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Personal, public, and professional identities : conflicts and congruences in medical school Beagan, Brenda L. 1999

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PERSONAL, PUBLIC, AND PROFESSIONAL IDENTITIES: CONFLICTS AND CONGRUENCES IN MEDICAL SCHOOL by BRENDA LORRAINE BEAGAN B A., Dalhousie University, 1987 M.A., Dalhousie University, 1988 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY •in THE FACULTY OF GRADUATE STUDIES (Department of Anthropology & Sociology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF B l W S H COLUMBIA December 1998 © Brenda Lorraine Beagan, 1998 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of SOCAOIO^J The University of British Columbia Vancouver, Canada Date t > r ^ W l 5 . 13 9 ft DE-6 (2/88) ABSTRACT Most research on medical professional socialization was conducted when medical students were almost uniformly white, upper- to upper-middle class, young men. Today 50% of medical students in Canada are women, and significant numbers are members of racialized minority groups, come from working class backgrounds, identify as gay or lesbian, and/ or are older. This research examined the impact of such social diversity on processes of corriing to identify as a medical professional, drawing on a survey of medical students in one third-year class, interviews with 25 third-year students, and interviews with 23 medical school faculty members. Almost all of the traits and processes noted by classic studies of medical professional socialization were found to still apply in the late 1990s. Students learn to negotiate complex hierarchies; develop greater self-confidence, but lowered idealism; learn a new language, but lose some of their communication skills with patients. They begin playing a role that becomes more real as responses from others confirm their new identity. Students going through this training process achieve varying degrees of integration between their medical-student selves and the other parts of themselves. There is a strong impetus toward homogeneity in medical education. It emphasizes the production of neutral, undifferentiated physicians - physicians whose gender, 'race/ sexual orientation, and social class background do not make any difference. While there is some recognition that patients bring social baggage with them into doctor-patient encounters, there is very little recognition that doctors do too, and that this may affect the encounter. Instances of blatant racism, sexism, and homophobia are not common. Nonetheless, students describe an overall climate in the medical school in which some women, students from racialized minority groups, gays and lesbians, and students from working class backgrounds seem to 'fif less well. The subtlety of these micro-level experiences of gendering, racialization and so on allows them to co-exist with a prevalent individual and institutional denial that social differences make any difference. I critique this denial as (unintentionally) oppressive, rooted in a liberal individualist notion of equality that demands assimilation or suppression of difference. TABLE OF CONTENTS Abstract ii List of Tables vi Acknowledgements vii Chapter I Introduction 1 1.1 Research Questions 4 1.2 Theoretical Framework 6 1.3 Organization of the Thesis 14 Chapter II Review of the Literature 17 2.1 Prior Research on Medical Socialization 17 2.2 Accounting for 'Difference' 29 2.3 Conclusions 47 Chapter ILT. Research Methodology and Design 49 3.1 Standpoint Methodology 49 3.2 Research Design and Implementation 50 3.3 Description of the Samples 61 3.4 Interviewing up 69 3.5 Summary 72 Chapter IV Becoming A Medical Student, Developing A Professional Identity . 73 4.1 Professional Identity - What Is It? 74 4.2 Changes Students Go Through 99 4.3 Processes Of Becoming, Identifying 106 4.4 Summary - Constracting a Medical-Student Identity 120 Chapter V Producing Homogeneity and Neutrality 125 5.1 Time Pressures and Absence of Balance 126 5.2 Striving for Balance 129 5.3 A Push Toward Homogeneity 132 5.4 Degrees of Separation / Integration 139 5.5 The Production Of 'Neutral' Physicians For 'Neutral' Patients . 156 5.6 Hegemonic Status of Privileged/Dominant Social Categories .. 164 5.7 Summary and Conclusions 175 Chapter VI Dealing With Social Differences 178 6.1 Diversity Among Medical Students 180 6.2 The Impact of Social Differences 182 6.3 Difference as a Site of Resistance to Conformity 212 6.4 Dealing With 'Differences' in the Medical School 215 6.5 Medical Education and the Politics of Difference 229 . . . i v . . . Chapter VTJ Conclusions 237 7.1 Everyday Oppressions in a Time of Formal Equality 242 7.2 Impartial Scientific Professionalism 246 7.3 The Embodiedness of 'Difference' 249 7.4 Theorizing Identity 252 7.5 Strengths, Limits, and Implications of the Research 256 Bibliography 263 Appendices 282 Appendix I 283 Appendix II 284 Appendix EI 292 Appendix IV 294 Appendix V 297 . v. L I S T O F T A B L E S Table 3.1 Survey - Student Gender 62 Table 3.2 Survey - Student Age 62 Table 3.3 Survey - Student Class Background 62 Table 3.4 Survey - Student Religion 63 Table 3.5 Survey - Student Relationship Status 63 Table 3.6 Undergraduate Backgrounds 63 Table 3.7 Graduate Backgrounds 63 Table 3.8 Students'Ethnic Origins 64 Table 3.9 Students' First Languages 64 Table 3.10 Country of Birth - Students and Their Parents 65 Table 3.11 Student Age 66 Table 3.12 Student Gender 66 Table 3.13 Student Class Background 66 Table 3.14 Relationship Status 66 Table 3.15 Academic Background 66 Table 3.16 Cultural Heritage 66 Table 3.17 Faculty Ages 68 Table 3.18 Time at This School 68 Table 4.1 Ever Called Doctor 113 Table 4.2 Feelings About Being Called Doctor by Various People 114 Table 5.1 Hours Spent on Medical School the Previous Week 127 Table 5.2 Degree of Stress Associated With Various Aspects of Students' Lives 127 Table 5.3 Degree to Which Students Think They Are Doing a Good Job of Various Activities 141 Table 5.4 Effects of Various Attributes on Students' Medical School Experiences 158 Table 5.5 Importance of Various Factors to How Students Think About Themselves Day to Day 160 Table 5.6 Extent to Which Students Think Various Characteristics Affect Physicians' Practice 161 Table 5.7 Extent to Which Students Think Various Patient Characteristics Affect Patient Care 162 Table 6.1 Residency Choices Considering; Proportions of Women, 'Minorities' 195 Table A.1 Hours Spent on Various Activities the Previous Week 297 Table A.2 Activities students would like to do after medical school 297 Table A.3 Importance of Various Factors to How Students Thought About Themselves Day to Day Before Entering Medical School 298 Table A.4 Difference Between the Importance of Various Factors to Students Before and During Medical School 298 Table A.5 Importance of Various Factors to Selection of Residency 299 ACKNOWLEDGEMENTS I would like to acknowledge the contribution made by the medical students and faculty who gave up their valuable time to participate in this research. Without them it wouldn't have happened. Joy Horan and Alayne Campbell provided invaluable assistance with interview transcription. Without their help I would still be typing. Joy's interest in and enthusiasm for the research was motivating. My supervisory committee, Drs. Gillian Creese, Fiona Kay and Neil Guppy, facilitated the revision and defense processes with rapid and careful reading of drafts. I greatly appreciate Neil's support for my research, which began my first month at UBC when he brought me an article directly related to my topic. Throughout the past four years conversations with Fiona about teaching, research, grant-writing, and the life of an academic provided the sort of mentoring few graduate students are fortunate enough to enjoy. Her advice to consider my Ph.D. research as one piece of a larger research agenda was invaluable. And Gillian's quiet confidence in my work was sustaining throughout the process, as was her ability to quell my moments of panic. Her assistance extended beyond the dissertation itself to invaluable advice on job application letters, CVs, teaching, and academic politics, as well as to stimulating conversations about feminist politics and teaching. I also owe a debt of gratitude to feminist and lesbian communities in Halifax and in Vancouver. They sparked and nurtured my interest in and commitment to women's health care - and later the health care of racialized minorities, immigrants, gays and lesbians, people with disabilities, and other subordinated groups. Friends in these communities keep me honest in my politics and in the practical applicability of my research and theorizing. Finally, my greatest debt is to my life-partner, Bethan Lloyd. The exchange of ideas we share is a constant joy. Her contribution to my Ph.D. experience has ranged from stimulating debate about feminist politics and literature, to finding good references, talking through comprehensive exam answers, debating research methods, co-writing book reviews, doing more than her share of household maintenance, making me take breaks when I needed them, and simply putting up with me during the months when I was least bearable. Much of my development as an academic, a feminist, and a community activist has been shared with her and has benefited from her wisdom and astute political insight. I cannot thank her enough. . vii. Chapter I: Introduction There is an assumption common among lay people and some researchers that women will practice medicine differently than men - and that women doctors will be better for women patients, if not for all patients (e.g., Lorber, 1985; Pizzini, 1991; Riska & Wegar, 1993; Roberts, 1981; Ulstad, 1993; Waller, 1988; West, 1990). Similarly, there is often an assumption that ethnocentrism in health care would be rectified by seeing a doctor of one's own cultural/racial group (e.g., Curtis, 1970; Davis, 1990; Frideres, 1994; Gomez & Smith, 1990; Komaromy et al., 1996; Secundy, 1994; Weaver & Garrett, 1983), or that gay men and lesbians would be better served by gay and lesbian doctors (Auger, 1992; Barnett, 1985; Gentry, 1992; Gomez & Smith, 1990; Lucas, 1992; Robertson, 1992; Stevens, 1992; Trippet & Bain, 1992). At the same time, there is an abundance of literature on the homogenizing influence of the intensive professional socialization 1 processes undergone by medical students through their five to ten years of training (Becker, Geer, Hughes & Strauss, 1961; Coombs, 1978; Fox, 1979; Haas & Shaffir, 1987; Konner, 1987; ReilTy, 1987; Shapiro, 1987). Virtually all of those studies and accounts were written about medical training as it existed twenty, thirty, even forty years ago. At that time medical students in Canada and the United States were a pretty homogeneous group, mostly middle- or upper-class, white, Protestant men, frequently the sons of doctors (Becker et al., 1961; Coombs, 1978). In Becker and colleagues' classic American study, for example, only about 5% of the students in any class were women, 5-7% were non-white, and fewer than 15% of 1 Merton, Reader and Kendall (1957:287) state: "The technical term socialization designates the processes by which people selectively acquire the values and attitudes, the interests, skills and knowledge - in short, the culture - current in the groups of which they are, or seek to become, a member. It refers to the learning of social roles. In its application to the medical student, socialization refers to the processes through which he [sic] develops his [sic] professional self, with its characteristic values, attitudes, knowledge, and skills, fusing these into a more or less consistent set of dispositions which govern his [sic] behavior in a wide variety of professional (and extraprofessional) situations." . . . 1 . . . students were non-Protestant (1961: 60)2. Even in the mid-1970s when Jane Leserman made gender central to her study of medical school, 74% of the students were male, 91% were white, and 75% appear to have been from middle- or upper-class backgrounds (Leserman, 1983: 81). Today the profile of the typical medical school class in Canada and the United States has changed a great deal. In the United States women made up only 9.4% of all medical students in 1969; by 1979 that number had increased to 28.3%; and by 1993, 42% of medical students were women (Bickel & Kopriva, 1993). In Canada, women's proportion of medical school classes increased from 8.5% in 1957-58, to 33.0% in 1977-78, to 52.2% in 1995-96 (Association of Canadian Medical Colleges [ACMC], 1996:16). In francophone medical schools in Quebec, women have made up more than 50% of all students since 1983, currently averaging about 60% (ACMC, 1995:13; see also Dufort & Maheux, 1995). Schools in English Canada average 46% female enrollment; three of the four largest schools have classes that are 39%, 40% and 41% female (ACMC, 1996:19-21). Though statistics are hard to find on other forms of diversity among medical student populations, what little evidence is available indicates a slow rise in the representation of students from historically underrepresented racialized minority groups. For example, in the United States in 1991-92 African American, Native American, Mexican American, Puerto Rican, other Hispanic, and Asian or Pacific Islander students made up 26.8% of all medical students (Jonas, Etzel & Barzansky, 1992:1088; c.f. Foster, 1996). However, it is noteworthy that more than half of those are Asian and Pacific Islander students, the only group whose representation has been 2 Calculated based on the rather sloppy descriptive statistics given by Becker et al. They say "each class contains a number of women, ordinarily around f ive . . . a few students from such faraway places as Central America or Africa, as well as a small number of American Negroes, possibly four or five" (1961: 60). However, they don't give the class sizes for the time of their study. They do say, though, that in 1958, two years later, "94 new students entered the first year" at the medical school where they did their research (1961: 53). Assuming class sizes are fairly constant, I estimate the percentages above. .2. increasing significantly. In Canada, the only statistics available are for citizenship status of students. In 1994-95, non-Canadians, including landed immigrants and those with student visas, comprised 5.8% of all medical students in Canada (ACMC, 1995:21) 3. However, this number would not include students who are Aboriginal, nor those of Asian, African, Indian or South American heritage whose families have Canadian dtizenship. Statistics on diversity in religious backgrounds, class backgrounds, and sexual orientation are even less readily available. However, for the latter we may be able to infer from the recent emergence of gay and lesbian student caucuses in medical schools in Canada (e.g., at the University of Toronto; also a standing corrimittee of the American Medical Student Association [Oriel, Madlon-Kay, Govaker & Mersey, 1996]), the development of a Canadian gay and lesbian medical student E-mail list, and recent journal articles devoted to the topic (Cook, Griffith, Cohen, Guyatt & O'Brien, 1995; Druzin, Shrier, Yacowar & Rossognol, 1998; Oriel et al., 1996; Rose, 1994; Wallick, Cambre & Townsend, 1992), that there are more publicly-identified gay and lesbian students than was the case historically. Canadian medical students are also somewhat older and better educated upon entry than they were in previous years, which may mean there are more parents in medical school (Gray & Reudy, 1998:1047). Finally, some medical schools have deliberately broadened their interpretations of the academic backgrounds expected of medical students. It is no longer the case that students must major in biology or chemistry in their undergraduate years; they can now gain admission to medical school in some places with a background in the arts, humanities or social sciences. Thus, the student population represents greater diversity in academic backgrounds. 3 Even that proportion is artificially inflated by the presence of 138 non-Canadian students at one medical school in Quebec, for a proportion of 25%. The proportion at other medical schools ranges from 1.5% to 7%. Furthermore, a little over half of these non-Canadian students are from the United States, Australia and Europe. . 3 . Not only has the composition of medical student populations changed a great deal in recent years, but also the content and form of medical training has been under continual revision. Many medical schools have recently increased their attention to -among other areas - ethics, dealing with death and dying, bedside manner, and communication. Some schools have been exploring the use of poetry, literature and art in medical education (see Wear, 1997), and most have been revising their curricula to better meet the needs of faculty, students, and community. Many schools4 have begun adopting some version of the McMaster Model, a curriculum based on self-directed learning and a case-study approach (Bloom, 1988; Haas & Shaffir, 1987). 1.1 Research Questions Given that medical students in the late 1990s come from far more diverse backgrounds, are far less homogenous than they used to be, and experience a significantly altered curriculum, what does that mean for what we know about the professional socialization medical students go through during their intense training? To what extent was the homogeneity formerly found in medical graduates a product of the homogeneity of the group when they entered medical school, and to what extent was it a product of training? Is the process of coming to identify as a medical student, as a future physician, the same for students who are and are not middle- to upper-class, white, Protestant men? Grant (1988) argues that any school has its own latent culture, "the patterns of meanings, behaviors, and beliefs that students bring to medical school." That latent culture dictates the boundaries of appropriate behaviour. When professional school members share a latent culture, elements of that culture will filter into the school's informal environment. The gender, 4 In fact, the only two Canadian medical schools that d id not include some type of self-directed learning introduced new curricula in 1997 and 1998 to move toward that model. .4. race, and religion of faculty and students affect their relationships, even when these attributes are ostensibly irrelevant (Grant, 1988:109). Do certain background characteristics, and attendant forms of socialization, allow some individuals to 'fif more easily within the dominant medical school culture while others fit less easily? Grant suggests that, "Those who share the latent culture have a sense of belonging; those who do not may feel alienated and marginal" (Grant, 1988:109).5 Or is it possible that women, racialized minorities, working-class and gay and lesbian students, and students from a variety of academic backgrounds have reached a critical mass, such that they have begun to alter the culture within medical schools rather than being required to adapt themselves?6 What I examined in this research was students' experiences of coming to self-identify as student-physicians, and how membership in or prior identification with particular social groups affects the processes of professional identity formation. In particular I explored how the congruences and conflicts between students' membership in disparate social groups and their emergent professional identities might affect their experiences of medical school. My central research questions, then, were: • How are processes of professional identity formation experienced by undergraduate medical students in the late 1990s, in the context of a diverse student population?? ^ As one student put it as I was still conceptualizing the research, if you are other than a middle- to upper-class, white, Canadian, heterosexual man must you "forget where you come from" in order to successfully become a doctor? 6 Clearly the jury is still out. Compare: "Medical school is a systemically deforming milieu that nullifies ordinary social experience" (Gallagher & Searle, 1989:441); "Medical training does not erase the specifically female ways of behaving from women doctors, as is sometimes feared" (Charon, Greene & Adelman, 1994: 216); and "Are women actually changing medicine, are they somehow different as doctors - or does the long and rigorous medical training produce doctors who are simply doctors, male or female?" (Klass, 1996:83) ^ Medical undergraduate education refers to the training students experience in their first four years of medical school. In the school where I conducted my research the first two years consist of basic science courses, including anatomy, physiology, pharmacology, microbiology, biochemistry, pathology, neuroanatomy, and so on. The third year consists of a clinical clerkship during which most of students' time is spent on the hospital wards or in clinics rotating through a range of medical departments. There may be lectures one morning a week. The fourth year is a student internship, similar to the third-year clerkship with more responsibility. At the end of the fourth year graduates are granted the Medical .5. • How do students' membership in or prior identification with social groups based on such characteristics as gender, 'race,' social class, and sexual orientation affect their experiences of professional identity formation? • How do students, faculty and administrators deal with the social differences represented among medical students in the late 1990s? 1.2 Theoretical Framework The dominant theoretical approach to understanding socialization and identity development comes from the work of social psychologists, and symbolic interactionists in sociology. George Herbert Mead's (1934) theory of socialization provides important grounding. Mead explains how the individual is socialized, internalizing social norms and cultural patterns to become a functional member of a society or social group. The development of the self emerges solely from social experience. It relies upon the internalization of the attitudes of the social group of which one is a member, the "generalized other." This can also be a form of social control, as it is the manner in which the community enters as a determining factor into the individual's thinking. The individual then governs his or her own conduct accordingly. It is the ability of the person to put himself in other people's places that gives him his cues as to what he is to do under a specific situation. It is this that gives to the man what we term his character as a member of the community; his citizenship, from a political standpoint; his membership from any one of the different standpoints in which he belongs to the community (Mead, 1934:270). Finally, Mead points out the unique socializing role of education: "Education is definitely the process of taking over a certain organized set of responses to one's stimulation; and until one can respond to himself as the community responds to him, he does not genuinely belong to the community" (1934: 265). Doctor (M.D.) degree, though they must pass Federal qualifying exams and complete at least two years of post-graduate training (residency) to get a license to practice. . 