In our final entry on Harden’s SPICES model (1), the S distinguishes between a planned, systematic clinical experience versus one that is built around apprenticeship where trainees are “bonded” to their master and acquire skills by following him around and working with him. Examples of this latter approach can be found in our culture through the model of, say, a Jedi knight undergoing training as a “padawan” (novice) following a Jedi master, or by those doctors lucky (or unlucky) enough to work for Gregory House on House, MD. In truth, this problems affects medical education is some ways far more than it can chiropractic education, because we do not have the breadth of hospital contacts that medical students may be involved with, but our preceptor model is built on the idea of an apprenticeship model, though for reasons we can well understand.
In the apprenticeship model, students are assigned to a single teacher, or to a clinical unit or ward, for some period of time. They work on that ward, seeing only those patients on the ward, and therefore see only those conditions that opportunistically present themselves in the unit or clinic. What this means is that these patients are not predicted, nor predictable, which might seem obvious on first thought, but which has implications for planning and training. We would not normally build classes on content that we could not predict, for example. So what students learn, what they are exposed to, is built around which patients are available, the interests of clinic doctors with whom they work, and some change. Students may never get exposure to a representative sample of chiropractic or medical practice. This is less so in chiropractic, since our patient base is typically looking for relief of back pain, but still holds true in general.
The latest thinking is that it would be better if we did not leave clinical training to chance. This requires us to look at clinical training in a new way, one that is systematic and which is designed for all students so that they all get experiences that are necessary for their training. Thus, it may require students rotating through specialties and in various kinds of settings. This still requires enough planning that students understand the expectations and are given a list of skills that need to master, as well as a list of conditions that they are expected to see. Such an approach could be adapted within our own educational settings.
Harden suggests the following factors support a move to a more systematic approach: (1) Students need to experience a range and variety of health problems. Our own research shows that most of our students are exposed to musculoskeletal problems, but not to organic disease, for example, as they do their internships in our clinics. (2) It can help rationalize competencies, letting us know which are essential and which are useful but not absolutely necessary. All chiropractic interns should see cases of shoulder pain, but they do not all need to see cases of food allergy, for example. (3) It allows for better use of time. Once we have seen certain conditions, we may not need to spend much more time seeing many more cases, in the limited training time we have. We could move on.
The benefits of an apprentice ship model include (1) It has organizational advantages. This is a far easier approach to administrate. (2) There is continuity of teaching. A good relationship with a teacher always helps enhance learning.
This completes our discussion of Harden’s model, which can be used in how you plan your curriculum, and in how you see yourself positioning your class along the spectrum that exists for all six components of the model. There is no one perfect position for each decision level; it simply requires you to consider what it is you are trying to do. I hope that it will be of help to you.
1. Harden RM, Sowden S, Dunn WR. ASME Medical Education Booklet No. 18. The SPICES Model. Med Educ 1984;18:284-297