Clinical School, School of Medicine, University of Auckland; Stephen Child, Director of Clinical Training / Physician Consultant, Clinical Education and Training Unit, Auckland District Health Board, Auckland; Wayne Hazell, Head of Emergency Medicine Education & Research Emergency Care, Middlemore Hospital, Counties Manukau District Health Board, Auckland; Joy Rudland, Director Faculty Educational Unit, Faculty Education Unit, University of Otago, Christchurch; Tim J Wilkinson, Associate Dean (Medical Education), Faculty of Medicine, University of Otago, Christchurch

Acknowledgements

Correspondence

Dale Sheehan, Medical Education and Training Unit, Canterbury District Health Board, LGF Parkside, Christchurch Hospital, Private Bag, Christchurch, New Zealand. Fax: +64 (0)3 3437731

Correspondence Email

dale.sheehan@cdhb.govt.nz

Competing Interests

None known.

Spencer JA, Jordan RK. Learner centered approaches in medical education. BMJ. 1999;318(7193):1280-83.Medical Training Board. Foundations of Excellence: Building infra structure for medical education and training. Wellington. Ministry of Health; 2009.Stalmeijer RE, Dolmans DJ, Wolfhagen HA, et al. The development of an instrument for evaluating clinical teachers: involving stakeholders to determine content validity. Med. Teach. 2008;30:8;e272-77.Collins A, Brown JS, Newman SE. Cognitive apprenticeship: teaching the crafts of reading, writing and mathematics. In L.B. Resnick, (ed) Knowledge, learning and instruction, essays in honour of Robert Glaser. Hillsdale, NJ: Erlbaum & Associates. 1989, p453-94.Dornan T. Experience based learning. Learning clinical medicine in workplaces. Dissertation, Maastricht University, Maastricht; 2006Van der Hem-Stokroos HH, Daelmans HEM, et al. A qualitative study of Constructive clinical learning experiences. Med Teach. 2003;25(2):120-6.Sheehan D, Wilkinson TJ, Billett S. Interns participation and learning in clinical environments in a New Zealand hospital. Acad Med. 2005;80(3):302-8.Teunissen P, Boor K, Scherpbier A, et al. Attending doctors perspectives on how residence learn. Med Educ. 2007;41(11):1050-58.Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge University Press; 1991.Wenger E. Communities of Practice: learning, meaning and identity: Cambridge. Cambridge University Press; 1998.Taylor TK, Care WD. Nursing education as cognitive apprenticeship: A framework for clinical education. Nurse Education. 1999;24(94):31-36.Sternberg RJ, Hoorvath JA. (Eds) Tacit knowledge in professional practice. Researcher and practitioner perspectives. Mahwah. New Jersey: Lawrence Erlbaum Associates Inc; 1999.Sheehan D, Wilkinson TJ. Applying theory to practice to train supervisors for the future. Poster ANZAME Conference Sydney, Australia. July, 2008.Bowen J. Diagnostic Reasoning Process. N Engl J Med. 2006;355:2217-25.Fish D, de Cossart L. Developing the wise doctor: A resource for trainers and trainees in MMC. The Royal Society of Medicine Press Ltd; 2007.Schon DA. The Reflective Practitioner. How Professionals Think in Action. New York: Basic Books; 1983.Kolb DA. Experiential learning: Experience as the source of learning and development. Englewood-Cliffs, NJ: Prentice-Hall; 1984.Boud D. Appreciating Adults Learning: Ipswich Book Co. Ltd; 1994.Cox K. What is included in Clinical Competence. The Medical Journal of Australia. 1988;148(4):25-27.Killion J, Todnem G. A process for personal theory building. Educ Leadersh. 1991;48:14-16Silverman JD, Kurtz SM, Draper J. The Calgary-Cambridge approach analysis of consultation. Educ Gen Pract. 1996;7:288-99.Pendleton D, Scofield T, Tate P, Havelock P. The consultation: an approach to learning and teaching. Oxford: Oxford University Press; 1984.Ende J. Feedback in clinical medical education. JAMA. 1983;Volume 250(6):777-81.Teunissen PW, Doran T. The competent novice lifelong learning at work BMJ;2008;336:667-69.Australian Council for Safety and Quality in Healthcare. National Patient Safety Education Framework.http://www.safetyandquality.gov.au/internet/safety/publishing.nsfAlaszewski A, Horlick-Jones T. How can doctors communicate information about risk more effectively? BMJ:2003;327:728-31.Paling J. Strategies to help patients understand risks. BMJ. 2003;327:745-48.