6 . In the 1960s Peter Berger and Thomas Luckmann (1966) developed further on Mead's theory, and added specific details about processes of secondary socialization, which they saw as, "the internalization of institutional or institution-based 'subworlds'" (1966:127). Secondary socialization though is always impeded by a fundamental problem; it must confront a preceding primary socialization which is particularly firm due to the individual's relationship with his or her very first significant others. Secondary socialization has to deal with an already formed self. This presents a problem because the already internalized reality has a tendency to persist. Whatever new contents are now to be internalized must somehow be superimposed upon this already present reality. There is, therefore, a problem of consistency between the original and the new internalizations (Berger & Luckmann, 1966:129). As I will discuss in more detail in Chapter 5, the range of possible outcomes to resolve conflicts in secondary socialization include: detaching role-specific parts of the self; total transformations, kind of switching worlds; and more moderate adjustments, building on the primary socialization rather than eradicating or negating it. In any case, a significant component of secondary socialization is the isolation of the individual within the new world he / she is adopting, such that most or all significant interation takes place with other members of that new world (Berger & Luckmann, 1966:145-146). As we will see in Chapters 4 and 5, this is highly pertinent to the situation faced by medical students, in which they are so pressed for time that they see almost no one outside the medical school and do almost nothing that is unrelated to their education. That medical undergraduate training is in fact a secondary socialization process seems beyond doubt. In his overview of medical socialization Peter Conrad claims that: Through the rigor and the tension of medical education, students' beliefs about medical care change as they increasingly adopt the dominant clinical perspective that pervades medicine. Most adopt it readily, while others must be converted; some accept it only uncomfortably; a few resist it actively (1988:329). Conrad argues that a change in identification is one of the most profound transformations medical students experience. Students begin identifying with the patients and end up identifying with the doctors and other health care personnel on the medical 'team' (Konner, 1987:365). Some have used the metaphor of initiation into a priesthood to describe professional socialization in medical school (Haas & Shaffir, 1987: 70; Klass, 1987:41). Similarly, Haas and Shaffir define professionalization as "a process of differentiation and alienation from lay society and of the elevation of the professional" (1987:6). What Mead, Berger and Luckmann, and other interactionists tend to leave out of their theories of socialization is the existence of competing socializations or "ways of being" in any given society or social group, and the factors that determine which one will predominate. They leave out the fact that some members in a society or social setting hold more power than others, and that this power difference affects whose ways of being will come to be seen as normal. The Gramscian notion of hegemony is valuable in understanding how such dominant practices, values or worldviews can come to dominate without blatant imposition. Hegemony refers to rule without coercion; rather the worldviews and interests of one social group eventually achieve consensus such that they dominate political, economic and cultural life with the active consent of most members of a society (Bocock, 1986). One of the key processes in establishing hegemony is naturalization, whereby particular practices and ways of being come to be seen as natural; thus countering these ways of being, or posing alternatives, is paramount to challenging nature. This notion of hegemony, and the difficulty of countering hegemonic practices, is central to understanding how socially structured power relations operate within the micro-level, social-psychological processes of socialization. As we will see in Chapters 4 and 5, medical students are quickly drawn into specific worldviews that hold hegemonic status within medicine. That is a key aspect of their professional socialization. 1.2.1 Identity and professional identity Identity is simultaneously individual and social, internal and external. Identity is socially constructed, meaningful only in relation to other people; at the same time, though, identity is unimaginable in isolation from embodied individuals (Jenkins, 1996: 20-21). It is, simply stated, our answer(s) to the question 'Who am I?' (Yuval-Davis, 1994:409). But that implies the corollary, 'Who am I not?' We identify ourselves in relation to social groups; groups constitute the individual as well as the reverse (Young, 1990). Social categories, or aggregates, are external classifications of people according to some attribute 0enkins, 1996; Young, 1990). Defined and identified by others, they lack the social salience that social groups have. Group identifications, in contrast, are not mere combinations of people, they are defined as a group by a sense of shared identity - they are largely self-defining. That identification may be associated with objective attributes, but the attributes alone do not constitute the group. More pointedly, collective or group identities are usually asserted in political contexts (Jenkins, 1996; Yuval-Davis, 1994). But the process of identification is never unilateral. It is not enough to assert an identity; that identity must be confirmed by others. Similarly, it is not enough to categorize another as a member of a specific group; he or she must affirm that categorization, and must be accepted as a member of that collectivity before it approaches a social identity. Broadhead defines an identity as being "socially situated and assigned membership by self and others in a particular reference group, organization, social world, or 'scene'" (1983:38). Identity, then, is an accomplishment, a non-static outcome of the dialectical interplay between internal and external processes of definition. Self-identification involves the ongoing to-and-fro of the internal-external dialectic. The individual presents herself to others in a particular way. That presentation is accepted (or not), becoming part of her identity in the eyes of others (or not). The responses of others to her presentation feed back to her. Reflexively, they become incorporated into her self-identity (or not). Which may modify the way she presents herself to others. And so on ttenkins, 1996: 50). Processes of identity-construction are not infinitely flexible, though. At least in some instances they are constrained by the materialities of embodiment: skin colour, secondary sex characteristics, physical disability, for example. Claiming some collective identities implies the ability to meet the relevant standards, being able to successfully perform or actualize the identity. Recent postmodern theorizing has emphasized that identities are multiple and fragmented, constantly shifting, and internally contradictory (e.g., Haraway, 1990). But the concept of multiplicity within identities is not completely new. Freud's Id, Ego and Super-Ego, as well as Mead's I and Me were early conceptualizations of multiple selves. Jenkins (1996) critiques characterizations such as these as depicting a self made up of component "bits" that converse with one another. This, he argues, is not how most of us experience ourselves most of the time. We experience more consistency than that. In contrast, a unitary model of identity, allows us to recognise the self as a rich repository of cultural resources: organised biographically as memory, experientially as knowledge; some conscious, some not; some of them in contradiction, some in agreement; some of them imperative, some filed under 'take it or leave if; some of them pure in-flight entertainment; etc. The self is an umbrella under which this is organised Qenkins, 1996: 46). Jenkins stresses that the self, though unitary, is complex and multifaceted. Each of us, to maintain some sense of ourself as a relatively coherent person, finds some way(s) to articulate various facets of our identity to one another, sorting out the convergence and divergence of attitudes, assumptions, activities and perspectives (Broadhead, 1983). One of the divergences that may exist is that between "nominal social identity" and "virtual social identity" (Jenkins, 1996). The former is how we are perceived, and therefore labelled, by others; the latter refers to what meaning that nominal identity comes to hold for us over time. For example, the nominal identity 'medical student/ .10. remains the same throughout four years of training, but the meaning of the term changes dramatically for the student. Professional identity construction is about developing primary allegiance with others of that profession - in this case, physicians - rather than with lay persons. It means coming to see oneself as a member of that group, acting as a member of that group, being treated as a member of that group by others, and being accepted as a fellow group member by other physicians. Early sociological study of the professions focused on defining the essential traits of a profession. These include professional autonomy (setting standards of education, training, and licensing; being self-governing), exclusivity (rigorous standards for admission into training, rigorous socialization in training), and high power and prestige (including high income) (Goode, 1960; see also Weiss & Lonnquist, 1997:149). Later sociologists took these traits in a more critical direction, focusing on the power and control wielded by professionals. Eliot Freidson's (1970a; 1970b) studies of professional dominance identified medicine as the epitome of professions, and examined the extent of influence physicians held over the terms of their own work. Professional power in the field of medicine includes more than the ability of medical professionals to control their own training and work, and the training and work of others - such as nurses, physiotherapists, occupational therapists, respiratory therapists and so on (Battershill, 1994; Wotherspoon, 1994). Professional dominance in medicine also includes considerable power over patients and over the broader conceptual or ideological sphere surrounding health and ill-health, through the power physicians hold more generally in society (e.g., Ehrenreich & Ehrenreich, 1978; Ulich, 1976; Zola, 1978). The exclusive knowledge and technical competence of medical professionals, along with their social authority, gives them the power of definition, the power to define when illness exists (Friedson, 1970b). Medicalization, the defining of certain states as pathological, at the same time constructs and reinforces social norms by defining what is 'normal' or non-pathological (Riessman, 1983; Zola, 1976). Thus, it becomes particularly important to understand how individuals are socialized into the profession of medicine. This has resulted in a series of studies of professional identity formation, particularly in medicine (see Chapter 2 for a detailed discussion). The degree to which these studies have been critical of the power and control held by physicians has varied. What remains constant, though, is the awareness that professional socialization is training for power. The processes of professional identity formation follow the framework of identify formation more generally, as sketched above. In particular, a professional identity is the non-static outcome of dialectical processes of self-definition and definition by others. Furthermore, the individual's historical particularities and his or her embodiment of particular subjectivities, may have a greater or lesser degree of 'fif with dominant discourses about what it means to be a physician. Different students, then, will face greater or lesser convergence among the subjectivities they embody and the subject positions they take up through their training to become doctors. 1.2.2 Social construction of social differences With respect to the social differences that are increasingly represented among medical students, and that are a key focus of this research, I follow the theoretical approach of social constructionism. Increasingly theorists are focusing on social relations and social processes, rather than employing identity categories as if they existed independent of people's actions and reactions. There is a move away from studying categories of 'race' for example, as if they existed in biology rather than as social constructions which make use of physiological features for social and political purposes.8 Instead the focus is shifting to processes of 'racialization/ in which the center of analysis is how a particular social group is constructed as a distinct 'Other' (e.g., Anderson, 1991; Miles, 1989). 'Race,' gender, sexuality are increasingly understood as social accomplishments, outcomes of social relations and social processes (Connell, 1995; Katz, 1995; Seidman, 1994; West & Zimmerman, 1987). We do a specific gender, rather than we are a specific gender. Social relations, then, are constantly produced and reproduced through human agency and interaction. Yet these practices are not random nor individual. They are institutionalized and coordinated, not contained in the local interaction but determined by extra-local social relations (Smith, 1987), relations that bear the weight of history. Identity is not only about what you do, it is also about what others do, and have done (Jenkins, 1996). It is a socially organized way of knowing yourself in relation to others, in terms of group social relations that carry historical salience. In this study, I assume those historical relations. I do not attempt to prove that there is social inequality in Canadian society, in which people's experiences and life-chances differ by gender, age, sexual orientation, 'race,' class, culture, and so on. I take it as a given that there are particular relations of dominance and subordination that privilege some social groups and disadvantage others. This has been thoroughly established in the literature. 8 Like many others, I am in the problematic position of needing to use a term that I deny the validity of, except as a social construct. To continue to use the word 'race' as if it were unproblematic reifies it and solidifies it as if it were a biological reality. Nonetheless, that which is perceived to be real is real in its consequences, and in the late 1990s Canadians still operate as if 'race' were a biological reality. That makes it real in its social consequences. I think it is irresponsible to move too quickly away from the use of categorizing terms because their use may be implicated in the maintenance of oppressive dichotomies (or pluralities), if that leaves us no way to recognize, analyze or talk about the patterned and structured differences that affect people's lives. In other words, to abandon use of the term 'race' while the reality of racism continues unabated is not acceptable (see Henry et al., 1995; Kitzinger, Wilkinson & Perkins, 1992). The conflict between insisting on the constructedness of 'race' and insisting on the reality of its social consequences is an ongoing tension in my writing, reflected in my use of quotation marks around the term 'race.' Where possible I try to use some variant of the term 'racialized minority groups' to focus on the social process of racialization and destabilize the presumed biological grounding of the term 'race.' But stylistically, this is not always possible. .13 . Furthermore, it is important to note that the processes I am examining here are not unique to the profession of medicine. Many fields of work that were previously male-dominated have been regendered in the past two decades. In an era of heightened litigation regarding employment discrimination based on gender, 'race/ sexual orientation, and age (among other factors), and in a era of heightened awareness of and aversion to such discriminatory practices, many occupations are experiencing increased diversity in their workforces (Reskin & Roos, 1990). In many professions, manual trades, factory jobs, skilled trades, unions and so on, employers and trainers are seeking to "diversify" their workforces, for a variety of reasons and with varying degrees of success (Cockburn, 1983,1985,1991; Reskin & Roos, 1990). The particular importance of these processes in professions such as medicine is heightened by the traditional exclusivity and social desirability of these professions (Tang & Smith, 1996). 1.3 Organization of the Thesis The next chapter, Chapter Two, provides a detailed review of the literature on medical professional socialization. Though dated, the earliest classic studies are still surprisingly relevant. The processes of medical education have changed very little, despite revisions to curricula and content. Virtually none of the large-scale analyses of how students come to take on a medical professional identity paid any attention to issues of social differences. Even when there were substantial numbers of women and racialized minorities among the students the ways their experiences may have differed were not examined. However, more recent research has specifically studied the effects of gender, 'race' and other 'differences' on medical practice and education. In general, these studies have found that there is substantial overt discrimination, as well as a more-micro-level latent culture that lets certain students know they simply do not quite belong. .14 . Chapter Three details the research methods employed in this study, a three-part design including a survey of students, interviews with students, and interviews with medical school faculty. It also describes the resultant samples upon which the results and analysis are based. Finally it offers brief reflections on the research process itself. The next chapter begins the analysis of the research data. In Chapter Four I clarify the elements that make up a professional identity, as depicted by the research participants. I also outline the changes students go through during their training, and identify some of the processes through which students become medical professionals. In short, almost all of the traits and processes noted by classic studies of medical professional socialization still hold true in the late 1990s, as much as forty years later. Students leam to negotiate complex hierarchies; develop greater self-confidence, but lowered idealism; learn a new language, but lose some of their communication skills with patients. They begin by playing a role that gradually becomes more real as responses from those around them confirm this new identity, and increasing responsibilities demand that they take up this identity. In Chapter Five I examine the aspects of medical education that lead toward homogeneity among the students. In particular I focus on their struggles to find balance and degrees of integration between their medical-student selves and the other parts of themselves. Students illustrate many modes of articulating aspects of their identities to one another, with varying degrees of success. I argue that there is a strong impetus in medical training to erase the social particularities students bring with them into medicine, as social beings. Building on a predominant social philosophy of liberal individualism that pervades Canadian society, medicine seeks to produce neutral, undifferentiated physicians - physicians whose gender, 'race/ sexual orientation, social class background, religion, age, parental status does not make any difference. While there is some recognition that patients bring social baggage with them into doctor-patient encounters, there is very little recognition that doctors do too, and that this may affect the encounter. I argue that students are learning to see 'difference' only where it contests the ideologies and standards of dominant social groups. Chapter Six extends this understanding of the impact of social difference, by examining how students experience gendered, racialized, and other such aspects of their training. While students tended to say gender (or 'race,' sexual orientation, class) did not matter, they usually then went on to detail how exactly it has made a difference in their lives as medical students. I also explore how students and the medical school itself deal with these social differences. Not surprisingly, the predominant approach seems to be denial that 'difference' makes any difference. From a stance rooted in the politics of difference, I critique this position of denial as (unintentionally) oppressive, demanding as it does assimilation or suppression of self. The concluding chapter, Chapter Seven, continues this emphasis on a politics of difference, outlining in more detail how a commitment to formal equality and nondiscrimination based in liberal individualism is insufficient. I point to the ways individualism is buit into our concepts of both science and professionalism, intensifying the pressure on students to learn blindness to their own social particularities, as well as to the social situatedness of the identity they are taking up. I contrast this with a politics that allows for and celebrates the embodiedness of identities and insists on the benefits of retaining social differences and challenging the prevalent belief in impartial, objective individuals as the basis of (medical) professionalism. .16. Chapter II: Review of the Literature 2.1 Prior Research on Medical Socialization In recent years there has been a proliferation of literature on medical education. Many of these accounts are "insider accounts" (Conrad, 1988), written by men and women who have been through medical school themselves (e.g., Gamble, 1990; Harrison, 1982; Klass, 1987; Klitzman, 1989; Konner, 1987; Mizrahi, 1986; Nolen, 1968; Reilly, 1987; Shapiro, 1987). These accounts provide rich descriptions of the direct experiences of medical students in their preclinical, clinical, internship, and residency years. Many of these authors kept journals in which they regularly recorded the events of their days. Konner (1987) and Shapiro (1987) wrote their accounts after the fact, and bring to them a particular interpretive distance. Melvin Konner taught Anthropology for several years before entering medical school. He brings that ti"aining to bear in his account. Martin Shapiro took a year off after his internship to reflect on his experiences. He interprets them through a Marxist framework of alienation. Most insider accounts, though, are simply "tales from the field" (Van Maanen, 1988) stories about experiences shared by a select group of people. The overwhelming commonality in all of these personal accounts is that medical school is an incredibly intense experience in many ways: in terms of the time and energy demanded, the intellectual demands, the emotional demands, and the immersion into medical and medical-student cultures. These authors write about hnding tricks to learn everything they have to learn in the pre-clinical years, about coping with cadaver dissections, about the first autopsy. They write about learning to accept the impossibility of learning everything, yet having to act with confidence when faced with patients. They write about learning the hierarchy of medicine, often quite brutally. Medical students - who were previously esteemed top students, often pre-medical students - are at the very bottom of the heap. They write about the frustration .17. of doing endless "scut-work" from which they feel they learn very little. They write about learning the language of medicine, but also the informal language of medical students, interns and residents used to express their unique concerns and responsibilities (Konner provides an 11-page glossary of slang). They write about sleeplessness, year after year of never-enough sleep. They write about having no time for friends, families, and outside interests. They write about their fears, frustrations, anxieties, and discomforts, as well as their pleasures, their feelings of pride and satisfaction, the rewards and excitements of their work. They also write about the beauty of human anatomy, the beauty of diagnosis, the beauty of relieving pain, illness and suffering. And they write about their developing sense of competence, their growing self-confidence, their growing sense of themselves as almost-doctors. "Outsider accounts" of medical education by sociologists and anthropologists are less common. Two classic studies - The Student-Physician (1957) by Robert K. Merton and his colleagues, and Boys in White (1961) by Howard Becker and his colleagues - are still the groundwork for sociologists in this field. Though subsequent studies have been conducted, most recently by Simon Sinclair in England (1997), recent work still tends to build on the interpretive frameworks of the early works. Even more tellingly, the fact that Becker's (1961) and Merton's (1957) studies from almost 40 years ago are still highly relevant indicates the lack of significant changes in processes of medical education in the interim. Sociological and anthropological studies of medical education have focused on professional socialization and professional identity formation. This focus is driven by an assumption that how students are socialized, how they learn to be as professionals, will affect their behaviour with patients (Bloom, 1979). One of the more significant aspects of medical school socialization that has been identified is the development of emotional control. Rene6 Fox (1957) found that students are encouraged to control their emotions and adopt a position of "detached concern" with regard to patients. .18. Emotional involvement and over-identification are seen as dangerous; students must strike a balance between empathy and objectivity. There is no room for feelings in medical training (Conrad, 1988; Haas & Shaffir, 1987), and students "are taught to overcome or master their emotions rather than talk about or examine them in detail" (Baker, Yoels & Clair, 1998:298).i Students develop specific techniques to facilitate this position of detached concern. They learn "gallows humour" (Coombs, 1978; Shapiro, 1987; Weiss & Lonnquist, 1997) and use extensive irony (Sinclair, 1997). They learn to depersonalize patients (Cockerham, 1995; Conrad, 1988; Coombs, 1978; Konner, 1987) and even more specifically, they learn to 'scientize' patients. By adopting a scientific gaze they reduce patients to their bodies, separated from their "socio-emotional selves" (Baker, Yoels & Clair, 1998:299). This allows students to concentrate on learning what is medically important, and to focus on disease, procedures, and techniques (Haas & Shaffir, 1987) rather than emotions - their own or their patients'. While the short-term benefits for stress management are clear, later in their clinical years some students recognize that they have mastered "detachment at the expense of genuine concern" (Weiss & Lonnquist, 1997:183); it is not uncommon during postgraduate training to develop outright hostility toward patients (Mizrahi, 1986; Reilly, 1987). Eventually students come to accept emotional detachment as the proper professional stance, believing it is in patients' best interests because doctors cannot practice effectively without it (Haas & Shaffir, 1987). A second aspect of medical student socialization is what Renee Fox (1957) called "training for uncertainty." She identified three main types of uncertainty: 1) that arising from the inability to learn everything; 2) that arising from the realization that medical knowledge itself is incomplete, limited, filled with gaps; and 3) that arising from 1 This appears to begin in preclinical years with cadaver dissection. Some analysts consider this early training for emotional coping mechanisms that students will need later when they work with patients (Charlton, Dovery, Jones & Blunt, 1994; Hafferty, 1988). . 