Medical interns' learning in the 21st century

Background Historically, the Australian medical internship was "intended to be a period of apprenticeship" (Geffen, 2014, p. S20). However, the 21st Century is far more technological, with many tasks previously carried out manually now replaced with some type of automation or digital processing and medical care is not immune to this change. This raises the question of whether the 'apprenticeship' model of learning is still valid or, as Van Der Weyden suggested in a Medical Journal of Australia editorial (2006, p. 313), whether the "learning environment is less personal, …. and captive to self-directed learning". Aims The purpose of this study was to investigate how medical interns learn in the 21st Century and what drives interns to learn the way they do. The sub-questions were: 1. From whom or from what do interns learn and what specifically do they learn via these encounters? 2. To what degree do interns still learn via an apprenticeship model, if at all, and how much of an interns' learning is self-directed? 3. What drives interns' learning in these directions? Methods This study explored 'apprenticeship' learning in medicine. It utilized a concurrent mixed methods design consisting of a combination of embedded and convergent parallel mixed method study designs. Firstly, a qualitative data collection strand was embedded within a quantitative survey to allow participants to elaborate on learning experiences identified in their quantitative responses. This collective data strand was analyzed. Secondly, using a convergent parallel design, this collective strand was then merged with analyzed qualitative interview response data to allow triangulation of data and interpretation of merged results. This study was conducted within the Townsville Hospital and Health Service which consists of a large regional hospital, four small rural hospitals and a number of small community-based units. Interns from the 2012 cohort volunteered time to the study; one intern acted as a research assistant to develop the online survey tool; 18 interns assisted in refining the online tool; 16 interns participated in a pilot study which was conducted in Term 5 of 2012. Semi-structured interview pilots were also conducted in 2012 with the assistance of three interns and three supervisors. Study participants included 61 interns from the 2013 and 2014 intern cohorts. Participants agreed to provide anonymous reflections on the learning they experienced whilst managing the first case of each shift in the first week of each internship term. Additionally, twenty of these interns volunteered time to be interviewed for the qualitative part of the study. Eighteen of the 2013 and 2014 supervisors of interns also agreed to be part of the study by volunteering time to be interviewed. Results Learning medicine is complex because human illnesses do not necessarily mirror what was described in textbooks. Interns must learn on the job, learn by doing. Medical interns' self-reported learning reflections indicated that 52.7% of their learning occurred via the apprenticeship learning relationships they had with their supervisors. The other 45.9% of their learning occurred via self-directed modes. This was as it should be in a cognitive apprenticeship where supervisors incrementally decreased their level of supervision and teaching as the intern increased their knowledge and skills towards being an independent practitioner. Interns valued the interactions they had with knowledgeable supervisors but needed to be adaptive learners to recognize and take advantage of both apprenticeship and self-directed learning opportunities if and when they arose. Learning during the internship was iterative in that it was rarely a straight forward construction of new knowledge and skills. To further complicate learning, interns had to negotiate a number of tensions, for example service-provision versus learning, administrative processes versus opportunities for clinical/practical experiences and the desire to be independent versus the requirement to be supervised. Proportionally more content was learnt by interns in non-core rotations (65.7%) than in core rotations (56.6%) and there was proportionally less administration (18.7%) and professional identity items (15.7%) in non-core rotations than in core rotations, (24.5% and 18.9% respectively). Interaction with supervisors was especially important for interns to learn the aspects of medicine that were difficult, if not impossible, to teach such as the tacit knowledge and skills the interns need to be accepted members of the medical fraternity. Intern interviews indicated that their motivations to learn included a desire to be deemed competent. However, fear of failure or doing patients harm were the most common drivers of interns' learning. Interns were also striving to get in to college training programs. Conclusion Learning during a medical internship is multimodal. Learning occurs via a cognitive apprenticeship which consists of learning through 'apprenticeship' relationships with supervisors and by self-directed learning. The cognitive apprenticeship requires incremental decreases in the level of supervision with a corresponding increase in clinical responsibilities over time as the intern works towards becoming an independent practitioner. Interaction with supervisors is especially important for interns to learn the aspects of medicine that are difficult, if not impossible to teach. This includes learning the tacit knowledge and skills that enables them to be accepted members of the medical fraternity. In time-poor learning environments, interns reported taking every advantage of apprenticeship relationships with knowledgeable supervisors; however, because service provision was often prioritized over learning, they supplemented this with self-directed learning. Interns therefore must have been adaptive learners, able to recognize learning opportunities if and when they arose. The learning of medicine is complex and an iterative process. Interns learnt aspects of content, administration and professional identity during their internship year, however the details of what was learnt differs from rotation to rotation. It was therefore important that interns were provided a range of different clinical experiences. Interns' motivations to learn included a desire to be deemed competent, fear of doing patients harm and working towards getting in to college training programs. Evidence collected during this study in North Queensland indicates that the current medical interns' learning environment is dominated more by the personal learning relationships they have with their supervisors (consultants and registrars) than it is by self-directed learning