Medical Doctor Degree Apprenticeships in the UK
A logical development but their success will rely on regular review and adjustment
The new NHS England Long Term Workforce Plan
Coincident with the 75th anniversary of the founding of the UK National Health Service and in the midst of the biggest staffing crisis in its history, NHS England has announced a new, awkwardly-named five-year Medical Doctor Degree Apprenticeship, the “MDDA”, not to be confused with an unrelated UK organisation for doctors and dentists that has the same initials!
These apprenticeships are part of a recently-published NHS England Long Term Workforce Plan to address the severe shortage of healthcare professionals that has built up in the service as a result of long-term under-investment in staff and the more-recent decline in numbers of European clinical staff due to Brexit. These staffing problems have been amplified by increased NHS sickness absence and retirements due to Covid-induced burnout as well as the large backlog of work that has built up during and since the Covid pandemic.
Three principles of the NHS England Long Term Workforce Plan
The Long Term Workforce Plan aims to increase the number of UK-trained clinical staff and to support them to work more efficiently and effectively than at present.
The Plan is based on three principles:
(1) an increase in the numbers of trained staff and in the case of medicine a doubling of the numbers of medical school training places by 2030-1.
(2) retention of these staff.
(3) reform both of their training and of their working methods.
The Long Term Workforce Plan (first promised back in 2017-18) has been generally well-received, if only because it has been so long in gestation.
Resistance to aspects of the Long Term Workforce Plan
So far, although an industry Standard has been created for the MDDA programmes, much uncertainty necessarily remains about their detail at this early stage; however the apprentices during their five-year undergraduate training will spend less time in classroom or seminar activities than students who enter medical school immediately after secondary education, because part of the five year training will be spent in the workplace.
The BMA and HCSA medical trade unions have expressed concern that the condensed teaching time in the MDDA programmes may produce lower quality doctors with insufficient “softer” skills such as communication proficiencies and an ability to undertake and interpret research.
Additionally it is not yet clear whether additional funding will be committed for long enough by future governments to see the whole workforce plan through to fruition, while existing specialists and GPs are already so busy that they may well have insufficient time to train and supervise the considerable increase in numbers of medical students planned.
The BMA says that this is one reason why they are particularly concerned that there is not enough detail about retention of existing staff in the Long Term Workforce Plan.
Will condensed training produce lower quality doctors?
I’m not very concerned about the quality issues around an accelerated undergraduate medical training programme because medical students on UK graduate entry schemes (ie those who already have a degree in another field) already typically complete their medical degrees a year earlier than other medical students without an apparent difference in quality. North American doctors also have a shorter period as medical students than is the case in the UK because their training from start to specialist certification is regarded as a continuum. Increasingly that principle also applies in UK medical training.
UK undergraduate medical training anyway needs to refocus on how to teach students from an early stage how to master the growing complexities of modern medical care.
The changing role of doctors
Currently considerable media attention is being given to whether technologies such as Artificial Intelligence (AI), particularly generative AIs such as ChatGPT, will remodel the medical profession in the way that they are predicted to reshape other professions.
At this stage we can only guess how AI will change the everyday work of doctors.
However we can be more certain that although doctors will always need to memorise certain key facts to be able to classify and understand their patient’s problems and to make rapid clinical decisions, the focus on learning a large body of knowledge by rote is already long-outdated. After all, medical students and doctors can rapidly find most of the evidence they need by searching the internet, sometimes on handheld devices while working on the wards. As has always been the case, they grow their expertise through development of properly-supervised clinical experience and logic on a foundation of the time-proven basics of thorough history taking and clinical examination.
In my view undergraduate medical education and training now needs to concentrate much more (but not exclusively) on activities and behaviours such as:
· identifying the right clinical information to make properly-informed decisions - and recognising when one does not have that information.
. clinical reasoning and dealing with diagnostic uncertainty.
. knowing the limits of one’s knowledge and skills.
· the avoidance of indecisiveness and buck-passing when dealing with uncertainty.
· effective, concise and timely recording of clinical information and clinical decisions.
· effective communication with patients and colleagues.
· techniques for optimal collaborative working with a wide variety of other healthcare professionals.
· the importance of personal accountability, the acceptance of responsibility and the delivery of effective clinical leadership.
· how to supervise clinical nurse specialists and PAs who undertake “crossover” roles that are often also performed by doctors.
Some of these topics are already well-covered in sections of the undergraduate and postgraduate curricula and training as well as in the General Medical Council document Good Medical Practice. However they could be even more-strongly emphasised without undermining acquisition of the “harder” clinical skills by weaving them further into traditional topic-based teaching.