1 9 . difficulties distinguishing between personal lack of knowledge and the limitations of medical knowledge and technology. The personal accounts of medical school are filled with examples of students' feeling anxious because they do not know enough (e.g. Klass, 1987: 57; Konner, 1987:129). Fox argued that not only did students gather knowledge and experience to gradually reduce these feelings of uncertainty, but they also grew to simply tolerate high levels of uncertainty. In contrast, Weiss and Lonnquist (1997) suggest that medical students learn to resolve, control or disregard uncertainty, rather than tolerate it. They suggest that students quickly discern it is risky to display lack of knowledge or certainty in front of their instructors (and possibly in front of patients), and often present themselves as more certain about a matter than they are. Impression management becomes a central feature of clinical years (Conrad, 1988). Haas and Shaffir title their study of one Canadian medical school Becoming Doctors: The Adoption of a Cloak of Competence (1987). They argue that dinical students face routine expectations of competence - from patients who expect them "to know it all" and faculty who often expect them to know far more than they do and who will evaluate the students on the basis of their competence. Students exhibit a common response: When individuals are uncertain about what they should know or how they should apply it, they 'cover' themselves by deflecting others from probing their ignorance... This 'cloaking' behaviour is often accompanied by initiative-taking behaviour intended to impress others with their competence (Haas & Shaffir, 1987: 59). They go so far as to conclude that the process of professionalization involves above all the successful adoption of a cloak of competence such that audiences are convinced of the legitimacy of claims to competence (Haas & Shaffir, 1987:110). Like Weiss and Lonnquist then, Haas and Shaffir believe medical students learn not to tolerate uncertainty but to resolve or deny it. . 2 0 . A third aspect of the socialization process experienced by medical students is the acquisition of a new language and particular communication skills. Good and Good (1993: 97) claim that a central metaphor for medical education is "learning a foreign language." Coombs et al. (1993) point out that there are really two languages students must learn, a formal language and an informal one. In their study of medical slang they state that the informal language that spontaneously arises among participants in a formal system expresses the shared values and conduct norms that exist among those participants. They categorize more than 300 medical slang terms used by medical personnel across the U.S. These terms serve five functions: "Slang: (1) creates a sense of belonging to a select inside group, (2) establishes a unique identity, (3) provides a private means of communication, (4) is an exercise in creativity, humor and wit, and (5) softens tragedy and discharges strong emotions" (Coombs et al., 1993: 992-993). This medical slang is a central feature of medical novels, personal accounts of medical training (see especially Konner, 1987), ethnographers' reflections on their research (Becker, 1993), and ethnographic accounts (e.g., Sinclair, 1997). In terms of formal medical language, acquisition of a huge vocabulary of new words and old words with new meanings, both in written form and orally, is one of the most crucial tasks facing medical students, and one of the central bases for examining them (Sinclair, 1997). Sinclair emphasizes that it is not just any technical jargon or language specific to a profession, but it is the language of science. It is formalized and concrete, unambiguous, and objective. Good and Good (1993: 98) suggest that it is the basis for constructing an entirely new world. They quote one student pointing out that once you learn names for every tree, they are no longer just generically 'trees.' In the same way students learn names for structures and processes they may not have even been aware of. Sinclair would support this view of the significance of medical language: "the language learned by student is . . . far better analysed along the lines that social identity is in large part established and maintained by language" (1997:23). He also . 21 . states that "without this language, and its associated emotions of objectivity, detachment and judgment in such dramatic settings, it is difficult to see how some doctors could do the work they do" (Sinclair, 1997:321). The formal language of medicine is highly reductionistic. As students move from whole bodies to tissues to tissue types to cells, and from structures to functions to mechanisms and systems, a world view in which body systems are seen as isolated from the rest of the person becomes normal, natural, "the only reasonable way to think" (Good & Good, 1993: 98-99). Accompanying this is the development of a way of thinking that is geared to 'case presentations' on clinical rounds or case conferences. One of the first things a clinical student learns to do is to take a patient history and do a physical examination and translate this into the language of medicine, a highly formalized format. Sinclair notes that, "This marks another transition for the student, in that he would have described any previous episode of illness (his own or a member of his family's, say) as patients do; he now develops the clinical narrative style" (1997: 201). The case presentation is the major form of communication among medical staff, and is highly stylized (Atkinson, 1994). It uses depersonalizing language, separating biological processes from the patient; it uses the passive voice to omit agency, or at times attributes agency to a technology (e.g., 'the EKG showed...'); and it encodes skepticism about patients' self-reports, using phrases such as 'the patient reports' or 'the patient claims' (Anspach, 1988). Anspach argues that the format of the case presentation "serves as an instrument for professional socialization" because so many of its underlying assumptions about what constitutes relevant knowledge are unexamined and unquestioned (1988: 372). Klass (1994) provides a powerful example of the way a pediatrician constructs a formal medical narrative from the visit of a mother with a 6 month-old baby who will not stop crying. The questions she asks are guided by the process of making a .22. differential diagnosis; she is mentally tilling out a check-list in her head of attributes that rule out one disease and strengthen the probability of another. Fisher (1991), though, shows how that limits and constrains physicians' ability to communicate effectively with patients. In transcripts of doctor-patient interactions she shows how doctors may follow the path of their diagnostic detective-work, probing when a symptom started, how it is experienced, how related biological systems are functioning and so on, while missing direct cues as to the real psycho-social reasons for the patient's office visit. Again, learning to do a patient history and physical is a key task of students' early dinical education. Not surprisingly some argue that students lose the natural abilities to communicate that they had upon entry to medical school, as they learn the formalized technique of medical interviewing (Baker, Yoels & Clair, 1998). A fourth asped of medical student sodalization that research has indicated is a growing tendency toward apathy, "an attitude of 'lefs not take any risks'" (Rosenberg, 1979: 90). It seems to arise from a series of structured conflicts faced by medical students, such as that between a need for cooperation and an impetus toward competition; a need to be a team player and a need to be an authority figure; a need to learn techniques and language and a need to serve patients. It also arises from a pedagogical approach common in medical education, "teaching by humiliation" (Sindair, 1997). Becker et al. (1961) argue that the students develop an approach geared to getting along with faculty. Faculty can prevent students from getting through, or can make it more difficult. They can humiliate and degrade students. It is necessary to make a good impression on them - but it is not always dear what will impress them positively. Therefore, it is it is necessary to attend to faculty demands and behave accordingly even when those demands seem foolish or wrong. As Becker and colleagues comment, "One must please the faculty in order to finish school or avoid the .23. delay of repeating a course or a whole year, no matter what is required to please them" (1961: 281). Sinclair calls this "appeasement" of the faculty (1997:29). Students experience medical school as a trial by ordeal and develop a sense of themselves as occupying a distinctly subordinate status in which it is best to play it safe (Bloom, 1973; Gallagher & Searle, 1989; Weiss & Lonnquist, 1997). According to Bloom, "the typical response of the student is to concentrate on the difficult problem of how to survive [italics in original]... in general adhering to a policy expressed in the phrase 'Don't make waves'" (1973: 20). A related response is the desire for anonymity, to simply get out. As one student in Becker et al.'s study said he didn't want to make an impression on anyone, positive or negative: "I don't want anybody to know who I am. Dr. Lackluster - thaf s who I want to be. Just so long as I get out of here" (1961: 284). At the same time, students may experience tremendous pressure to fit in with the team (St. Onge, 1997). Perhaps consequently, many students, and later residents and physicians, learn not to say anything even when they see colleagues and superiors violating the codes and norms of the profession (Light, 1988). Such violations are frequently disregarded as matters of personal style. A fifth aspect of medical student socialization that seems to be firmly established is the loss of initial idealism and increase in cynicism. First noted in the mid 1950s, it was solidly grounded in Becker and colleagues' study (1961) and confirmed in subsequent studies (e.g., Broadhead, 1983; Coombs, 1978; Haas & Shaffir, 1987; Rosenberg, 1979). Though medical students tend to begin with higher levels of humanitarianism, or idealism, than do other professional students such as law students, their idealism wanes more rapidly such that upon graduation levels of cynicism are equally high (Bloom, 1988). Students move from wanting to help people to wanting to learn what they need to learn to get by and pass exams. There is little doubt then, that medical students' initial idealism gives way to pragmatism and cynicism. But the .24. question of whether this loss of idealism is temporary or permanent remains an unresolved debate. Becker and colleagues (1961), as well as Coombs (1978) later, argued that changes in students during medical school were situational, adaptations to the specific circumstances of school life. Idealism returned as graduation approached. The return of idealism may be partial, though, tempered by a stronger desire for remuneration and social status, and lower desire to work with indigent populations (Broadhead, 1983). Haas and Shaffir (1987), on the other hand, follow in the tradition of Merton et al. (1957) arguing that the waning of idealism has greater permanence. They believe students construct an absence of idealism as inherently part of medical professionalism: Rather than salvaging their ideals by postponing their application to a future time, they became increasingly convinced that the demands of professionalization, which do not lend themselves to an idealistic approach, are unlikely to change or be successfully challenged... If they are to complete the passage to professionalism, idealistic attitudes must go (Haas & Shaffir, 1987: 86-87). The differences of opinion about the permanence of medical student attitudinal changes reflect a broader debate about the status of medical students. As Bloom characterizes it, "Are they most essentially students, required to prove themselves in a rite of passage that emphasizes trial by ordeal? Or are they physitians-in-training, junior colleagues to the medical professional...?" (1979:18). The study by Merton and his colleagues (1957) assumes the latter, and depicts the changes students go through as part of the development of the values, standards, and norms they will need as full-fledged physicians. Becker and colleagues (1961), in contrast, depict students as students first and foremost. They learn to see the faculty as the enemy, not as their colleagues, and student culture is quite distinct from medical culture, being situationally exclusive to medical school as a distinct institution. Students' increased cynicism then, can be either an adoption of values that will be professionally valuable, or a situational response to feeling oppressed by faculty. .25. It seems highly probable that the medical school experience contains elements of both (Conrad, 1988). In fact this inherent demand on students to be simultaneously an autonomous professional and a subordinate underling seems to me to be the overall tension that structures the conflicts Rosenberg (1979) describes as the "Catch 22" of medical education. For example, the need to learn versus the need to serve; the need to be self-sufficient versus the need to follow authority; the need to take responsibility versus the need to check everything with superiors (Rosenberg, 1979: 84-88). Even if we grant, though, that medical students experience both student-oriented demands and professionally-oriented demands, that leaves unresolved the question of the extent to which changes in medical school are internalized. Bloom (1979) argues that a distinction must be made between changes that are more superficial - learning to meet role expectations, for example - and changes that are more deeply internalized, that become part of who someone is. Simon Sinclair (1997) in his recent medical school ethnography argues that Becker et al. (1961) were too modest in their analyses. By only studying students, and not including interns, residents and physicians, Becker et al. failed to see how the perspectives they discerned among medical students were not limited to students but reflected a more general medical culture. He employs Bourdieu's notions of 'disposition' and 'habitus' to rework Becker's analysis in his own research. According to Becker and his colleagues (1961) medical students develop a student culture, based in collective negotiation and norm-setting about the amount and direction of effort students should expend. They adopt the perspective and urgencies of medical students: exam anxieties, having too much to learn, being at the bottom of a hierarchy, and so on. In the preclinical years they move through an idealism in which they want to learn it all, to a provisional perspective in which they try to identify only the most important things to learn, to a final perspective in which what they learn is determined by what they think the faculty want them to know. They also adopt a .26. perspective on how to get by the faculty, on co-operation with other students, on the desirability of gaining clinical experience and on the value of increased responsibility. But again, these are transient perspectives, situationally specific. In contrast, Sinclair (1997: Chapter 2) argues that there is a particular medical 'habitus,' a way of being that is collectively created but individually embodied. It is the sum of "dispositions" which are akin to, but more fundamental than Becker's perspectives. Sinclair sees dispositions as similar to individual psychological schema that we learn as children to make sense of the world. Such schema have cognitive, emotional, behavioural and embodied aspects; they are relational in that as a child encompasses what it is to be 'child' he or she also takes in what it is to be 'adulf or 'parent.' Similarly, dispositions are schema on a social scale. According to Bourdieu, they are regular without being regulated; they are socially organized and structured even as they socially organize and structure; they bear the weight of history; they are "collectively orchestrated without being the product of the orchestrating action of a conductor" (Bourdieu, 1977: 72). Dispositions are durable and habitual patterned ways of being acquired through social experience (Bourdieu, 1990). Habitus is a system of dispositions, both structured and structuring. It is a product of history that perpetuates itself though making possible particular sets of individual and collective practices - and not others (Bourdieu, 1990: 54-55). Sinclair argues that in medical school particular medical dispositions are conveyed to students through formal instruction, through language, through silences, and through bodily movements. They are enacted by students, embodied by students, in the same ways. The general professional dispositions that constitute a medical habitus are cooperation, competition, idealism, status, knowledge, experience, responsibility, and economy.2 I will discuss Sinclair's theory in more depth in 2 Cooperation is concretized in the emphasis placed on team work in medical school and medical practice. Competition is the integral inverse of cooperation; teams imply rivalry. Sinclair suggests both competition against a common adversary, and competition for individual gain. Idealism starts as a ...27... subsequent chapters. What matters here is that these qualities, collectively held as desirable in medicine, and shared by students and practitioners, are embodied -therefore are accorded much greater permanence than Becker and collegues imagined when attributing them to mere perspectives (Sinclair, 1997). So, what do we know from past research about medical student socialization? We know that they develop emotional control, 'detached concern' for their patients. They learn to master their emotions. They learn to deal with uncertainty, tolerating or disregarding it. More concretely, they learn to present themselves to patients and to physicians as competent, whether or not they are. They learn new languages, an informal one of humour and disparagement, and a formal, technical, reductionistic one that eliminates emotions - even people - from the standard forms of medical communication. They learn to desire anonymity, learn to not make waves. They learn to abandon idealism for cynicism and pragmatism, either temporarily or permanently. And they learn to balance an ambiguous status as lowly student and elevated medical professional, at the same time. These teachings, conveyed overtly and covertly to medical students, may be discarded upon graduation, but alternatively may be adopted as inherent to professionalism, or less intentionally, may be internalized, encompassed and embodied - not so easily discarded. What do we not know from prior research on medical socialization? We know very little about how these processes of professional socialization3 may be experienced personal disposition, but develops as a professional one focused on the notion of professional service. Status stresses the importance of social status while knowledge focuses on the emphasis on 'book-learning.' Experience and responsibility are akin to Becker's perspectives, pointing to the value medical students and professionals place on these qualities. Finally, economy is the disposition that allows for and arises from the resolution of conflicts between dispositions. When students face conflicts between their idealism and their need to acquire knowledge, their ability to compromise care or sacrifice studying displays the economic disposition. 