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Apprenticeship is a well established, traditional, and valued component of medical education.1,2 During internship and registrar years, doctors learn by applying their knowledge to real workplace problems in the context of professional practice. Learners start by observing clinical practitioners and are then given progressive responsibility.3 However, competing interests occur as the core activity of hospitals and primary care providers is patient care rather than clinical teaching.Time pressure, competing demands on staff from service, research, administration and teaching conspire to make the hospital a highly unstructured and complex learning environment.1 Learning is often driven by the day-to-day demands of the workplace where learning opportunities and supervision may not have first priority.4,5 Despite these challenges apprenticeship remains an important component of postgraduate and undergraduate medical education.2This paper considers and describes the attributes and behaviours of a good apprentice in the light of current research. We adopt a view of the apprentice as an active participant moving into a social learning environment requiring participation and active engagement in the clinical team, and the professional medical community.6-8It answers the following questions: What are the key elements of apprenticeship? What can an intern or registrar do to assist their own learning and development? What is apprenticeship?The basic notion of apprenticeship is showing the apprentice how to do the work and helping the apprentice to do it. In this article, we have drawn on two conceptual models we see as suited to modern healthcare environments: apprenticeship as situated in a community of practice and cognitive apprenticeship. These two models are not mutually exclusive.Apprenticeship within a community of practiceLave and Wenger9 argue that, for new practitioners, learning begins by practising clegitimatelyd on the periphery of a community. Initially newcomers to a workplace assume a relatively passive role and watch what is happening (at the periphery). Provided such newcomers feel entitled to be attendant (legitimate), much significant learning can occur as they become more involved in the activities of the workplace and assume more responsibility. Through this process, newcomers learn about the practice of the community by being situated within it and receiving guidance from its established members. We see this well embedded within the way vocational medical colleges admit, support, teach and provide ongoing education for their members. cThe community of practiced is defined as; cGroups of people informally bound together by shared expertise and passion for a joint enterprised.9 (p. 139)Communities of practice are a way practitioners can share and gain practice knowledge. As a learner becomes more engaged in the learning workplace, increasing interactions will occur with other members of that community. It is these interactions that promote good apprenticeship learning. By the sharing of stories and discussing problems, practitioners can reflect on experiences and receive feedback from other members of the group on their shared passion or subject. This sharing leads to new ways of cdoingd, and so creates a cyclical learning pattern that is driven by practitioners themselves. Wenger 10 theorises that meaning is continually negotiated and renegotiated through the processes of participation, the active experience of ongoing practice and the use and development of shared tools (e.g. case notes, ward rounds).Cognitive apprenticeshipIn cognitive apprenticeship, one needs to deliberately bring the thinking to the surface, to make it visible. The experts thinking must be made visible to the novice just as the novices thinking must be made visible to the expert. In the cognitive professions, such as medicine, learners benefit from insight into the cognitive processes underlying expert performance; it can make it easier for them to reproduce certain procedures on their own.11As novice learners share their thoughts and reasoning, expert clinicians can listen in order to diagnose errors in reasoning and defective analysis or synthesis of patient information. Making explicit the generally tacit cognitive processes of experts can elucidate complex task performance and help students in observing, enacting and practicing such tasks.12 This requires both the teacher and learner to cthink aloudd. For example, this might mean not just asking for the problems/diagnoses but also asking how these were arrived at.What can an intern or registrar do to assist their own learning and development?Considering these two conceptual models of apprenticeship allows us to describe the behaviours and attributes of a good apprentice. We have selected four themes in the current literature to describe the good apprentice and we present these as tips to students and teachers: engagement; managing uncertainty in decision making; learning from practice and maximising feedback; and adopting an ethical and moral commitment to patient safety.EngagementEngagement and participation have key roles in workplace learning. It is essential to the ccommunity of practiced style of learning. Clinical workplaces can enhance effective learning through encouraging or inviting newcomers to engage in interactions with peers and practitioners that are more experienced, encouraging newcomers to participate fully as a member of the healthcare team.7,13 This benefits the learner as well as the entire healthcare team.Key components of this engagement are listed in Box 1. It is important to note also that learning occurs from a wider healthcare team than one might initially think. The healthcare team includes, but is not limited to, a more experienced supervisor, the inter-professional team delivering care, the patient and their family, the more expert medical practitioners, and the relationships inherent in the clinical environment. Learning is participatory and knowledge is built within the clinical team as the community of practice that provide patient care and the medical colleges as those that support the novice practitioner Box 1. Key messages for engagement and participation Get involved by building relationships Be willing; take all opportunities to be involved. Look for things to do, do not stand back, offer to do things, accept all invitations to be involved in patient care. Be proactive, show enthusiasm Bring a sense of urgency and enthusiasm to your work and others will notice you and respond. Ask questions and develop an attitude of enquiry. Be an active learner Look up information, read around cases, attend case meetings and contribute even in small ways. Offer suggestions and do not be afraid of being wrong. Talk through your decision making process with your peers and supervisors, check that the way you are solving problems is effective. Ask questions all the time and of everybody. Managing uncertainty in decision makingGood decisions require underpinning knowledge and skills but also require a diagnostic approach i.e. a way of thinking about problems which is not innate, but needs to be learnt. Diagnostic skills are often acquired subconsciously but there is growing literature that explains how this occurs. Clinical decision making arises within the context of varying needs of patients, who do not necessarily present as ctextbook casesd. Therefore clinical decision making requires the development of judgment in applying knowledge to