gms | German Medical Science

‘The firm’ is ubiquitous within clinical teaching in the UK context – it is the key mechanism and organisational unit for apprenticeship style learning for undergraduate medical students and junior doctors. Despite its centrality within medical education, it has rarely attracted sociological scrutiny. Medical staff, in particular, tend to take ‘the firm’ for granted, for they themselves have undergone training within it. The term and its usage, however, effectively hide historical, speciality and local variations of ‘the firm’ and mask the way in which the concept and its real life organisational practices have changed over time [1].

Within the medical education literature, clinical attachments have received relatively little scrutiny [2]. Bleakley attributes this to the prevalence of “the psychological model of pedagogy that focuses upon transmission of knowledge and skills from one individual to another” ([2], p.9). Social scientist have sought to highlight the social and contextual dimensions of learning [3] and the importance of informal and implicit aspects of the ‘hidden curriculum’ that are oftentimes more powerful than the ‘manifest’ or official curriculum [4], [5].

What is important to note is that the apprenticeship model does not solely or primarily depend on explicit instruction. Rather, knowledge is (also) transmitted through informal learning that relies on time spent together (context, shared language and experiences, observation, implicit rather than direct communication) and the formation of relationships of trust (that allows for mutual dependability and support) which in turn facilitate – or hinder – the transmission of how things are done in a particular set up [6]. The hierarchical nature of the firm is also likely to have given rise to some forms of exploitation. As noted above, the nature of ‘the firm’ remains under-researched – historically and in its current (and relatively recent) form.

Through various changes in the NHS and the phased introduction of the European Working Time Directive medical firm structures are currently in flux and some argue that they have become eroded [7]. Medical schools and deaneries (in charge of postgraduate training) throughout the UK are struggling to identify ways to address these changes, especially in terms of the firm’s educational function.

The presentation is based on interview data with clinical teachers who have trained and worked in firm structures throughout their careers. Our analysis of this data will seek to define what ‘the firm’ was in the context of different specialties and it traces its development (or demise). Without an appreciation of how ‘the firm’ operated in terms of benefits and disadvantages to the various stakeholders and how it developed over time – as a work unit and as site and mechanism for teaching / training – any account of current changes will be severely limited, as will attempts to design new ways of working and teaching to make up for its dissolution.