3 I do not wish to overstate the homogeneity of these processes. A s social processes, they are interactive and therefore include some diversity. I do not mean to imply that a group of socially diverse students are put through exactly identical socialization processes, in a factory model. It does make a difference what individual clinicians the students encounter, who they model themselves after, and so on. Different clinicians practice medicine differently and have vastly different pedagogical philosophies - as will become more apparent in subsequent chapters. Nonetheless, to the extent that sociologists can generalize .28. differently by students who are significantly different from one another upon entry to medical school. None of these studies paid significant attention to gender, 'race,' culture, ethnicity, age, sexual orientation, and so on. 2.2 Accounting for 'Difference' Obviously the main reason most existing analyses of medical professional socialization ignore issues of social difference is that for most of history medical students have been middle-class white men. However, there is also a measure of oblivion operating in some accounts. For example, comparing Melvin Konner's (1987) account of his experiences in medical school in the 1970's with Michelle Harrison's (1982) personal account of her experiences in a residency program around the same time is eye-opening. Like Harrison, Konner was older than the average medical student and was a parent of a young child. Yet unlike Harrison, childcare never enters into his story of medical school experiences. Only the fun parts of his parenting experience, such as picnicking with his daughter on weekends, enter into the account, as something he missed when working inhumane hours at the hospital. Harrison's (1982) account is strikingly different. She entered an obstetrics and gynecology residency part-time after several years as a general practitioner. She had a great deal of experience working with midwives at home births, and worked from a feminist critical perspective. In the end she was not able to complete the residency program. Partly this was because of the constantly competing demands she faced as a medical resident and a single mother of a young child. Partly it was because she could not bear to participate in a medical model that she believes relies on the dehumanization of patients. In her case the patients were women, and her identification with the women patients, as a feminist, was impossible to reconcile with any attempt to socialization processes at all, I do assume some degree of (institutionalized) similarity in students' experiences in medical school. . . . 29 . . . identify with the physicians, residents, interns, and medical students around her. In the end she felt she had to choose between identifying as a woman and identifying as a physician. The same type of oblivion displayed in Konner's account is apparent in the most recent full-scale outsider study of medical education. Simon Sinclair's (1997) ethnography of a British medical school was conducted in the mid-1990s, when 52% of medical school entrants in Britain were female (Allen, 1994:3) and at least a third were Asian or 'black' (Sinclair, 1997:76). Yet he tells his readers almost nothing about how these students may have experienced school differently than the white men. He simply remarks on more than one occasion that his own sex and colour prevented him from being able to fully investigate the experiences of less-dominant groups of medical students (e.g. 1997: 9,127), and that ideally he would have had a woman of colour as a co-researcher. While I agree that this could have improved his study4,1 also believe that he could have deliberately chosen to attend to issues of 'race' and gender (among others) more than he did. He failed to interrogate the co-construction of whiteness and masculinity accompanying the constructions of medical student identity he attended to. He ignored how women and students of colour reacted to the frontstage and backstage activities he describes. He did not seek out the reactions of those students. He simply failed to problematize social differences, and even in the 1990s evoked an image of the generic medical student (read upper class, white, heterosexual male). In all of the earlier research on professional socialization in medical schools, women were present only in token numbers. In most of the studies women and other 'minorities' made up such a small portion of the student population that they were not even considered in analyses. For example in the research by Merton and colleagues (1957) the gender and 'race' of students is not even described. Presumably all, or nearly 4 My research, too, could have benefitted from the additional perspective of a co-researcher. . . .30.. . all, were white men.5 More recently, in the study Coombs conducted in 1967-71, fully 98.4% of the students were white, and 96% were male; most had relatively well-educated parents (Coombs, 1978: 23-25). Haas and Shaffir's Canadian study, though not published until 1987 was conducted shortly after McMaster University's new medical school had opened, in 1965 (1987:115). Again they do not describe their sample with regard to demographics, but women constituted less than a third of the graduates from that school until 1977 (ACMC, 1995:35-39). Howard Becker and his colleagues did their research in 1956-57, at a time when the medical student population was very homogeneous. Almost the entire class in each year was "young, white, male, Protestant, small-town native Kansans who are married" (1961: 59). While they were clearly looking for generalizations, shared perspectives among students, they nonetheless failed to explore the few cases that fell outside of the generalizations they made. Nor did they systematically separate out the experiences of the students who were atypical, who did not fit the norm in terms of gender, race/culture, religion or age, for exploration. °" While they found remarkable consistencies in students' concerns, experiences and actions, they did not examine who the students were that experienced things differently. Furthermore, Becker and his colleagues deny the significance of sociodemographic differences. They emphasize that medical student culture is the dominant influence on students, eliminating other differences and becoming a sort of "master status" (Schur, 1971).7 5 I assume this based on the preponderence of white male students in medicine at the time, but also I assume that had Merton and colleagues' (1957) sample not been homogeneous, that would have been noteworthy enough to mention. 6 While Becker and colleagues are exploring what they call the process of medical school turning "boys into men" (hence the title, Boys in White) they nonetheless use quite different language for male and female students throughout the book. While male students are usually referred to as "men," in the few places where female students are discussed at all they are called "girls" (e.g., pages 98-100). In a similar lack of parallel construction, Sinclair (1997) tends to refer to "students" and "female students." 7 As defined by Schur (1971) ,master status is part of the social construction of deviant identities. But more broadly, it refers to the way one aspect of identity becomes exceptionally important for an . 3 1 . Elements in the students' background do not exert any decisive influence on how students behave in medical school. Such background factors may have indirect influence in many ways, but the problems of the student role are so pressing and the students' initial perspectives so similar that the perspectives developed are much more apt to reflect the pressures of the immediate school situation than of ideas associated with prior roles and experiences (Becker et al., 1961:47). In other words, gender, race/culture, social class, sexual orientation, religion and so on are mere background variables that have little or no impact compared with the impact of student culture. Though this is not stated so explicitly in the 1997 study conducted 40 years later (Sinclair, 1997), the same attitude is apparent in the lack of attention to social differences among students. 2.2.1 Gender and medical socialization In more recent years there has begun to be a considerable amount of research specifically on gender differences within medicine. Much of that work has been done by people within the field, and a substantial amount has focused on differences in practice styles between male and female physicians. In general, the research indicates that women tend to be more humane, warmer, more empathic, communicate better with patients of both sexes, are more egalitarian with patients, achieve better patient compliance, and are more interested in the psychosocial and preventive aspects of medicine (Charon, Greene & Adelman, 1994; Ducker, 1988; Hall, Irish, Roter, Ehrlich & Miller, 1994; Hojat, Gonnella & Xu, 1995; Kutner & Brigan, 1990; Lorber, 1985; Pizzini, 1991; Ulstad, 1993; West, 1984,1990). A frequent implication is that women will change the practice of medicine. As a consequence of being socialized toward caring roles, women physicians may be more wuling to 'go the extra mile' for patients, but that may also cause them greater difficulty setting personal boundaries around their work, and consequently individual, overshadowing other aspects of self. The classic example is disability, but Becker's description of the dominance of student identity closely paralells this. .32. cause greater difficulty balancing work and family (Alexander, 1996; Klass, 1996). They may have more trouble negotiating working relationships with (predominantly female) nurses (Cassell, 1996; Klass, 1996; Pringle, 1996) but on the other hand they make take up the reins of authority much the way men have and may be equally hard on junior women (Candib, 1996). A few studies have directly examined discrimination against women in medicine. Stephen Cole (1986) showed quite conclusively that there has been little or no active discrimination against admitting women to medical school since the late 1920s. When women applied they were as likely as men to be admitted. The gendering of medicine as a profession is more subtle and complex, including the bases upon which men and women decide to apply to medicine (or not), their experiences in medical school, the range of factors that influence specialty choices, and their access to residencies and professional circles (Florentine & Cole, 1989; Gross, 1989). Judith Lorber's classic study (1984) documents discrimination against women students in the selection of postgraduate residencies, exclusion of women physicians from the inner circles of referrals and professional networks, and blocking of academic women from positions of authority in medical education. More recently, in a survey of all Canadian women surgeons 49% reported that they did not feel discrimination had hindered their careers in any way and a further 29% said cUscrimination had had little effect. Yet, 51% reported having experienced discrimination from male attending staff during their fraining, and 41% experienced nursing staff as discriminatory (Ferris, Mackinnon, Mizgala & McNeill; 1996). Finally, women residents seem more likely to experience or witness sexual harassment: 39% of women residents and 25% of men, in one study (Farley & Kozarsky, 1993). Harassment was usually initiated by a faculty member or administrator. Most of the literature on gender differences in medical education has focused on experiences and perceptions of gender discrimination and sexual harassment. Routinely .33. women students experience and perceive more of both (Bergen, Guarino & Jacobs, 1996; Bickel, 1994; Bickel & Ruffin, 1995; Dickstein, 1993; Grant, 1988; Hostler & Gressard, 1993; Komaromy, Bindman, Haber & Sande, 1993; Moscarello, Margittai & Rissi, 1994; Schulte & Kay, 1994). In one American study 73% of women and 22% of men reported having been sexually harassed at least once during medical training (Komaromy et al., 1993). Women's harassers were almost exclusively male and were almost always faculty, staff, interns or residents. Male students were harassed mostly by nurses, and their harassers were equally likely to be male or female. A recent study at the University of Toronto found 70% of women and 66% of men reported verbal or emotional abuse during medical school, while 46% of women and 19% of men reported sexual harassment (Moscarello et al., 1994). Again, perpetrators of sexual harassment against women were significantly more likely to be clinicians and faculty, persons with substantial authority.8 Finally, an American study found 71% of women students and 29% of male students had experienced at least one incident of patient-initiated inappropriate sexual behaviour (Schulte & Kay, 1994). Differing experiences and perceptions of harassment seem to lead to differing perceptions about the "general school climate" among medical students. Among both male and female students, having experienced or witnessed harassment is associated with a more negative perception of the overall climate (Bergen, Guarino & Jacobs, 1996). American studies found that though women experience relatively little overt discrimination from patients, nonphysician staff or students, they still perceive more discrimination (emanating primarily from faculty) and more subtle forms of discrimination than do men (Grant, 1988; Hostler & Gressard, 1993). In short, women still perceive medical school as a less hospitable environment than do men. 8 Perhaps not surprisingly, both of these studies set off flurries of letters to the editors of the peer-reviewed journals in which they were published. The letters almost invariably contested the validity of the findings, or even the premises of the research, and challenged what appeared to be quite solid research methods. .34. This evidence is bolstered by a few studies that have examined 'microinequities' such as male students being called doctor while women are not, use of gender-exclusive language, absence of parental leave policies, gender-biased illustrations in medical texts, sexist questions and comments in admissions interviews, sexist jokes in class, and so on (Bickel, 1994; Dickstein, 1993; Guyatt, Cook, Grifith, Walter, Risdon & Liutkus, 1997; Kirk, 1994; Lenhart, 1993; Mendelsohn, Neiman, Isaacs, Lee & Levison, 1994). A Canadian study found women felt marginalized in many subtle and not-so-subtle ways: being mistaken for nurses, being called 'girls,' being ignored by instructors, being faced with sexist, misogynist and pornographic humour in 'skits nights' and other informal social events (Kirk, 1994:175).9 Again, all of these lead to a gendered climate in medical school that may cause women to feel less welcome and more marginal.10 The impact of these differences in terms of stress levels has been examined but results are not conclusive. Two studies found women and men experience medical school as equally stressful, though women express their stress more through anxiety, and men more through heavy cbrinking (Richman & Flaherty, 1990; Stern, Norman & Komm, 1993). There is also some indication that male and female students are stressed by different things, with men most stressed by academic demands while women are most stressed simply by being women, in medicine (Bernstein & Carmel, 1991). Another study found women were more stressed than men by sexual harassment and conflicts between career and personal life (Firth-Cozens, 1990). Like the research on women physicians, there has also been some attention paid to gender differences in emotion, humanitarianism, and communication among medical y See also Sinclair (1997) for detailed descriptions of sexist, misogynist humour as a basis of medical student culture in the British school he studied. Though he does not examine the impact on women students, one can imagine the feelings of marginality that might arise. 1 0 There is some indication that the climate varies from department to department. One study found the use of gender-exclusive language by male and female residents was significantly higher in surgery and lower in psychiatry and obstetrics/gynecology than in other departments (Guyatt, et al., 1997). This may be because surgeons are still disproportionately male, or it may be that a 'macho' climate in surgery fosters sexist language. .35. students. There is some evidence that women medical students are more sensitive to emotions than are men (Bickel, 1994), or enter medical school with more humanistic and holistic orientations, though usually gender differences disappear by final year (Dufort & Maheux, 1995; Leserman, 1981). A survey of graduating students conducted by the American Association of Medical Colleges found that among 1994 graduates women were less likely than men to have been involved in research and to have published papers, and more likely to have worked in providing medical services to underserved areas, inner city communities and public health clinics (Bickel & Ruifin, 1995). It does not seem, though, that these gender differences are the result of greater resistance to loss of idealism during medical school socialization. In one of the few large-scale studies of professional socialization of medical students that has systematically studied gender differences, Jane Leserman examined changes in "professional orientation" over time in medical school. She found that women students were more humanitarian and liberal in orientation upon entering medical school (1983: 141), and she expected the gap between women and men to widen over time. She predicted less conformity with the medical professional model from women by their senior year, assuming frequent encounters with gender-bias would politicize women students toward alternative ways of practicing medicine. In fact both men and women became slightly more conservative. In their senior year women were still more liberal and humanitarian than men were, but the margin stayed the same, with both groups less liberal and less humanitarian than they had been. Leserman concludes that socialization works the same way for men and women in medical school (1983:163). There is some support for these findings in Martin Shapiro's analysis of medical training. He claims that in his experience the women medical students were even more eager than the men to "assume the mantle of physician" in order to distinguish themselves from the nurses (1987: 70). It may also be that women in medicine identify more closely with men whose social class background they share, rather than with other .36. women of lower class backgrounds or other ethnicities; certainly in the past class-loyalties were stronger than gender ties among women in medicine (Leserman, 1983: 33). In Leserman's study the only significant difference in patterns between men and women was that women started out believing in discrimination against women more than men did, and by their senior year men and women had polarized on that issue. Differences in degree of belief in discrimination against women were explained most by degree of familiarity with and support for the women's movement, rather than by gender (1983:185). Martin, Arnold and Parker (1988) argue that for women medical socialization involves a dynamic balancing act between prior gender socialization and the professional socialization they encounter in medical school. Women have to seize every opportunity to prove they are "tough enough" to be a doctor (Klass, 1987) and women who communicate in ways considered gender-appropriate are seen as not assertive enough (Dickstein, 1993). Toward the end of their undergraduate training, medical students narrow the scope of their future careers by selecting residencies for which they will apply. The gendered climate of different departments, as mentioned above, may influence students' decisions (Guyatt et al., 1997). In addition, a substantial body of research on gender differences in specialty choices has found that women students are more influenced by personal values, family demands and negative experiences in specific clerkship rotations, leading to residency choices that result in a sustained gender segregation within medicine (Bickel, 1994; Calkins, Willoughby & Arnold, 1992; Lorber, 1987,1984; Redman, Saltmans, Straton, Young & Paul, 1994; Riska & Wegar, 1993; Xu, Rattner, Veloski, Hojat, Fields & Barzansky, 1995).11 Some observers predict increased 1 1 Of all medical residents in Canada in 1994-95, the specialties with the lowest proportions of women were urology (2.4%), cardiovascular/ thoracic surgery (3.8%), and orthopedic surgery (9.5%). Two-thirds of all women residents are concentrated in five specialties: family practice, internal medicine, psychiatry, paediatrics, and obstetrics/ gynecology ( A C M C , 1995: 82-83; see also Bickel & Kopriva, 1993, for comparable American statistics). Not too surprisingly, the latter five specialties have long been among the .37 . internal stratification vvithin medicine, with women concentrated in relatively low-prestige, low-paid specialties and general practice (Light, 1988). So, we know from existing research that women may be more empathic and humanitarian, both as medical students and as medical practitioners. However, it also appears that these gender differences are the result of gender socialization prior to medical school, and while in training male and female students are similarly affected by their socializing influences such that both end their training with reduced humanitarianism and decreased idealism. While in school, and later in practice, women are more likely to face direct discrimination and harassment, from faculty, clinicians, peers, and patients. Perhaps consequently, women students perceive the overall climate of medical school more negatively than do male students. Though reported levels of stress are similar, the sources of stress differ for men and women - gender is only a significant stressor for women students. Finally, women seem to be 'turned off some specialties because their climates are unwelcoming for women, and they tend toward some specialties because they are more welcoming and have a better fit with family demands. The long-term result may be heightened internal gender segregation within medicine. 2.2.2 'Race' and medical socialization There is considerably less information available about the experiences of physicians and medical students who come from racialized minority groups, than there is about women. As we saw with respect to gender, students who were not of Caucasian/European origins were simply not represented in most medical schools at the time the bulk of the professional socialization research was conducted.12 And again, lowest paid in medicine, while cardiothoracic surgery and orthopedic surgery are two of the top three specialties in earnings as well as public prestige (Gellman, 1992; Pope & Schneider, 1992; Rosoff & Leone, 1991). 1 2 Until the late 1960s virtually all African-American medical students enrolled in one of two "medical schools for Negroes" established in the 1860s, or one of six other such schools open from the 1880s till .38. even when non-white students may have been present, student experiences were not analyzed on the basis of racial or cultural differences. The greatest research attention has been given to practice patterns of racialized minority physicians, particularly studying where they practice, who their patients are, and what specialties they choose. In the United States, the research shows quite clearly that African American and Hispanic physicians are more likely to practice in "underserved communities," communities where the patient populations are predominantly Black and Hispanic (Komaromy, Grumbach, Drake, Vranizan, Lurie, Keane & Bindman, 1996; Nickens, 1992; Steinbrook, 1996; Weiss & Lonnquist, 1997). Even when the racial/ethnic make-up of the community is controlled for, racialized minority physicians care for 21-36% more African American and Hispanic patients than do white non-Hispanic physicians (Weiss & Lonnquist, 1997:165; Komaromy et al., 1996). Like the discussions of gender differences in practice style, there is also anecdotal evidence that suggests at least some racialized minority physicians practice medicine differently than do physicians from the white-dominant majority population. One clinician argues that compared with white women, African-American women physicians use a more holistic approach, are more empathic, less detached, more sensitive to patients' cultural needs, and identify more with their patients (Secundy, 1994). Finally, as with women physicians, racialized minority doctors tend to concentrate in particular medical specialties. One American study found that underrepresented minorities tend to cluster in the same lower-paid, primary care specialties that women concentrate in, though there are differences among ethno-cultural groups. Aboriginal and Mexican men were almost twice as likely to choose 1910 (Curtis, 1971). While other schools did not formally exclude African-American applicants, an understanding that African-Americans would go to 'their own' schools led to de facto segregation. . 