specific cases. Judith Bowen15 offers a process an apprentice can utilise when making decisions about a clinical problem. (Figure1). Decisions will be influenced by knowledge already acquired, the context in which the decision making occurs and past experience. Taking the history, gathering data, accurate problem representation and generating the problem are skills usually well developed by graduation from medical school. The difficult step for the apprentice can be matching their hypotheses to an 8illness script. An illness script is how more experienced clinicians store diseases, conditions or syndromes. Matching the problem representation against the illness script enables recall of knowledge and appropriate matching - hence diagnosis. Apprentices usually have limited knowledge and prior experience to draw on and will therefore need to discuss diagnostic reasoning with senior colleagues and frequently consult medical texts. Figure 1. Diagnostic Reasoning Process 3 from Bowen 14 When interacting with a supervisor, a good apprentice should provide a differential diagnosis, including ranking why some diagnoses are more probable than others. To aid learning, the apprentice should be able to highlight which key features of the history, examination and investigations support the favoured diagnoses, and be willing to debate these with their supervisor. To develop good clinical decision making the good apprentice should be prepared to be active rather than a passive receiver of information. Fish and de Cossart15 provide some guidance for those new to clinical reasoning based on their research within the surgical education programme in the United Kingdom (Box 2). Box 2. Guide to clinical diagnostic reasoning (Adapted from Fish & de Cossart15) Prioritise tasks, focus on the decision in hand, and be willing to reconsider the order of their tasks View the problem from a distance, look for inconsistencies Welcome uncertainty, recognise the inevitability of complexity Do not ignore or leave to one side those elements that do not fit ones developing decision Think carefully about the significance of all elements Look at the patient as a whole Do not rush to identify resemblances between this case and others Be willing to ask for another opinion Learning from practice and maximising feedbackAn independent practitioner, as well as good apprentice, should continually reflect on practice in order to ensure ongoing development as an effective practitioner. Schon,16 Kolb,17 and Boud18 have described processes by which professionals learn from practice (experiential learning and reflection). It is the reflection on experience and the problem solving that occurs alongside experience that creates what Ken Cox19 describes as cworking knowledged. Cox19 describes learning cdoctoringd as involving: the exploration of clinical working knowledge, practical skills and responsible behavior to learn how clinical experience builds judgment, expertise and eventually wisdom in the specific context of the patient. (p. 768) Reflection can be a retrospective activity after the process (on-action), reflecting as you are doing it (in-action), and/or reflecting forward (for-action), which is anticipatory, thinking about what might happen, planning for the future, and how it can be improved.20 Whilst reflection requires self-evaluation, the use of peer and supervisor feedback is required to accurately self assess ones level of competence and to gain insight. Insight is not innate but can only be learnt when there is recognition of congruence or discrepancies between ones self assessment and the assessments of others. If feedback from others is not forthcoming, or if there is insufficient reflection on which to build self-assessment, then insight will be lacking. Feedback is important to aid reflection and also practical development but it is not the sole responsibility of the supervisor or other members of the health care team. Many articles focus on the role of supervisor as the giver of feedback (for example, Ende, Pendleton, Silverman) underplaying the importance of the active role of the receiver (the apprentice).21323 The good apprentice will identify deficits or areas for improvement and seek feedback from more experienced practitioners in order to confirm these deficiencies. They will accept and value feedback from multiple sources within their community of practice, reflect on their practice and the feedback they receive and use it to plan their own learning. For new or uncertain areas of practice, the apprentice should take the responsibility of asking more senior colleagues chow you might do it?d 24 Box 3. Suggestions for obtaining feedback (Adapted from Teunissen & Dornan24) Challenge yourself , seek feedback, but remember If you are inexperienced, get instructions first. Think first about the areas you already know are satisfactory, and areas that you know are not. Check if your supervisors agrees with this Think about areas that you are uncertain of, and pose these as questions to your supervisor. Seek answers to the following three questions. Where am I going? How am I getting there? What next? Get feedback directed at: the task, processes needed to understand the task and how you can monitor your own performance on the task An ethical and moral commitment to patient safetyThe good apprentice holds the patient central to all decisions for learning and delivery of care and is constantly looking to improve both their patients health and the health of the system as a whole. 25 Part of ensuring patient safety is the necessity for practitioners to have excellent communication skills and competence in communicating risk.25327 Box 4 provides some practical tips. Box 4. Patient safety tips Know your limitations and be honest about these with your supervisor. Reflect on your practice and its implications for patient safety. Recognise when you are overwhelmed by your caseload and its complexity; seek help early. Consult widely and utilise the wider health care team and systems to assist you. Recognise serious illness and the deteriorating patient; seek help early Communicate clearly and comprehensively at all times but especially with phone consultations. Maintain a life-work balance; seek to build personal and professional resilience and develop strategies to manage stress. Summary We see the good apprentice as an active participant.9 It is engagement with the team (through conversation and dialogue) that aids the passage from observer to involvement with the clinical team and wider inter-professional and medical community.15 The good apprentice is proactive making the most of the formal and informal learning opportunities available within the workplace. The apprentice doctor demonstrates commitment to the medical and inter-professional teams in which they work by acknowledging team members, sharing within the team respecting the diversity of members within the team and respect for each of these members. It is the conversations, the questions/answers and hearing more experienced practitioners cthinking aloudd that helps the new practitioner improve their skills in clinical reasoning. It is the dialogue, the language and the behaviours that give the experience meaning. While it is possible to learn by cdoing the jobd it is not easy to do this alone and there is evidence that the quality of supervision is the most significant factor in the clinical learning environment. A subsequent article in this series focuses on supervisors practices that encourage participation and learning.