New ways of learning fewer facts may take less time. The role of the doctor in this changing world is not yet fully clear but with less emphasis on rote learning, medical educationalists such as Emerita Professor Parveen Kumar feel that three years may be enough time to learn the basics of being a doctor; the rest will be learned through well-supervised clinical practice and speciality training.
Issues that need to be settled before the start of the MDDAs
For many years doctors have learned medicine through “science-based apprenticeships” that start on a medical student’s first day on the wards, with most learning taking place in the wards and clinics as the student encounters different clinical situations and learns from the different practice styles of senior clinicians.
A change in the culture of medical education and training should not be needed with the introduction of MDDAs because doctors in speciality training are already required to take time off during working hours for their professional development, so a blend of time spent on training and at work is already the norm for speciality trainees and would become so for undergraduate MDDAs too.
The medical trade unions may be emphasising the wrong risk for medical students studying on MDDAs. As I see it the problem is not that condensed undergraduate training could result in inadequate doctors; it is that the new MDDAs create the possibility of two classes of medical student differentiated by income; the “official” MDDAs will receive pay during their training while other medical students will continue to have to find the money to cover their costs.
Assuming that MDDAs will not later have to return the pay that they receive as undergraduates (in which case their apprenticeship pay could be regarded as a form of student loan), they could potentially emerge from medical training with less debt than their traditionally-educated medical student colleagues.
Thus in order maintain fairness, why not offer all medical students MDDAs? That would immediately make access to medical training less dependent on the student’s ability to find funding, and costs to students could be further reduced by allowing some to live at home if their apprenticeship were based nearby.
Medical training for some medical students is supported by bursaries from the armed services in return for employment in the forces for a minimum period after graduation. A stipulated period of employment in the NHS after graduation could reasonably be required of the new MDDAs.
Because their training will be more work-based than at present, MDDAs may have to work longer hours than other students and foundation trainees to graduate after five years. While this may self-select exceptionally- motivated students, it may also raise concerns about the ability of MDDAs to adhere to working time laws.
All this will be happening at a time when a growing number of doctors appear to no longer regard medicine as a vocation (although my impression from doing consultant appraisals is that most still do).
PAs and experienced clinical nurse specialists are taking on many of the duties of doctors. Many have acquired degrees in other scientific fields but PAs particularly do not yet have a satisfactory career progression pathway. Could they move on to become MDDAs? I suspect that if they did, some PAs could find that they already have considerable theoretical background in, and practical experience of, many of the things they are taught as medical students. Could PAs legally thus be excluded from undergoing medical training on the grounds that they already have related experience and qualifications, or could they be offered an even more-truncated version of medical training than the planned MDDAs?
Conclusions:
· Paid medical student apprenticeships are a logical innovation provided that measures are taken to ensure that the apprentices are not regarded as “second-tier doctors”.
. The work that MDDAs undertake during their apprenticeships will be crucial and needs to be carefully monitored and adjusted as required. Gratifyingly, the NHSE Long Term Workforce Plan advocates frequent review of training programmes thus allowing adjustments to MDDAs as experience with them grows. The Institute for Apprenticeships and Technical Education that sets the standard for MDDAs has also made clear that students will not be able to start on their MDDAs until “a suitable end-point assessment organisation …. has given an ‘in principle’ commitment to deliver assessments on this apprenticeship standard”.
· The study lives of students doing MDDAs are likely to be very similar to those of current medical students, although possibly more-intense because of their merged training and work.
· The introduction of MDDAs should act as a focus for a wide-ranging review of the undergraduate medical curriculum along the lines that I detailed earlier.
· Depending on how effective and acceptable the MDDAs turn out to be, consideration should be given to offering paid medical student apprenticeships to most medical students although some students (notably those from abroad and those who want to feel less constrained) will continue to self-pay for their studies.
· English medical schools offering MDDAs should continue to offer intercalated BSc and PhD degrees in the same way that study and research are offered to postgraduate trainees as “Out of Programme Experience”.
· Doctors in the UK work in an extraordinarily complex healthcare system. It is comforting and even wise for most to confine themselves to their speciality “silos”. However this comes at the cost of an often-superficial knowledge of the healthcare environment in which they and other specialties work. For that reason I would like to see management and leadership projects included in all undergraduate medical education and training so that medical students understand and can adapt to the social and economic conditions in which they will be working.
. My experience of such projects through action learning sets for physician associates, nurses and doctors is that healthcare professionals have the potential to become extremely innovative managers provided that they are trained and encouraged to do so early in their careers. Healthcare students in all fields need to be encouraged to take a strategic view of the problems around their roles so that they can follow Niebuhr’s Serenity Prayer to “have the patience to accept those things which [they] cannot change, the courage to change those things that can be changed and the wisdom to know the difference”.