3 9 . family practice as nonrrtinority men (Colquitt, Smith & Killian, 1992). Another study found these students disproportionately entered family practice, internal medicine and pediatrics, and were significantly underrepresented in surgical subspecialties (Pamies, Lawrence, Helm & Strayhorn, 1994). There is some reason to wonder what racialized minority students experience in their medical training, especially their postgraduate residencies. A recent U.S. study found that three years after graduation African-American and other underrepresented minority students were significantly more likely than white students to have switched specialties, or dropped out of residency programs - both highly unusual moves (Babbott, Weaver & Baldwin, 1994). Furthermore, significantly higher proportions of racialized minority students are not matched to residency spots in the National Residency Matching Program (Lee, 1992). As medical students, there is also some indication that racialized minorities may have higher attrition rates and take longer to complete their undergraduate training (Lee, 1992). Considerable attention has also been paid to the academic performance of underrepresented minority students. An American study found their academic performance was significantly lower than that of white students, but clinical scores during clerkship were comparable (Campos-Outcalt, Rutala, Witzke & Fulginiti, 1994). In the United Kingdom, "ethnic minority" students were found to be 2.09 times as likely to fail one or more exams as were white students (McManus, Richards, Winder & Sproston, 1996). The authors argue that this cannot be due to racism because the students did poorly on multiple choice and computer graded exams, and because "ethnic students" not from the U.K. performed better than did white students. This is a very narrow understanding of how racism operates, viewing it exclusively as active discrimination. It overlooks the possibility that students may have very different daily experiences in medical school, such that the learning environment differs for white students and students from racialized minority groups. .40. Those daily experiences of racialized minority students in medical school remains an under explored area, about which little is known. One study found that 19.7% of students at ten U.S. medical schools reported experiencing racial or ethnic harassment (Baldwin, Daugherty & Eckenfels, 1991). Examining a later stage of training, a national survey of medical residents found 23% had experienced at least one incident of racial or ethnic discrimination in the previous year (Baldwin, Daugherty & Rowley, 1994). About 10% (31% of the 'minority' students) had experienced such discrimination "sometimes" or "often" - 5% of the white residents, 18% of Hispanic residents, 29% of Asian/Pacific Islanders, 45% of Indian residents, 39% of African-Americans, 48% of Middle Eastern residents. The most serious types of discrimination (being denied opportunities, being given poor evaluations) occurred most to Middle Eastern, African-American, Hispanic and Native American residents. Patients were the most common source of racial/ethnic discrimination, but almost as many incidents came from attending clinicians, other residents, and nurses. (Baldwin, Daugherty & Rowley, 1994). The consequences of this fairly high level of racial cUscrirnination on medical students has not been conclusively demonstrated. But there are some indications. One interesting study examined students' 'need for power' in first and third year. The researcher found that during this time white students' need for power decreased and non-white students' increased (Rressin, 1996). She suggests that all students experience being at the bottom of a status hierarchy and have a desire to compensate by expressing power. White students get satisfaction from respectful interactions with patients, interactions which allow them to feel powerful. In contrast, at least some non-white students experienced interactions with patients as reinforcing their powerlessness and marginality. This study is bolstered by the growing body of personal accounts of medical school written by members of racialized minority groups. Some African-American .41. physicians write of their medical school years as extraordinary ordeals (Blackstock, 1996; Gamble, 1990; Rucker, 1992). They faced racist comments and stereotypes from doctors, patients, nurses, and fellow students. They were occasionally mistaken not for nurses - as white women students have been - but for cleaning staff, cooks and clerks. Those students who also came from backgrounds of poverty felt particularly marginalized and torn between worlds; minority students from upper-middle class families seemed better able to assimilate (Blackstock, 1996; Gamble, 1990). But all of these students had to find ways to cope with membership in institutions they perceived as racist: During medical school I also got to see firsthand that medicine did reflect the views of a racist American society. I saw black people ridiculed because of their dialect. One hospital even kept a list in its emergency room of 'humorous' examples of black dialect and folk medicine knowledge (Gamble, 1990: 60). Surviving in such environments seems to have demanded non-response to such incidents. Gamble (1990: 61) describes learning to be silent rather than risk her status in the medical school. The one example she gives of having spoken up was to distinguish herself from the Black patient being disparaged, to make her fellow medical students realize African-Americans are not homogeneous - in a sense saying that she was not one of 'them.' Not surprisingly, the stress on medical students from racialized minority groups is high. In addition to experiences of racial and ethnic discrirnination, they may face increased financial concerns (Sullivan, 1977), as well as pressures to be role models for their entire racial group, and to return to their home communities to work (Robb, 1997). A recent US study found average stress levels were higher for "minority'' medical students (Calkins, Arnold & Willoughby, 1994). Fully 82% of those "minority'' students were Asian.13 The factors that caused higher stress were not race-related, but were Asian is left undefined in the study. ...42... about academic aspects of the program. The authors suggest Asian students have higher need to achieve in medical school, due to cultural or familial pressures. Unfortunately they did not report what factors were most stressful for non-Asian minority students. There is very little evidence about more subtle issues of 'race' and culture, issues that nonetheless might construct a 'racialized' medical school climate. There are some signs in the personal accounts above, though those authors tend to focus on instances of outright racism. Simon Sinclair's (1997) recent ethnography of medical school, though, contains a few hints that that particular school at least might be a place where students of colour would feel marginalized - though this is not his focus. He describes a few incidents of students' being subjected to racist comments, especially from patients. But more compellingly, his description of the medical student informal culture - the team sports and variety shows, as well as beer drinking at the medical student pub - are populated almost exclusively with white students. He mentions that Asian students tend not to participate, and tend to hang out together at another pub. He depicts a fairly high degree of racial segregation. So what do we know about 'race' /ethnicity and medical school socialization? Considerably less than we do about gender. Nonetheless, it does appear that medical students from racialized minority groups are disproportionately likely to want to work in primary care and in underserved communities, and that physicians from these groups are in fact disproportionately serving minority patients, and are concentrated in lower-status, lower-paid specialties. These students have less success in the residency matching program, and higher attrition rates there and in medical school itself. They may perform less well than students from dominant cultural/racial groups, though the reasons for that are not clear - it could be due to less adequate early education, greater financial struggles, experiences of racism in school, feelings of marginality, or any number of other factors. We do know that minority students experience a considerable .43. amount of racial and ethnic cUscrimination and deal with somewhat higher levels of stress while in school. Finally, it is worthy of note that almost all of the available research, and even the personal accounts, of medical school as experienced by students from racialized minority groups come from the United States. There is almost nothing in the literature examining these issues in Canada. 2.2.3 Social class, sexual orientation, and medical school socialization Very little research has examined the impact of social class on physicians' practice styles, or on students' experiences in medical school. In an overview of the topic Roter and Hall (1992: 64-65) cite two studies that suggest a poorer quality of communication is demonstrated by doctors of working-class origins; they spend less time with patients and give fewer explanations. Roter and Hall argue that medical education can be a vehicle for social mobility but only for students who have already demonstrated mastery of middle-class values. It has been suggested that medical students are homogeneous in their class affiliations, regardless of origins; that by the time they gain admittance to medical school students of lower-class origins will have "assimilated middle-class norms and values" through their undergraduate educations (Cockerham, 1995:195). In contrast to this supposition, though, in a Canadian study where only two of the 80 medical students studied were working-class,14 both reported that they felt marginalized by the interests and values of their middle-class fellow students. One working-class student joked that the hardest thing for him to learn at medical school was "the wine and cheeses" (Haas & Shaffir, 1987: 23). This illustrates a sense of 'outsider-ness' that is complex, involving a subtle sense of belonging rather than 1 4 It is not clear how class was measured in the study; it may have been self-report (Haas & Shaffir, 1987). ...44... outright dismmination. Similarly, Dale Blackstock felt marginalized in medical school not just because she is African-American, but because of her working-class background: I was also somewhat intimidated by the backgrounds of many of my peers. Most of the students came from well-to-do families, including many of my African-American classmates. In my class alone there was a student who was a relative of Jackie Onassis, several students whose parents had written textbooks that we would be using in class, several students who had parents on the faculty, a student whose father would win the Nobel Prize in Medicine . . . My claim to fame was my mother who received her LPN degree after raising six children, and I was very proud of her. She had attended school full-time, worked full-time, taken care of the family and gotten off welfare (Blackstock, 1996: 77). It is difficult, especially in the American literature, to separate the impact of racism and the impact of poverty on students' experiences, since 'race' and class are more thoroughly conflated there than in some parts of Canada. That having been said though, one of the few studies on the impact of family incomes and medical school performance found that regardless of racial category, students from lower income families tend to perform somewhat less well academically (Fadem, Schuchman & Simring, 1995). The authors cannot really explain this finding. There is little evidence about the impact of students' sexual orientation on their experiences of medical training. While there are indications that some students are affected by homophobia (as prevalent in medical schools as it is elsewhere) others report having been 'ouf all the way through school with no particular negative encounters. 15 However, the ability to 'pass' as heterosexual, and the familiarity with a heterosexual culture one has been immersed in from birth make this slightly different than issues of gender and race/culture. 1 5 By "homophobia" I mean the irational fear and hatred of, or more mildly, hostility and condemnation directed toward people known or believed to be gay, lesbian or bisexual. I will distinguish it from "heterosexism" by which I mean the overwhelming assumption that the world is and must be heterosexual, and the systemic display of power and privilege that establish heterosexuality as the irrefutable norm - and by extension establish homosexuality as deviance. Heterosexism centres on oblivion about the very existence of gays and lesbians. .45. A very recent Canadian study found that of a random population sample in a large urban centre, 11.8% said they would refuse to see a gay, lesbian or bisexual physician (Druzin, Shrier, Yacowar & Rossognol, 1998). The authors suggest that rate may be even higher among those who refused to respond to the telephone survey, assuming at least some were unwilling to discuss the topic. The main reasons given were fear that the physician would be incompetent and patient discomfort. A small proportion of respondents expressed outright hostility toward gay, lesbian, and bisexual physicians. A small-scale British study found that doctors perceived a fairly high degree of homophobia within the medical profession (Rose, 1994). A recent Canadian study found about 40% of general internists experienced homophobic remarks from fellow physicians, nurses, other health care workers, and patients (Cook et al., 1996: 570). The authors conclude that, "Homophobia among physicians is common, negatively affecting the care of lesbian patients, gay men, and patients with HTV and AIDS, and the careers of gay, lesbian, and bisexual physicians" (1996: 570). In the United States Wallick, Cambre & Townsend (1992) found that on average 3 hours 26 minutes of curriculum time were devoted to teaching about homosexuality, out of a four year curriculum. The vast majority of that time was in first-year lectures on human sexuality.16 Finally, an American study examined attitudes of family practice residency program directors to determine how a medical student's disclosure of homosexuality might affect an application for residency (Oriel et al., 1996). They also examined third-and fourth-year students' perceptions of the impact of disclosure about homosexuality on their residency application process. They found that although 67% of residency directors showed "homophilic attitudes" (supportive to gay men and lesbians) 25% 1 6 The authors give no cmparative data on how much time is spent, on average, addressing issues of gender or racial/cultural differences. .46. would rank applicants lower if they were known to be gay or lesbian. Homophobic attitudes were expressed by 8% of residency directors, and another five surveys were returned uncompleted with homophobic remarks written on them. The authors suggest negative attitudes may be more prevalent among non-respondents. Finally, 46% of students had experienced discrimination based on sexual discrimination during medical school, and 71% considered their sexual orientation as a factor in choosing specialties. Most hid or planned to hide their homosexuality during their residency application process, even if it meant omitting leadership roles in gay and lesbian organizations. Oriel et al. (1996:720) quote a popular guide to getting onto medical residencies as warning gay and lesbian students that disclosure of their sexual orientation may "doom" their applications. They state that overall: Gay and lesbian medical students learn medicine and care for patients in an environment that often assumes heterosexuality and, at times, is actively hostile to gays and lesbians... Disclosure of homosexual orientation by medical students or physicians has generally been regarded as having dire professional consequences (1996: 720). In short, it seems reasonable to assume that the prevalence of homophobic attitudes are no higher or lower among medical students and faculty members than in the general population, and that students who identify as gay, lesbian or bisexual might feel more marginalized in medical school than do heterosexuaUy-identified students. 2.3 Conclusions The professional socialization experienced by medical students is an intense and effective process. For 'typical' students - read: white, male, heterosexual, upper- or upper-middle class, young, Judeo-Christian, unmarried, no children - the experience seems to be transformative. Through the rigor and the tension of medical education, students' beliefs about medical care change as they increasingly adopt the dominant ...47 . . . clinical perspective that pervades medicine. Most adopt it readily, while others must be converted; some accept it only uncomfortably; a few resist it actively... By the final year of medical school... they have learned how to think like doctors... Medical school fundamentally affects ones world view (Conrad, 1988:329). They learn to control their emotions, to present themselves as competent, to use new languages, to not buck the system. They learn to become professionals. For less typical students - women; those from working class backgrounds, racialized minorities and/or minority cultures and religions; those who identify as gay or lesbian; those who are older, married or parents - the processes of professional socialization may be less straightforward. They simply don't 'fif as easily. As Jane t Leserman says, Professional socialization in medical school may be less orderly and more problematic for such minorities as women due to some of the difficulties that they face in a predominantly male profession. Therefore a description of the socialization process should take into account how this process may vary for minorities such as women (1983: 39). When gender and racial/cultural differences have been studied in medical education, it has usually been in a 'deficit model' in which the central question is why women or racialized minority students do less well in medical school and how they could be more like white men. Alternatively, we see a 'glorification model' in which it is assumed that women will practice medicine more humanely than men do, and that minority physicians will practice medicine in 'their own' ways and 'their own' locations. Apart from experiences of open discrimination and harassment, which are decreasingly common, we still know surprisingly little about how these less-typical students experience socialization processes in medical school, and how effective that professional socialization is. The research methods through which I sought to address these questions are detailed in the next chapter. .48. Chapter III: Research Methodology and Design 3.1 Standpoint Methodology All research is done from a standpoint - not just the researcher's own personal background, but also the researcher's choices concerning whose concepts and categories to use, whose experience to start from, in whose interests to frame research questions, and to whom research is accountable (Harding, 1993; Smith, 1987). It is like shifting a kaleidoscope - if you shift the standpoint from which you begin, the whole pattern changes. The standpoint a researcher employs, then, becomes largely a matter of choice. It may be the standpoint of the student, the teacher, the principal, the parent, or the school board. Or it could be the standpoint of a subgroup of students, or a subgroup of teachers. Or the standpoint of academic discourses entrenched in traditional sociological concepts and methods. Dorothy Smith (1987) has most fully developed the notion of standpoint in research methodology. She argues that research must begin from the relevances of individuals in their everyday lives which set the problematic of the research inquiry. Research should help people understand what social relations determine the particular aspects of their lives that they identify as problematic!. VVrtile I draw on Smith's methodology, this research did not employ it in its purest form. I did not begin inquiry directly from the experiences of medical students, adopting their collective relevances as the standpoint of my mquiry. Ji I had done that, concerns about exams and grades and money would undoubtedly have come to the forefront. Rather, I started from the standpoint of some students, the standpoint of the students who are in specific ways different from the historical norm in medical schools. 1 Smith understands the concept of social relations to mean concerted sequences of action, performed by more than one and perhaps sometimes by a multiplicity of individuals not necessarily known to one another. These coordinated practices happen outside the realm of the everyday experience of individuals, and organize and articulate the activities of people in widely dispersed settings (Smith, 1987:183). .49. To some extent I am privileging the standpoint epistemology developed by Patricia Hill Collins (1990; 1991) over that of Smith. 2 Collins argues that "personal and cultural biographies [are] significant sources of knowledge" for "outsiders within" in the academy (1991: 53). She believes that Black women, especially those from the working class, are likely to be struck by the "mismatch" of their experiences and the paradigms of the academic relevances around them; they are thus more likely to identify anomalies than would true "insiders" (1991: 50). I would argue that my research began from the relevances I found in the talk of some medical students - the students who are "outsiders within," who have found it difficult to identify as student-physicians. Some of this talk is documented in the form of autobiographical accounts of medical school. Some of this talk was relayed to me by people I met at conferences, email connections, and chance encounters as I have worked in the area of health and illness for several years. Some of this talk occurred informally with friends who were medical students and are now doctors. What I have heard from lay people over the years - and from students in sociology of health and illness classes I have taught - is their high expectations of 'minority' and women doctors to do things differently. What I have heard from women and minority medical students is the conflict they experience between the expectations of those they are connected to outside of medical school and the expectations they face inside medical school - and an accompanying feeling of being split, or divided. These are the relevances that structured my inquiry. 