Summary

Abstract

This paper targets both current apprentices and their supervisors drawing on current research to answer the following questions. What is apprenticeship and what are the key elements? What is a good apprentice and what can an intern or registrar do to assist their own learning and development? It takes a pragmatic approach and seeks to assist apprentices and their supervisors by attending closely to what is practicable, realistic, expedient and convenient; articulating this and laying it out as clearly as possible.

Aim

Method

Results

Conclusion

Author Information

Dale Sheehan, Clinical Teaching Coordinator, Health Sciences University of Canterbury & Medical Education Coordinator, Medical Education and Training Unit, Canterbury District Health Board; Warwick Bagg, Associate Dean (Medical Programme), Director Medical, Programme Directorate, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland; Wayne de Beer, Director of Clinical Training, Waikato Clinical School, School of Medicine, University of Auckland; Stephen Child, Director of Clinical Training / Physician Consultant, Clinical Education and Training Unit, Auckland District Health Board, Auckland; Wayne Hazell, Head of Emergency Medicine Education & Research Emergency Care, Middlemore Hospital, Counties Manukau District Health Board, Auckland; Joy Rudland, Director Faculty Educational Unit, Faculty Education Unit, University of Otago, Christchurch; Tim J Wilkinson, Associate Dean (Medical Education), Faculty of Medicine, University of Otago, Christchurch

Acknowledgements

Correspondence

Dale Sheehan, Medical Education and Training Unit, Canterbury District Health Board, LGF Parkside, Christchurch Hospital, Private Bag, Christchurch, New Zealand. Fax: +64 (0)3 3437731

Correspondence Email

dale.sheehan@cdhb.govt.nz

Competing Interests

None known.

