From Apprenticeship to Assembly Line: Recovering Relationships in Medical Education

There is debate about the success of competency-based medical education (CBME) as a framework for supporting learner growth and assessment within graduate medical education. The proponents of CBME promised clear communication of the desired outcomes of medical education and promotion of greater learner-centeredness in training.¹  However, concerns have been raised about the reductionistic implementation of competency-based frameworks and assessment creating an assessment culture that limits learning and growth.^2,3  These concerns challenge CBME frameworks’ usefulness as a tool to support learners in the development of a holistic professional identity, a representation of self, developed over time, that integrates various statuses and roles.²  Competency cannot be divorced from professional identity formation, and educators continue to attempt to unite these threads, seeking to resolve the tensions between the stated values of CBME and the reality of implementation.^4,5  In uniting CBME with professional identity formation, educators must not overlook the importance of trusting relationships between faculty and learners in overcoming the contextual factors hindering CBME.⁶  In this perspective, we propose that creating connectedness within our training systems can realign CBME purposes and practices and unlock the potential of CBME to support learners’ professional identity formation.

Our health care system has devalued human connection in the delivery of health care and, by proxy, in medical education. The US health care system is increasingly industrialized, treating patients as consumers and physicians as service providers who generate value to institutions, which are run as businesses.⁷  Within this system, the pressure for profitability pushes institutions to prioritize residents’ inexpensive labor over the time it takes to educate them to become caring and excellent physicians.⁸  While seeking to provide optimal medical education, educators are constrained by a system that devalues the need for human connection. While competency frameworks provide a roadmap for learning and growth in medicine, they are placed within an inflexible system with rotational structures that fail to emphasize the importance of human connection during training. Medical education has moved away from the traditional apprenticeship model, which is based on long periods of contact between faculty and learners.⁹  Thus, we have created an “assembly line” that prioritizes efficiency and productivity. We insert our medical school graduates into one end of the residency training conveyer belt and believe that we spit them out the other end as fully formed physicians, ready for “unsupervised practice.” Yet, the process of education and patient care, which require relationship-building, cannot be reduced to efficiency and productivity.

For example, at the Mayo Clinic Internal Medicine Residency Program in Rochester, MN, we have sought meaningful change to our training models to provide optimal opportunities for resident learning and growth. In 2018, to create a standardized resident continuity clinic experience for our trainees, residents in separate clinics within our system were combined into one large resident primary care clinic. While the changes enhanced several elements of primary care training (eg, robust interprofessional team-based care model, diverse patient panels, integrated mental health and specialty medicine professionals), residents’ assigned clinic half-days became variable, changing with rotations and clinic scheduling needs. While this change expanded opportunities for growth in patient care and systems-based practice, a notable trade-off was less continuity between clinic faculty and residents, decreasing ongoing relationship-building. For example, residents felt unsure of where to seek help outside of their normal clinic days. The residency program had to create additional structures to provide this support, something previously accomplished through existing faculty-resident relationships. Overall, this intervention sought to optimize learning within our current structures but underprioritized the importance of connectedness for education and growth.

Our experience is not unique. The medical education literature contains a growing body of evidence that relationships matter for learning and growth. First, assessment for learning, with the provision of high-quality feedback, is a central component of CBME.¹⁰  Feedback has been characterized as a learning conversation within an educational alliance, highlighting the importance of relationships.^11,12  Relationships between faculty and learners affect how learners receive feedback and can overcome challenges to integrating assessment for learning into busy clinical learning environments.^13-15  While relationships are important for feedback, research has also demonstrated that meaningful relationships are more than the amount of time spent together¹⁶  and that familiar relationships may create tensions, like not wanting to damage the relationship by providing critical feedback.¹⁷  Second, the professional identity formation literature highlights the need for relationships to support learners’ identity construction.¹⁸  Relational continuity between faculty and learners provides the framework for critical dialogue that supports professional identity transformation.^19,20  Third, to support both CBME and professional identity formation, coaching has been proposed as a unique relationship to support feedback and learner growth.^3,4,21  With relationship-building at its core,^21,22  coaching promotes engagement in reflection,²³  belonging, multidimensional learning, and identity formation.²⁴  Collectively, we see the need for relationships and connectedness in medical education; nurturing relationships hold promise for connecting CBME and professional identity formation.

This makes sense. As humans, we have a fundamental need for connectedness. Within Maslow’s hierarchy of needs, once physiological and safety needs are met, humans demonstrate a need for belongingness, manifested as a hunger for relationships with people and for a place within a group.²⁵  A newer motivation theory, Self-Determination Theory (Figure), posits relatedness as 1 of the 3 basic psychological needs that drives intrinsic motivation.²⁶  Based on Self-Determination Theory, the idea of autonomy support within trusting relationships can realign supervision to support learner development²⁷  and junior faculty’s identity formation.²⁸  Accordingly, how do educators overcome the pressures of efficiency and productivity within a busy clinical environment to create a learning environment that reinforces relationships between faculty, learners, and the patients that they serve?

If we are to move away from assembly line medical education, we need to support meaningful relationships between faculty and learners. The concept of entrustment in CBME highlights the importance of developing connectedness between faculty, learners, and patients. To strengthen connectedness, leaders need to provide educators with time to invest in the next generation. This means building structures that sustain longitudinal relationships between faculty and learners. As programs assess existing curricula and build new curricula, they should pay attention to how those structures facilitate or hinder faculty-learner relationships. We need to move beyond the assignment of specific relationships (eg, supervisor, advisor, mentor, coach) and create an environment that nurtures faculty-learner relationships to develop physicians with mature and healthy professional identities.²⁹  In addition, ongoing research should focus on fundamental questions about connectedness in medical education. What are the necessary elements that encourage connectedness and how can we build those elements into our training models? What does educational continuity mean to residents and what do they want out of their preceptor relationships? Finally, we all must resist the forces of industrialized medicine, forces that constrain relationship development and create significant struggle as learners develop their professional identities.³⁰ 

Some programs and institutions are addressing the need to increase connectedness in medical education. At the Mayo Clinic Internal Medicine Residency Program, we have developed a clinic-coach pairing for each resident to meet at least twice annually and are also working to align schedules between residents and their faculty coaches. For complex patients, we are pairing residents with faculty and nursing colleagues to create longitudinal teams to support clinical coaching. We have conducted research in professional identity formation and uncovered tension within the process.³⁰  We presented the findings to our residents and faculty, as well as outside our program, to stimulate discussions about change. Beyond our institution, others are working on education innovations, research, and resistance to champion connectedness in medical education (Table).

We are not calling for a return to an apprenticeship model of medical education, but rather for the pursuit of connectedness in medical education. We are inviting educators and scholars to move away from an assembly line model of medical education that prioritizes efficiency and productivity, toward more meaningful education to support learners’ development and growth. We believe that strengthening connectedness will align CBME with the goal of supporting professional identity formation.