3.2 Research Design and Implementation A key way to improve any research is to use multiple methods of data collection and analysis - to "triangulate" the methods (Creswell, 1994:174-178). This research employed three complementary research strategies: A survey of an entire third-year 2 See Naples (1996) for an excellent analysis of the differences between these two standpoint theories. ...50 . . . class (124 students) at one medical school; in-depth serm-structured interviews with 25 students from that class; and in-depth semi-structured interviews with 23 faculty members from the same medical school.3 The survey was intended to provide a broad, population-based picture of the experiences of the class as a whole. It was not meant to test hypotheses so much as to explore whether my guiding assumptions were reasonable, and to guide the in-depth interviews. In addition, it allowed meaningful comparisons among groups, and enabled me to study patterns of association. Finally, it permitted me to interpret the interviews within the context of the responses of the whole class. The qualitative components of the design allowed me to explore the central aspects of the inquiry at greater depth. They allowed me to ask 'how' and 'why' questions; and to discover how students create meaning of their own lives, expressed in their own words. Interviews with faculty provided a different perspective on the same issues discussed with students - a longer-term, more historical perspective. These interviews allowed me to explore the meanings faculty attach to the changes they see in the student population over time, and how they understand the changes individual students go through during their training. I was slightly surprised to find the faculty also used the opportunity to reflect on their own experiences of medical school, and draw comparisons. One of the weaknesses of the research design is that it was retrospective, relying on respondents' ability to remember accurately what they were like a few years ago and what changes they have undergone since, or how the student body has changed over time. Students may have been unaware of or unable to articulate clearly how they 3 I do not identify the medical school where the research was conducted. This was an agreement I made with the administration of the school in order to gain access to the research site. While that decontextualizes the research in some ways, nonetheless I believe the main findings have some degree of generalizabilty to other Canadian medical schools. The school in question was located in a large city with a racially and ethnically diverse population, and the school followed a traditional undergraduate curriculum. .51. changed over time. Any cross-sectional design would be limited in this way; only a longitudinal design following a single group of students from first year through their undergraduate education would have been completely adequate. The time and money required for such a study were prohibitive for a dissertation. In addition, in surveying and interviewing students who were already in their third year, I studied people who were already 'acclimatized' to the culture of medical school. Irtings that took them aback at first may have become commonplace after three years. The impact of socialization and peer pressure may have already reduced their consciousness of the details of the world into which they are being socialized. Nonetheless, there is some basis in the literature for choosing third year students as an appropriate study population. Third year is clearly a key point for medical students; it marks an important transition point as students move out of the classrooms to spend the vast majority of their time on the hospital wards and in clinics working with patients. Becker et al. (1961:185-187) found that while the first year of medical school brought significant changes for students, the second year was much the same as the first. At the other end, both Konner (1987) and Reilly (1987) claim that the fourth year is an anticlimax after the grueling transitions of the third year. Broadhead (1983) concludes that during the first two years the primary identity is that of medical student; in the third and fourth years the primary identity shifts to that of student-physician (see also Coombs, 1978: 217). Similarly, Haas and Shaffir argue that the third year intensifies the symbolic manipulation and impression management that are formative processes for professional identity development (1987:55,106). Additionally, in terms of the more specific questions I am asking in this research, interactions with patients and other health care personnel - which really begin in the third year - are an important part of how medical students put together their student-physician identity with other identities that are important to them. Several authors argue that a major factor in students' coming to see themselves as doctors is being .52. called doctor and treated as a doctor by others (Klass, 1987; Konner, 1987; Reilly, 1987; Shapiro, 1987). Coombs states that "being called 'doctor7 by patients and staff helps students view themselves as physicians. Such a social looking-glass enhances the development of a professional self-image" (1978:227). Thus, the third year is a key point for medical students' transitions to a future-physician identity, due to the increased interactions with staff and patients. Furthermore, these interpersonal encounters may also be a forum in which students are reminded of their other salient identities, and in which those other identities are enforced. Interactions with patients and other hospital workers can enforce gendered and racialized notions of what is appropriate behaviour and position/status for whom. For example, as we saw in Chapter 2, women and racialized minorities are less likely to be called doctor, and more likely to be called nurse or maid. Thus the third-year clerkship, when students begin to spend most of their time in the hospital, is an appropriate point in their education to ask them about the complex mixes of identities they experience, and how those identities are enacted and enforced by others' actions. 3.2.1 Student survey The survey was pre-tested on a convenience sample of 10 graduate students, revised several times, and pre-tested with 12 medical students and faculty I was in contact with through E-mail. In response to their feedback the survey was revised again, and the final version was printed (see survey instructions Appendix I). I used a saddle-stitched booklet format. Enclosed with the survey were a letter of introduction explaining the purpose of the research, emphasizing the voluntary nature of their participation, and clarifying issues of confidentiality; a stamped addressed return envelope; and a separate card agreeing to be interviewed, on which students wrote their first names and phone numbers (see Appendix II). A second stamped addressed return envelope was enclosed to return the interview card separately from the survey. . 5 3 . Each survey was numbered to enable record-keeping. The return address for surveys and interview cards was a rented post-office, partly to accommodate the potential volume of mail and partly to protect my own privacy and safety. The survey was administered through the students' mailboxes at the hospital; 124 survey packages were distributed on January 29,1997. I followed the protocol outlined by Mangione (1995) to maximize response rate, with two follow-up notices and one follow-up survey package. Two weeks after the initial distribution of the survey, on February 13,1997, a reminder notice was distributed to all student mailboxes. On February 26,1997, a second survey package was distributed to all students who had not yet responded. A final reminder notice was placed in the mailboxes of those who had not responded by March 13. (See Appendix JJ for follow-up letters and notices.) Mangione (1995: 67) claims that a follow-up protocol such as this should provide approximately a 75% response rate. My final response rate was 58% (N=72). While this is lower than I would have liked, given the extreme time commitments faced by medical students, it may be as good as can be expected. Faculty members in this medical school and others thought it was a high rate of return. Similar surveys, when conducted with non-captive populations of students or recent graduates, achieved response rates from 51% (Hostler & Gressard, 1993) to 62% (Hojat, Gonnella & Xu, 1995). I took two steps mid-way through the process that increased my responses, that - had I taken them from the first - might have improved the overall response. I should have arranged to speak to the class when I distributed the initial survey package in January. The face-to-face contact and the chance to 'pitch' the importance of the survey would undoubtedly have improved the initial response. Instead, when I realized the response was low I arranged to meet with the class on February 26, the day I . 5 4 . distributed the second survey package to students who had not yet responded. Some students told me in later interviews that this contact made a difference. Secondly, before I started the survey I debated the pros and cons of offering monetary or other compensation for students who completed the survey. Mangione (1995) suggests this can significantly improve response rates. I decided against this for three reasons: my limited resources would not permit compensation of any significance to 124 students, and a lottery for all respondents would still be costly and produce less substantial improvement in response rates. Secondly, I assumed that medical students would be more likely to come from affluent families and might have less concern about money than most other students have, thus would be less motivated by a draw for a relatively small amount of money. Lastly, I was concerned that offering money would cheapen the research, decreasing the internal motivation to participate while not significantly increasing external motivators. Several of the first surveys that were returned mentioned financial issues as a major concern that I had neglected to ask about. I started to realize my assumptions about the affluence of medical students might be in error! So when I arranged to meet with the class to pitch the survey, I also added an external motivation: I announced that I would enter the identification numbers of all surveys returned by March 21 into a draw for $200, including those surveys that had already been returned. I believe this, along with the personal contact, increased my response rate markedly. Mangione demonstrates that with the follow-up protocol I used one can expect each wave of mail-outs to return half as many surveys as the previous wave. Thus, if 40% were returned after the initial survey distribution, the first reminder should bring in another 20%, the second survey package another 10% and the final reminder another 5% for a 75% total. In contrast I had a 17% (N=21) response to the first survey package; 12% (N=15) after the first reminder; 20% (N=25) after the second survey package and . 5 5 . class visit plus the announcement of the $200 draw; and a final 9% (N=ll) after the final reminder, for a total 58% response (N=72). Though the responses picked up in March, after I visited the class and instituted the draw, there is no way of knowing what the total reponse would have been had I met with the class and offered the lottery from the outset. By March students were already panicking about the intense examinations they would face at the beginning of April, and would have been less likely to spend time on the survey than they might have been in February. Finally, I made some decisions on the survey content that I knew might result in lower responses but that I believed were necessary, both politically and sociologically. In several series of questions about the impact of age, religion, 'race/ gender, social class and so on, I included sexual orientation. I knew that some students might be offended by these questions and refuse to answer the survey - which would lower my response rate. However, after years of critiquing surveys for totally excluding the realities of gay men and lesbians, I could not myself construct a survey that did the same thing. It was a difficult decision; I knew I might lose several respondents in order to capture one or two gay or lesbian respondents. At the same time I believe deliberately excluding specific social groups through exclusionary question wording is simply bad sociology. From some comments on the survey, and others by students I interviewed, it is clear that my inclusion of questions about sexual orientation did in fact offend some students. One man raised this issue after our interview was concluded. He said the talk around the school, around his class, was that the gay and lesbian questions were asked too many times and some people found them offensive. I pointed out that questions about sexual orientation came up no more and no less than religion, 'race/ culture, ethnicity, language, gender, age, and so on. He said he realized that, but that the perception was that I was asking too much about it. So again, I can assume that my .56. decision to be inclusive of gay and lesbian students (and to name heterosexual orientation as a social factor) cost me in terms of response rate, but I do not know how much. The survey results were analyzed using SPSS for Windows. It is worth noting at this point that the statistics that appear throughout this dissertation, based on the survey results, are primarily at the level of description, with some sub-group comparisons and analysis of variance. I have deliberately not included more advanced statistical analysis here, because I do not believe the sample size (N=72) warrants it. It is also important to comment here on how statistics are reported. In the social sciences a level of significance of 0.05 is conventionally used, though 0.10 is also seen with less frequency. Given the small sample size, the exploratory nature of the research, and the fact that the survey data are supplemented with two types of interview data, statistical significance is sometimes of less concern to me than would otherwise be the case. Thus, at times I indicate patterns in the data whether or not statistical significance was reached. Generally, I simply provide the probability levels and readers can decide for themselves what to make of them. If, for example, I report a trend in the data with a probability level p=0.08, readers may note that there is an 8% chance this trend is due to chance and interpret the evidence accordingly. Finally, where quotes from open-ended survey responses are used in the text, they are indented and set off with a bullet but are not attributed to anyone, since the only identification I have is the survey number. 3.2.2 Student interviews Interestingly, the pattern of returned interview cards suggest early respondents were probably more motivated by internal factors such as interest in the topic, while later respondents may have been more motivated by the potential of winning money. Of the first 21 surveys returned 10 (48%) were accompanied by cards agreeing to .57. interviews at a later date. In subsequent waves of returns, the proportion volunteering for interviews dropped to 26%, 16% and 18%. Upon completion of the survey I had first names and phone numbers of 20 students who were willing to be interviewed.4 To increase participation, I distributed a notice to all student mailboxes a few weeks after the survey deadline announcing the winner of the $200 draw (with her permission) and announcing a second draw for $100 from among the names of all those who completed an interview with me. That brought two more students willing to be interviewed. Finally, as I conducted interviews I asked students if they would be willing to tell me the names of a few classmates they thought it would be useful for me to interview, or who might provide a perspective very unlike their own. Many students named classmates who had already been interviewed or agreed to an interview. Nonetheless, this snowball sampling also generated an additional 35 names. In each case I wrote the student a brief letter indicating that someone had suggested they would be a valuble person for me to interview, and asking them to call me if they were willing to be interviewed. I contacted the students only once to avoid harassing them. This process brought an additional 4 interviews. My final total of student interviews was 25. The interviews were conducted between April 27,1997 and July 27,1997. At that time students were on a two-week break just after third-year final exam, or had just begun their fourth year rotatons. Most interviews were held in students' homes, though two were held in my home, one in a research lab I had access to on campus, and two were held near the hospital during breaks - one at a park and one at the student alumni centre. Each interview was tape-recorded with the written consent of the participant (see Appendix HI). Each tape was identified with a number and a pseudonym. I also completed a one-page demographic questionnaire for each student during the 4 One student later cancelled due to time pressures. . . . 58 . . . interview (see Appendix III). The interviews were usually 60 to 90 minutes long, though three went to 115 minutes and one woman was enjoying the interview so much she wanted to meet a second time to continue! That interview totalled almost 3 hours. In each case I followed an interview guide (see Appendix III), though it was revised continually as I went, in response to how well particular questions seemed to be working and to query students' thoughts on issues emerging from previous interviews. Furthermore, I did not ask all questions in every interview, but rather allowed the interview to be guided by what I was hearing from each participant, and his or her particular interests. Interviews were transcribed verbatim, and coded inductively. The final number of interviews was determined by the number of volunteers and by 'saturation' of the data. In qualitative research saturation is reached when the researcher no longer seems to be finding out much that is new from continued interviews. At that point there is diminishing return from subsequent interviews. They may be confirmatory but they supply little insight the researcher does not already have. I expected with the diversity I was seeking in the interview sample that I would not reach saturation quickly. But by the 23rd and 24th interviews I was starting to feel I was hearing the same thing over and over. I believe I saturated the data. Lengthy quotes from the interviews that are used in the rest of this text are identified with the pseudonym of the student. The quotes have been 'cleaned' of the usual grammatical errors, false starts, phrases like "urn" and "y'know," and pauses that all of us use in everyday speech. This is a controversial move, since many qualitative researchers believe in 100% authenticity when using quotations. My position is that cleaning the quotes simply avoids making my research participants look stupid and inarticulate, as they might if their unedited speech were portrayed next to my edited and re-edited writing. In no case have I altered the meaning or content of any passage. My editing has simply tidied their speech.5 5 For example, the first student quote I use in Chapter 4 is: . . . 59 . . . 3.2.3 Faculty interviews The final stage of the research was interviews with 23 faculty members. I was startled by the level of response and interest from faculty. Students were asked on the survey to identify faculty members who have substantial contact with students during their clinical years and who are especially interested in medical education. About half (N=37) of the completed surveys identified 1 to 6 faculty members; some names were raised by as many as 13 students. A total of 34 faculty were identified; 4 of those were not listed in any department within the Faculty of Medicine and I had no addresses, or even first names for them. I added 3 names to the list to increase the representation of women, and to add one gay male physician who is involved with support services for a particular sub-group of medical students.6 In total, then, I sent out 33 letters to faculty requesting interviews. Of those, 24 agreed to be interviewed - most were very eager. One interview with a family physician was rescheduled three times and we finally abandoned the attempt. Thus, in total I conducted 23 interviews with physicians/ faculty members. These interviews were conducted between July 11,1997 and October 10,1997. One was held at the physician's home, and one in a hospital cafeteria, while the rest took place in the participants' offices. Each interview was tape-recorded with the faculty member's written consent, and the interviews followed an interview guide (see Appendix IV). Again the guide changed over time as the interviews followed the Valerie: I would have to balance family and practice, and I wouldn't want to let my practice overrun, or take over family time. The odd occasion I guess you're on call and you have to go, but I'd want to keep a good balance. In the original transcript, it looked like this: Valerie: I would (pause) I mean I would have to balance family and practice, um, and I wouldn't want to let my practice overrun, or take over family time. You know the odd occasion I guess you're not, you're on call and you have to go, but I'd want to keep a good balance. U m . . . 6 This one physician is not actually a faculty member; he does invited lectures regularly, and works with students on placements in his practice. For simplicity, though, I will usually refer to this group as faculty, since all physicians but this one were on faculty, while not all faculty were physicians - some had PhDs in academic subjects. ..60 . . . relevances of each particpant, but also as the interviews became more focused around themes that were emerging from previous interviews and from the transcripts of student interviews. These interviews were usually 60 minutes long, though 2 were slightly shorter, and 6 were 70 to 90 minutes. Tapes were identified with a number and pseudonym. Interviews were transcribed verbatim and coded inductively. The pseudonyms are simply Dr. A, Dr. B, Dr. C and so on. This does not tell the reader anything about the person, whereas the student pseudonyms (Valerie, Mark, Bruce) at least indicate gender. I decided against indicating the demographics of each faculty member I quote in the text, because I am afraid that would make some of them, especially the small number of women, overly-identifiable. Even just noting age and gender, it would be easy for a reader who knows this relatively small community to put together, 'rim, Dr. A is female, mid-40s, appears to be a surgeon - must be so-and-so.' Where I think the demographic background of the interviewee is pertinent, I bring it up in the text surrounding the particular quote. 3.3 Description of the Samples 3.3.1 Survey sample The sample of students who completed the survey were split exactly between women and men (N=36 each) - the class itself was 48% female. Just less than half (44%) of all respondents were 25 years old (N=31), and 82% of respondents were under 30 (see Table 3.2). The average age was 27 years. The majority of the students named their social class background as upper middle class or lower middle class (see Table 3.3). I did not allow a "middle middle class" category to try to force some clearer categorization. I did not want to overburden respondents with demographic questions, so chose not to ask about what occupations or education levels their parents had. Therefore, I have only their self-reports about social class background. Perhaps most significant here is that only nine students (15.3%) claimed a poor or working class .61. background while fully half the respondents claimed a upper class or upper middle class background (50%, N=36).7 T A B L E 3.1 T A B L E 3.2 Survey - Student Gender Survey - Student Age Sex # % Age # V a l i d % C u m % Male 36 50.0 24 3 4.2 4.2 Female 36 50.0 25 31 43.7 47.9 26 8 11.3 59.2 T A B L E 3.3 27 8 11.3 70.4 Survey - Student Class Background 28 3 4.2 74.6 29 5 7.0 81.7 Class # V a l i d C u m 31 5 7.0 88.7 % % 32 5 7.0 95.8 Upper 3 4.2 4.2 33 1 1.4 97.2 Upper Middle 33 45.8 50.0 37 1 1.4 98.6 Lower Middle 23 31.9 81.9 40 1 1.4 100.0 Working 9 12.5 94.4 missing 1 missing Poor 2 2.8 97.2 Total 72 100.0 Other 2 2.8 100.0 Total 72 100.0 Almost exactly half of the respondents had no religious affiliation, while the majority of the rest were Christians (see Table 3.4). A small number named Sikh or Hindu religions and two students were Jewish. A third of the respondents were married or living with a partner while just over a third were in serious dating relationships. Just under a third were single or dating casually (see Table 3.5). All but one of the students identified as heterosexual, and only one student was a parent. Twenty (18%) respondents considered themselves members of minority groups, though three of those did not say on what basis. The 17 who identified the minority group they are part of all referred to racialized minorities such as Asian, Chinese, Indo-Canadian, South Asian and so on. About 30% of students in every medical school class for the past decade or so have been 'visible rninorities.' 