Spencer JA, Jordan RK. Learner centered approaches in medical education. BMJ. 1999;318(7193):1280-83.Medical Training Board. Foundations of Excellence: Building infra structure for medical education and training. Wellington. Ministry of Health; 2009.Stalmeijer RE, Dolmans DJ, Wolfhagen HA, et al. The development of an instrument for evaluating clinical teachers: involving stakeholders to determine content validity. Med. Teach. 2008;30:8;e272-77.Collins A, Brown JS, Newman SE. Cognitive apprenticeship: teaching the crafts of reading, writing and mathematics. In L.B. Resnick, (ed) Knowledge, learning and instruction, essays in honour of Robert Glaser. Hillsdale, NJ: Erlbaum & Associates. 1989, p453-94.Dornan T. Experience based learning. Learning clinical medicine in workplaces. Dissertation, Maastricht University, Maastricht; 2006Van der Hem-Stokroos HH, Daelmans HEM, et al. A qualitative study of Constructive clinical learning experiences. Med Teach. 2003;25(2):120-6.Sheehan D, Wilkinson TJ, Billett S. Interns participation and learning in clinical environments in a New Zealand hospital. Acad Med. 2005;80(3):302-8.Teunissen P, Boor K, Scherpbier A, et al. Attending doctors perspectives on how residence learn. Med Educ. 2007;41(11):1050-58.Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge University Press; 1991.Wenger E. Communities of Practice: learning, meaning and identity: Cambridge. Cambridge University Press; 1998.Taylor TK, Care WD. Nursing education as cognitive apprenticeship: A framework for clinical education. Nurse Education. 1999;24(94):31-36.Sternberg RJ, Hoorvath JA. (Eds) Tacit knowledge in professional practice. Researcher and practitioner perspectives. Mahwah. New Jersey: Lawrence Erlbaum Associates Inc; 1999.Sheehan D, Wilkinson TJ. Applying theory to practice to train supervisors for the future. Poster ANZAME Conference Sydney, Australia. July, 2008.Bowen J. Diagnostic Reasoning Process. N Engl J Med. 2006;355:2217-25.Fish D, de Cossart L. Developing the wise doctor: A resource for trainers and trainees in MMC. The Royal Society of Medicine Press Ltd; 2007.Schon DA. The Reflective Practitioner. How Professionals Think in Action. New York: Basic Books; 1983.Kolb DA. Experiential learning: Experience as the source of learning and development. Englewood-Cliffs, NJ: Prentice-Hall; 1984.Boud D. Appreciating Adults Learning: Ipswich Book Co. Ltd; 1994.Cox K. What is included in Clinical Competence. The Medical Journal of Australia. 1988;148(4):25-27.Killion J, Todnem G. A process for personal theory building. Educ Leadersh. 1991;48:14-16Silverman JD, Kurtz SM, Draper J. The Calgary-Cambridge approach analysis of consultation. Educ Gen Pract. 1996;7:288-99.Pendleton D, Scofield T, Tate P, Havelock P. The consultation: an approach to learning and teaching. Oxford: Oxford University Press; 1984.Ende J. Feedback in clinical medical education. JAMA. 1983;Volume 250(6):777-81.Teunissen PW, Doran T. The competent novice lifelong learning at work BMJ;2008;336:667-69.Australian Council for Safety and Quality in Healthcare. National Patient Safety Education Framework.http://www.safetyandquality.gov.au/internet/safety/publishing.nsfAlaszewski A, Horlick-Jones T. How can doctors communicate information about risk more effectively? BMJ:2003;327:728-31.Paling J. Strategies to help patients understand risks. BMJ. 2003;327:745-48.

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