7 I could not get official statistics on the class and age distributions among the third year students, nor their academic backgrounds or religions. . . . 62 . . . T A B L E 3.4 T A B L E 3.5 Survey - Student Religion Survey - Student Relationship Status Religion # V a l i d % C u m % Relationship # V a l i d % C u m % None 37 51.4 51.4 Single, dating 21 29.2 29.2 Protestant 17 23.6 75.0 Serious relationship 27 37.5 66.7 Catholic 9 12.5 87.5 Married, living Sikh 4 5.6 93.1 together 24 33.3 100.0 Hindu 2 2.8 95.8 Total 72 100.0 Jewish 2 2.8 98.6 Other 1 1.4 100.0 Total 72 100.0 Finally, there was some diversity in students' undergraduate academic backgrounds, though biological and health sciences still dominated (see Table 3.6). Most students named only one discipline in which they did undergrauate studies, though a few named as many as 4 disciplines. In total then, the 72 students named 115 academic backgrounds; of these 61% were in the biological and health sciences. A substantial number had some background in arts, humanities, social and political sciences, though these were still a minority (21%). Twenty-five students (35%) considered themselves "pre-med" while they were doing undergraduate studies. Of the 14 graduate degrees students held, 12 were in biological and health sciences (86%), and 2 were in physical and applied sciences (see Table 3.7). T A B L E 3.6 T A B L E 3.7 Undergraduate Backgrounds Graduate Backgrounds Discipl ine # % Discipl ine # % Biological, Biological, agricultural 46 40.0 agricultural 5 35.7 Health sciences 24 20.9 Health sciences 7 50.0 Arts, Humanities 15 13.0 Math, computers, Math, computers, physical sciences 1 7.1 physical sciences 15 13.0 Engineering and Political and social applied sciences 1 7.1 sciences 9 7.8 Total 14 99.9 Interdisciplinary 3 2.6 Engineering and applied sciences 2 1.7 Other 1 0.9 Total 115 99.9 .63 . Sixty-three of the 72 students were Canadian citizens and the other nine had dual citizenship. When asked an open-ended question about how they identified their ethnic origins, other than as Canadian, a significant number (18) did not answer the question or insisted they were simply "Canadian." Apart from these, the greatest number were of British, Scottish or Irish origin (N=19,31%). An additional 13 (21%) were of Chinese, Hong Kong Chinese, Japanese, Korean or Taiwanese heritage, and 6 (10%) were of Indian, Punjabi, or Pakistani heritage (see Table 3.8). Most respondents (N=59, 82%) were born in Canada, though only 26 (36%) had both parents also born in Canada. T A B L E 3.8 T A B L E 3.9 Students' Ethnic Origins Students' First Languages Heritage # V a l i d % Language # % Canadian 8 12.9 English 52 72.2 British, Scottish, Irish 19 30.6 Chinese, Sino-Tibetan 5 6.9 American 1 1.6 Korean 2 2.8 Chinese, including Hong Kong 10 16.1 Japanese 1 1.4 Korean, Taiwanese 2 3.2 Punjabi 4 5.6 Japanese 1 1.6 Hindi , Tamil 1 1.4 Indian, Punjabi, Pakistani 6 9.7 Germanic 2 2.8 German 4 6.5 Romance languages 8 2 2.8 Indonesian, Malaysian 2 3.2 Not English 3 4.2 Scandinavian 2 3.2 Total 72 100.0 Romanian, Hungarian, Polish 2 3.2 Italian, Portuguese 2 3.2 Jewish 2 3.2 First Nations 1 1.6 No answer 10 missing Total 72 99.8 The majority of their parents had come to Canada from the U.K., Hong Kong and China, though substantial numbers also came from other parts of Asia. Nineteen students (26%) did not have English as a first language; of these the greatest number spoke Chinese languages, while the next most common was Punjabi (see Table 3.9). 8 Following Statistics Canada census catagories, this includes Italian, Portuguese, Romanian and Spanish. .64. T A B L E 3.10 Country of Birth - Students and Their Parents Country of birth Canada United Kingdom Western Europe Southern Europe Eastern Europe Hong Kong, China Other Eastern Asia South East Asia Southern Asia Africa United States Oceania Missing data Total Respondent # % 59 81.9 2 2.8 1 1.4 1 1.4 0 0.0 4 5.6 1 1.4 2 2.8 0 0.0 1 1.4 1 1.4 0 0.0 0 0.0 72 100.0 # 28 11 2 2 4 9 5 3 6 0 1 0 1 72 Father % 38.9 15.3 2.8 2.8 5.6 12.5 6.9 4.2 8.3 0.0 1.4 0.0 1.4 100.0 # 26 11 6 2 0 11 3 3 5 2 2 1 0 72 Mother % 36.1 15.3 8.3 2.8 0.0 15.3 4.2 4.2 6.9 2.8 2.8 1.4 0.0 100.0 3.3.2 Student interview sample The students I interviewed were a fairly equal mix of men and women and ranged in age from 23 to 40 years old (see Table 3.11 and 3.12). They tended to be slightly older than the survey respondents, with an average age of 28.9 As in the survey sample, few self-reported as being from an upper-class background; collapsing upper and upper-middle class, though, more than half the sample falls into this category (see Table 3.13). The interview sample slightly over-represents students from working class and poor backgrounds, students who are married or living together, and students with previous Masters degrees. These three factors may be related to the older average age of these students. On the other hand there was only one student who was a parent. These students were similar to the survey sample in that just over half (N=14) reported no religious affiliation. Of those who did say they had a religious affiliation (N=ll), all were Christian denominations except for one Jewish student. Similarly this group reflected the survey sample in that virtually all identified as heterosexual; only one student interviewed identified as gay/lesbian. And the majority of the interview 9 Compared with an average of 27 years for survey respondents. . . .65 . . . sample had academic backgrounds in the sciences, including biology, biochemistry, biopsychology, and so on. One student came from nursing and one had a previous degree in an applied science. Only three had backgrounds in social and political science. T A B L E 3.11 T A B L E 3.12 T A B L E 3.13 Student Age Student Gender Student Class Background Age # Gender # Social Class # 23-25yrs 7 Male 11 Upper /Midd le 14 26-30yrs 12 Female 14 Lower /Middle 6 31-35yrs 4 Working 4 36-40yrs 2 Poor 1 Most students identified their cultural heritage as being "Canadian" or "American," which tended to mean their families were of European ancestry and came to North America some generations ago. I identify these as "old" European below (see Table 3.16). Those whose parents are of European descent (plus one student/s mother who was originally Australian) and moved to Canada, or students who immigrated here themselves, I call "new" European or commonwealth. One of these identified his/her cultural heritage as Jewish. Similarly, 6 students were of Asian heritage. Of these, one student's family had lived in Canada at least two generations ("old" Asian) while 5 had immigrated here with their families or were first generation Canadian ("new" Asian). Only two did not have English as a first language, though one other student had two first languages. T A B L E 3.14 T A B L E 3.15 T A B L E 3.16 Relationship Status Academic Background Cultural Heritage Relationship # Discipl ine # Heritage # Single, dating 8 Bioscience undergrad 17 "Old" Asian 1 Serious relationship 3 Masters in bioscience 3 "New" Asian 5 Living together, 14 Arts, social science 1 "Old" European or 10 married undergrad commonwealth Masters in arts, social 2 "New" European or 9 science commonwealth Other 2 . 66 . The major differences between the interview sample and the entire class (as reflected in the survey demographics), apart from slightly older average age and slightly more working class students, is representation of racialized minorities. A substantial number of students who completed the survey identified as Indo-Canadians and Sikhs; none were interviewed. Additionally, some Chinese-Canadian students suggested there is a sub-group of "culturally Chinese" students in the class, who identify strongly with their cultural heritage, speak Mandarin, and stick together in school. As far as I know none of these students were represented in the interview sample, though I did identify some of them and specifically requested interviews. 3.3.3 Faculty sample Unlike the student interviews, I did not systematically collect demographic information about each physician/faculty member I interviewed. I decided against this because these demographic questions are usually the ones that interview subjects take greatest offense to, especially about age, income and sexual orientation. I decided not to risk ruining rapport with these individuals to gather demographic information. Among the most relevant factors are gender and visible minority status, both of which I could see for myself. And I suspected that other pertinent information would come up during the interviews.10 In most cases, in response to the opening question asking them to tell me a bit about themselves they told me where they did their medical or academic training, when they finished it, how long they have been at this particular medical school and so on. Only two specifically stated their ages; the others I estimated from when they began or completed their training. Some mentioned relationship/marital and parental status, while others did not. In many cases I guessed from wedding rings and photos in their 1 0 In hindsight, I regret not collecting these data. I suspect my decision was partly influenced by my awareness that I was "interviewing up," as I discuss below, in section 3.4. .67. offices, and/or things they said.11 Similarly, while most did not mention ethnic /racial/ national origins, a few did and others I discerned from their stories about their lives, or from observation and listening to accents. T A B L E 3.17 T A B L E 3.18 Faculty Ages (N=23) Time at This School (N=23) Estimated age # Years at this school # 36-45yrs 6 0-10yrs 7 46-55yrs 12 ll-20yrs 9 56-65yrs 3 21-30yrs 7 66yrs + 2 mean time 15 years mean age 51 years Five participants were academic faculty teaching the basic sciences12; 18 were clinical faculty.13 Five were women, eighteen were men. All but two were white-skinned and were from the United States, Britain or New Zealand, or were Canadians of British or European origin. Twelve participants mentioned husbands, wives or partners; two women mentioned being divorced; I am unsure about the marital/ relationship status of the other nine. Two participants identified themselves as gay men; none identified as lesbian; three identified as heterosexual. Several others I assume from their marital statuses are heterosexual; the rest (8) I do not know. Ten of the 23 faculty members had adrninistrative positions ranging from heads of departments or divisions to Associate Deans. The sample of faculty members and administrators I interviewed was not a representative sample of the Faculty of Medicine; rather it was a purposive sample, chosen for characteristics desirable to my research. Students directed me toward faculty who have a significant amount of contact with undergraduate students, and who are interested in medical education in general. The three names I added to the list are 1 1 Obviously an imperfect method of data collection. 1 2 They represented anatomy, biochemistry, physiology, and pharmacology. 1 3 Their clinical areas included renal, pulmonary, pediatrics and pediatric oncology, medical genetics, family practice, surgery, neurology, ethics, internal medicine, infectious disease, endocrinology, anaesthesia, and psychiatry .68. physicians who have particular interest in the social impact of professional training on students. 3.4 Interviewing up One of the three research components for this study involved 'studying up.' I think most sociologists - most Canadians - would agree that when I contacted and interviewed physicians and medical school faculty members, I was researching a group of people whose social status is greater than my own. Not only were they all doctors and / or university professors while I was a graduate student, they were also all older then me, most were men, and undoubtedly all were wealthier than I. The usual concerns about the power of the researcher that have been so well examined by feminist and qualitative researchers in recent decades were reversed in this instance. In addition to awareness of my own power as researcher I had to contend with my awareness of the power of my interviewees. Susan Ostrander (1995) argues that issues of access and interview techniques differ in situations of studying up. She suggests that access is not especially difficult, but it is also true that elites normally have the power to shield themselves from exposure. According to Ostrander it is important to do background work and be well-prepared before attempting to gain access; to make contacts in the right order; to expect ongoing processes of being "checked out"; and to mamtain control over the research (1995:135). I found myself in what I thought was a background preparatory meeting on the way toward seeking access to my research site when I discovered that the administrator with whom I was talking was the person who would decide whether or not to grant me access. And from the discussion it seemed unlikely. I had stumbled upon the right contact completely out of order. Fortunately, I was able to pull credentials and documentation together on short notice, and was ultimately granted access. When I .69. arranged interviews I usually had to explain the purpose of the research fairly extensively before faculty would agree to an interview. In one case a faculty member said he had called my department to check on me before he called me.14 Throughout the faculty interviews, unlike the interviews with students, I remained aware that a complaint from any of the doctors/faculty members could likely end the research.15 While I did not feel control over the research was threatened, I did find myself altering the ways I conceptualized and described the research to make it more acceptable to medical school administrators. I found myself emphasizing the survey component, countering the assumed biased nature of the qualitative components with the assumed objectivity of the survey. I found myself broadening the types of student 'diversity' I was interested in more in line with the way non-sociologists might conceive of the issue: 'race,' class and gender became just three of a range of variables on which individuals might vary. However not only did this re-framing of the issues early in the process allow me to gain access, I think it also helped me to genuinely re-frame my investigation to begin from the standpoint of my informants. In terms of the interviews themselves, both Ostrander (1995) and Aldridge (1995) note that when interviewing elites status is continually being negotiated. Ostrander suggests that the interviewer must be appreciative but never deferential; must learn the language of the elites before interviewing them; and must maintain control of the interview itself. I think I may have crossed the boundary into deference when I failed to collect systematic demographic data on each faculty interviewee. More importantly though, in early faculty interviews I had a difficult time framing questions in terms of the language and relevances of the faculty without raising their ire. I tended to ask less challenging questions than I might have if I were not interviewing up. However, as the interviews progressed I learned to ask faculty to respond to things other faculty or 1 4 One medical student also called to question me about my stand on some political matters concerning the BCMA before he and his friends would complete the survey. 1 5 That may also have been true of complaints from students, but I did not preceive it to be so. .70. students had raised in prior interviews. That enabled me to frame challenging questions in their terms and even allowed me to distance myself somewhat from the question, constmcting a situation where one physician or professor was responding to another. Negotiating status showed mostly in maintaining control over the interview. Ostrander (1995:145) notes that elites are often accustomed to deference, to being in charge, and to talking easily and at length. The task for the researcher is to try to keep elites speaking to the research issues. I found that in interviews with faculty, unlike any others I have done16, my control over the interview was indeed challenged subtly. This started with scheduling the interviews, when I was usually contacted by a secretary or receptionist who told me when Dr. X would see me. Frequently I was kept waiting, and interruptions during interviews were common. At the outset of the interview, faculty often commented on the consent form, dismissing its importance and indicating how many of these forms they themselves have composed over the years. In contrast, most others I have interviewed have taken consent forms quite seriously. One physician started right in discussing my topic without signing the form, which meant I could not record the conversation until I interrupted her to please read and sign the form. In a few other cases I was quizzed about my interest in the topic, and found myself estabkshing my credibility by explaining about having lived with a medical student. Lastly I did indeed find that some faculty spoke volubly and at length without ever really answering my questions. They were also unusually willing to dismiss the issues of interest to me as unimportant and tell me what the important issues were. Some clearly had their own agendas concerning medical education that they hoped to advance through my research.17 On 1 6 Not just the 25 student interviews, but also 45 interviews for a concurrent study on diet and breast cancer, and a few dozen for other projects in the past. 1 7 Which is fair enough. This is one of the few things a researcher can genuinely offer back to the people he/she interviews. M y point is not that the faculty had strong interests, but rather that they felt more entitled to put them forward than has anyone else I have ever interviewed. .71. the other hand, some faculty allowed my questions and their own thoughtful insights to lead us both in challenging, thought-provoking directions. 3.5 Summary All knowledge is socially located. Starting research from the vantage point of particular human participants allows you to see some things and not see others. The starting point determines which relevances structure the project. In this research I started primarily from the standpoint of students who have written and expressed their accounts of being on the margins in medical school. Those relevances meant starting from the assumption that medical students may have aspects of their identities that do not fit easily with the new medical-student identity they are taking on. The non-random sample from a survey of an entire class, at a key point in their professional socialization, allowed me to explore the extent to which students feel conflicts and congruences among their multiple identities. Interviews with 25 self-selected students, many of whom were particularly interested in the topic, allowed me to probe more deeply into issues of difference and conformity in medical school as they who discussed their thoughts, experiences and reflections. Finally, though interviews with faculty and physicians were subject to the particular constraints of 'interviewing up' they also provided yet another vantage point, one that has the disadvantages of distance and hierarchical relationship as well as the advantages of longevity and the opportunity to observe patterns over time. . 72 . Chapter IV: Becoming A Medical Student, Developing A Professional Identity For most medical students, a remarkable and important transformation occurs from the time they enter medical school to the time they leave.... They become immersed in the culture, environment and lifestyle of the school. They slowly lose their initial identity and become redefined by the new situation. Medical students have to look for something to hang on to. And that something is provided: their new identity as 'doctor' (Shapiro, 1987: 27). As was reviewed in Chapter Two, much of what we know about students' coming to identify as medical students, as future-physicians, is derived from research conducted when students were almost exclusively male, white, middle or upper class, young and single. When women and students of colour were present it was usually in token numbers. Even when their numbers were substantial, as in Sinclair's (1997) ethnography, the possibly distinct processes of professional identity formation for these students were largely unanalyzed; additionally, the potential impact of their presence on the professional socialization of the heterosexual, white, male students was also unanalyzed. So what does becoming a physician-to-be look like in a medical school of the late 1990s? The students in this study clearly feel they are on their way to becoming doctors. In response to an open-ended survey question about what they enjoyed most about medical school, some wrote in the fact that they are beginning to become doctors, are starting to fit in with the profession, not just with their classmates. • I feel my talents and strengths fit in with the medical profession. • Turning slowly into a clinician. • Most of the aspects of becoming a doctor - dealing with patients and other health care professionals, learning about the human body and diseases, doing procedures. In his 1978 study, Robert Coombs found that when scoring themselves on a 7-point scale from layperson (1) to doctor (7), even first year students had a mean score of 3.4 out of 7. Each year the average score increased by 0.6 or 0.7, until in the third year ...73... students averaged a score of 4.7 out of 7, and by senior year 5.4 out of 7. They saw themselves as ever-closer to being doctors, but not quite there yet (Coombs, 1978: 221). Even in their first year, though, students saw themselves as almost halfway to being doctors. On a similar scale in this study students surveyed averaged 4.5 on a 7-point scale, ranging between 2.6 and 5.5 More than half the respondents (54.3%) placed themselves between 4.6 and 5.5 out of 7. Another 28.6% scored themselves between 3.6 and 4.5, while the remainder fell between 2.6 and 3.5 out of 7.1 had anticipated that white, middle-to-upper class men, of average age, would feel most at home in the medical school and would be slightly more likely to see themselves as 'almost a doctor.' In fact the reverse was true. The mean for women (4.6) was slightly higher than for men (4.4) though not significantly so. The mean for students who self-identified as 'minorities' (4.6) was slightly higher than for non-minority students (4.4) though again the differences did not reach significance. Upper class students thought of themselves as least far along the continuum toward becoming a doctor (mean 2.9), followed in order by upper middle class, lower middle class and working class students (mean 4.9) (F=3.3, d.f .=5, significant at p=0.01)1. The one pattern which matched what I expected was age: the youngest and oldest students saw themselves as having further to go toward becoming doctors than did the 25 to 30 year olds (difference not significant). 4.1 Professional Identity - Whatls It? It was not easy for most of the medical students and faculty I interviewed to articulate what the medical professional identity is that students are being socialized 1 The means need to be interpreted with caution. The number of students who identified as "upper class' is very small, so the mean of 2.95 may be misleading. However, even without that group the overall pattern holds true, with students of lower social class background tending to see themselves as further along toward being doctors than students from higher social class backgrounds. . 74. into. Nonetheless, some elements are cnscernible, including an approach to medicine that sees it as a vocation, a calling to service provision rather than a mere job. Other characteristics include being a 'good team player;' taking a particular position in the professional hierarchy - vis-a-vis other medical staff, other health care personnel, and patients; adopting some form of professional ethics; identifying with the concerns of the profession and with professional colleagues; and taking on a professional appearance. In some cases differences among the students - by gender, 'race,' class, and so on -were significant, in some they were not. Though I will allude to some of these differences here, I will not explore them fully in this chapter. The impact of social differences in medical education is a central theme in Chapters 5 and 6. 4.1.1 Medicine as a calling, a vocation One hallmark of a profession is that it is expected to be a vocation, a calling, not just a job like any other job. I mean here vocation in the Weberian sense of passion, responsibility and devotion to a cause; the vocation should be one's life, should nourish one's inner being. Weber sees the 'calling' to science as a passion to the point of irrationality. The scientist should be devoted to the task of science for the sake of knowledge itself (Weber, 1958). Similarly, some commentators describe medical professionals as a kind of science-based priesthood, and medical socialization as a kind of doctrinal conversion into a sacred identity (e.g., Haas & Shaffir, 1987). It involves selection and preparation, initiation, testing and ritual ordeals or rites of passage. "Symbolic changes in wardrobe of costume, props, script and demeanor both affirm the new role and identity and help to sustain it" (Haas & Shaffir, 1987: 4-5). Becoming a professional involves a series of ritual performances through which initiates learn to play the professional role. "The professionalization process... involves dramatic rituals which symbolize the transformation of the 'called' into 'the chosen.'" (Haas & Shaffir, 1987: 36). This notion .75. of "the chosen" and medicine as a "calling" are key - though contested - elements of a medical professional identity. There were differences of opinion among medical faculty members in this study about whether medicine is appropriately thought of as a vocation, a calling, or whether it is better understood as simply a job. Two faculty members were particularly clear about the vocational aspect of medicine: Dr. B.: Many people get into specialties they find themselves unhappy in. And they can't get out of it. And then they will be just doing medicine as a job, as opposed to a calling which we like to think it is. Dr. T.: I happen to come from a tradition that believed that medicine is a calling and that if s a privilege to serve. And I actually get irritated with people who feel that they need to have a balanced life of kayaking every weekend and so on. Two faculty members spoke about their concerns seeing older students admitted to medicine. Their understanding of medicine as akin to a calling is apparent in their notions that medical students have to "give back" to society through service: "your debt to society is a good forty years." A related concern was shared by several faculty members - namely that students these days are less willing to put in the hours they should. Students treat medicine as a normal job, when it requires a much deeper commitment. Dr. B.: I think if s a little disappointing, quite frankly, to hear tilings like, T prefer to take up this particular aspect of medicine because I'll always be off at five o'clock and to hell with....' Medicine has suffused my life in every way. And I don't think that my patients were any the worse for that. In fact, in some ways, I think they were better for it... And I think it's a little disappointing to hear that sort of thing. The notion of medicine as vocation was expressed most by students as fear that they were not as immersed in medical school as their classmates were. Several wrote in comments on the survey to the effect that, "I'm not as 'consumed' by medical school as some of my classmates are." A very few students who were interviewed described their ideal of 'a good doctor' as someone who approaches medicine as a calling, putting their ...76... patients above all else. Cindy, for example, referred somewhat scathingly to some doctors' "just treating it as a job, rather than as, you know... a calling or helping those in need." Most students, though, thought that the medicine-as-vocation approach led to an unbalanced lifestyle in which the doctor him/herself would not be a healthy person. They argued strongly that medicine should not take over your life, should remain "just a job." Valerie: I would have to balance family and practice, and I wouldn't want to let my practice overrun, or take over family time. The odd occasion I guess you're on call and you have to go, but I'd want to keep a good balance. I really think that having a balance just mentally makes you more, a better person, I think. Martin: [Medicine as a calling,] I don't agree with that at all. No. I don't think if s fair to do that to anyone. And I think if you talk to a physician who has that attitude they might be happy in their 30s and early 40s but if s going to tire them out into their 50s and 60s. If s gonna break up their family life, if s gonna break up their marriage, and they might think they're happy but they're just burying themselves in their work, I think. I don't think anyone should expect to have medicine as their life. And . . . I don't think they should expect other people to have that same attitude There's a lot more to life than medicine. I'll change careers before I let that happen. Faculty saw this focus on 'a balanced lifestyle' as a change among medical students in recent years. Many faculty commented that students are placing more emphasis than ever before on the lifestyle, hours and call schedules attached to particular specialties when they are making decisions about residencies. Dr. A.: A lot of them choose their careers around lifestyle, quality of life. So there's more consideration about that than I think there used to be.... They want a niche that is comfortable for them and one in which they can do their tiling. Have their families if they want or not or do other things. This seems to counter the notion of medicine as a calling, as something a student would/should wniingly allow to absorb his or her every waking hour. . 77. Some faculty, though, expressly argued that this move toward greater balance is a positive trend, that physicians definitely should cultivate more balanced lifestyles than has traditionally been the standard. Dr. N.: There are some wonderful physicians out there who have completely impoverished personal lives. They love what they do, and they've either never committed themselves to anyone or they couldn't find anyone, or they've had just a series of relationship failures because of their complete dedication to medicine. Some of them are exemplary teachers, researchers, clinicians and often loved and regarded because they're omni-available.... I see [lots of] physicians whose personal relationships are unraveling. Good people, well meaning people but their spouses can't do it anymore. Or their spouses are okay but their kids are in all kinds of trouble. Some also commented that this notion of balance is not taught particularly well in the medical school. Dr. U.: We don't help them very much in terms of lifestyle. If s almost like we have this older view of, listen this is the torture chamber, this is a gauntlet of fire and you've gotta go through it, like we all did. The old story about when I was an intern we were on call one in two. And there's almost a badge of honour associated with it. So that the ones that are here at six in the morning and stay 'till late at night, 'Oh that student is such a great student,' you know. 'Works his tail off.' But thaf s not a good lifestyle. And I don't think we show the students that maybe some of us don't like to work so hard either. All the role models are the ones that are here 'till all hours and you know - 'the dedicated physicians.' And thaf s the physician thaf s usually divorced and doesn't even know his kids. Has got ulcers and heart disease and dies early when he retires. One clinician suggested students today are asked to do two completely opposing things: devote their time to medicine as if it were a vocation permitted to suffuse their entire lives, and maintain balanced connections to their wider communities. 4.1.2 Becoming a 'team player' The concept of 'team-player' became a central metaphor in interviews with faculty as they talked about students learning to be medical professionals. Interestingly, it does not have such significance in most of the prior research on medical socialization. . 78. In the most recent full-scale ethnography of medical school, though, by Simon Sinclair (1997), the concept of team is central to his understanding of the development of co-operation and competition among medical students. He extends Becker et al.'s (1961) observation of the development of student co-operation to set standards for their work, arguing that official and unofficial teams within the medical school are based on internal co-operation with one another in competition against other teams. Sinclair focuses on the drama teams that put together plays and skits for public performances; the rugby team and other sports teams that represent the school and form the backbone of its unofficial social life, especially at the school bar; and the teams that organize and participate in "rag week" activities to raise money for charities (1997: 96-133). These he calls "representative teams." In addition there are "official teams" such as small groups for dissection or clinical rotations, and "official-purpose teams" that students form themselves to work together to divide up their labour. In my study, the sports teams were also important, though my research methods did not include observation of the students and therefore did not fully capture this aspect of their socialization as Smclair's study did. Nonetheless, well over half the students surveyed said they were involved with intramural hockey or other medical school team sports. Hockey players (male and female) were among the most frequently named 'cliques' on the survey, and a few students wrote that hockey had been one of the most enjoyable and important aspects of medical school for them. The significance of this aspect of medical school socialization may be greater than first appears. The concept of the team extends beyond the ice, or playing field, to the classroom, the hospital, and eventually the clinic or operating room. Several faculty referred to the concept of team when talking about students' becoming members of the medical profession.2 One clinician, who was trained in Britain, claimed the Dean of St. ^ An alternative, and much less common, metaphor is that of family. Sinclair says students in his study were given an introductory lecture in which they were told, "You've become part of the family, a very ...79... Mary's Hospital, a teaching hospital in London, deliberately recruited rugby players as medical students: "His claim, which was a bit exaggerated, was that if you work and you get on with people, playing rugby and drinking beer and so forth helped you get on well with patients." This dinician believed, "Sports is a team game and medidne is a team game." He argued that, "one really doesn't want loners in medidne." While others drew less direct links to sports teams, nonetheless the team concept was pervasive. Usually it was simply the description of medical students as "good team-players." The term sometimes seemed to mean slightly different things, though. Sometimes it was used to refer to the medical team, the clinidans, residents, student interns and student derks involved in the care of a patient. Dr. T.: [Once] you've contributed you're part of the team and then you become 'we.' Dr. M.: That sense of belonging, I think, is a sense of belonging to the profession as much as anything else. You feel you actually are now doing what you wanted to be doing. What medicine's all about... you're part of the process of health care Even if it's tenuous, even if if s just at the bottom end of the totem pole. I mean, you haven't a lot of the responsibility, but at least you're connected with the team. In other cases faculty made it explidt that they were talking about becoming members of the broader health care team of medical staff, nursing staff, sodal workers and so on. Dr. F.: They interact with the multidisdplinary team When you come in in fourth year, you're still probing what does the sodal worker do? What does the psychologist do in the dinic? What does the secretary do? And all this is a team.... So at the end you start figuring out what are the interactions between different professionals and how they complement each other... and where you fit in the team as a future physidan. Dr. U.: I think that the nurses here are . . . terrific at helping these students. . . . My feeling is in general that they're really a team, they have a real team concept Once they get on the unit then they find that the nurses kind of depend on them and they depend on the nurses and there's kind large family, which will nurture you and look after you" (1997:101). Similarly, one clinician I interviewed told me his own class's 25th reunion "was like my brothers and sisters came home." . 8 0 . of a, it reaches kind of, 'Hey we're on the same team here we, we gotta help each other. 'Cause the patients are most important.' Students' learning their place in this larger team, then, is seen as key to becoming a medical professional. A few students also talked about the importance of being a good "team player." In particular it came up when discussing the desire to present a united front for patients, to not display dissent among the ranks. It was sometimes discussed as not wanting to undermine the patienf s confidence in their doctor or doctors in general - a sort of generalized saving face for the profession. Josh: You have to go along with some things and do them but this isn't how you want to do it. But if s not your place to say, 'I'm not going to go along with this,' you know? You just have to go along with it, like in front of the patient, you know? For teams it wouldn't be good to have the ranks sort of arguing amongst themselves about the best approach for patient care at times. Or as to what to do at certain times. So in front of patients you have to sort of say, 'Okay well everyone holds the same general ground,' and then later on you'll be able to discuss and decide whether if s going to be different or not. mterestingly, this form of face-saving may also contribute to a perception among patients of physicians' closing ranks, protecting one another from scrutiny. Josh's description brings to mind Goffman's notion of "performance teams," "any set of individuals who co-operate in staging a single routine." (1959: 79). As Goffman argues more generally, the members staging a medical performance have to display a substantial amount of agreement, or minimally roles that will fit together into a coherent whole. "Open disagreement in front of the audience creates, as we say, a false note" (1959: 87). In Goffman's terms, such disagreements must be expressed "backstage," just as Josh describes above. Two underdeveloped elements of Goffman's dramaturgical analysis (1959) are highly relevant here: conflicting roles, and the assumption of a consensusal script. When Goffman talks about discrepant roles, he does not mean playing two roles that diverge widely, but rather having information that one shouldn't have given one's . . . 81. . . position in relation to the performance. But from Sinclair's (1997) description of medical school teams I get a clear impression of the exclusion of students whose roles might be discrepant with the mainstage performance. He states on several occasions that non-white students and women are largely absent from the teams he analyzes. The bar, a focal point for team-building and team-performances, is habituated by white students, mainly men, mainly rugby players. The Asian students, he remarks, frequent another bar entirely. The rugby team, Sinclair's archetypal team, is exclusively white men from upper-class schools. The drama troupes are composed of men and women, but almost no non-white students, and then only in non-acting roles. In Chapter 6,1 will discuss the extent to which 'race' and gender, among other social differences, affected the ability of students in my study to be fully members of both unofficial and official teams - and how they manage being member of multiple teams with multiple front and back stages. The second underdeveloped aspect of Goffman's framework that is immediately relevant is the absence of a director and assumption of a consensual script. While he does discuss the backstage negotiations that go on to produce the united front of any performance, he continues to stress that team performances rely on the "reciprocal dependencies," of their members. This does not adequately address the power hierarchies entailed in a setting such as medicine in which reciprocity is rare. I wonder ii the widespread adoption of the concept of team among medical school faculty members is a way of denying the hierarchy that exists in medicine while accepting the notion that people fill many different positions with distinct jobs. The team metaphor may illustrate a desire to level the hierarchy, or at least not acknowledge it as hierarchical. .82. 4.1.3 Working out relationships with others / learning the hierarchies One of the themes that came up consistently throughout the interviews was the need for medical students to learn their place in a complex hierarchy. Some saw this as an appropriate step in students' professional development; others saw it as a necessary evil; still others saw it as an abomination and fought hard against replicating hierarchical structures. Three somewhat separate themes emerged from the interviews: 1) the position of medical students within the medical hierarchy; 2) the relationship of medical students to the larger hierarchy of health care workers; and 3) the hierarchical or authoritative relationship of medical students and future-physicians to patients. Hierarchies within medicine Virtually everyone agreed that there is a clear hierarchical structure within medicine, and medical students are on the bottom. One of the key aspects of becoming a medical student is learning to negotiate this hierarchy. Dr. U. sees it as a fine and important tradition, facilitating the communication of knowledge, experience and skills to those following behind, and allowing more junior members of the profession to be protected somewhat by more senior members. Dr. U.: You're always taught by the person above you. Third year medical students taught by the fourth medical student Fourth year student he depends on the resident to go over his stuff. Resident he depends on maybe the senior or the chief resident or the staff person. And so they all get this, this hierarchy which is wonderful for learning because the attendings can't deal with everybody. So the one above helps the one below. Thaf s a very strong tradition in medicine. He also thinks it important to help junior members learn to accept their changing position in the hierarchy as they move upward: Dr. U.: I always tell the final year residents when they're going for their oral exam, I say the year before you go for your oral exam you start calling all the staff men by their first name because you have to get into the mode of I am no longer a resident, I am [a specialist], these are my colleagues and they are not my bosses anymore. .83. Dr. J., too, referred to a "time at which [students] need to start clicking over to being part of the power structure" themselves. The way most faculty talked about the hierarchy in medicine made it seem absolutely commonplace. They described the compliance it inculcates in students, who are afraid to question or critique their superiors. Dr. T.: Because by and large medicine is a highly structured hierarchical kind of thing you tend not to question. Dr. G.: Part of their concern is the fact that if they don't appear compliant and so on that they will get evaluated poorly. And if you get evaluated poorly then you might not get a good residency position. And so there's that sort of thing over their shoulders all of the time. I don't think i f s necessarily true, but i f s the fear. Students, understandably, were far less accepting of the hierarchy - and particularly of their place in it. Peggy: There's this whole staff/ student sort of thing.... Oftentimes I feel like I'm being treated like I'm very, very low on the totem pole Thaf s a different experience to have people, you know, looking down. And having to be the proper little medical student and wear our white coats and be looking up to the staff person and pretending that i f s four o'clock in the morning and this is exactly where you want to be and you wouldn't think of wanting to be anywhere else, you know? And sometimes I find myself getting caught up in that. I don't like to think that I'm being dishonest but I do find myself talking to staff people, playing the game in a way... almost acting younger than I am.... I hate having to pretend that I'm somebody that I'm not, you know. For the students, a central piece of learning to be a good medical student seems to be about learning not to challenge dinicians. Though virtually every student described seeing things on the wards that they disagreed with, as long as there is no direct harm to a patient the students usually stay silent and simply file away the inddent in their collection of 'things not to do when I am a doctor.' Most students are very dear that this is their current student role: they are there to learn, not to critidze. Mark: I remember seeing things that were wrong. I didn't challenge. But thinking back, I kinda wish I did. Suppose i f s part of the learning .84. process. Next time I probably will challenge, but if s kind of a shame that -1 saw some things that might have made a patient feel uncomfortable. I don't think any harm was really done, but people were feeling a bit uncomfortable, which was unnecessary. But, at the time, this guy was way above me. He had an evaluation in his hands. He really had so much power over me. And in medical school we're always tMnking about letters of reference etc, so you never want to step on too many people's toes If s a really tough situation to be in, when you're there though, 'cause - just the power he has over you. And if s not even threatening grades or threatening evaluations or stuff like that, but just the power that he's someone who's teaching, and you're supposed to respect what he's doing. And you try, sometimes you go a bit too far and try and force yourself to respect what he's doing, when in a sense you shouldn't. You should be a bit more critical. Lily: Lots of times there are, just the way people are treated sometimes I disagree with, just lack of basic human kindness, and it upsets me. And depending on, actually I don't know if I've ever called someone on it. I've called a couple people on it, like residents or something, just kind of mentioned it as a conversation, but as a student if s difficult to sort of question the authority of others. A few students had more thoroughly internalized the notion of not criticizing clinician. They saw it as part of being a good "team player." It is one thing to critique superior or colleague behind closed doors, but never in front of a patient. Denise: In an interaction between a doctor and patient, I've never seen a doctor criticize another doctor's work. The most that they'll ever do is say something like, 'Yes, well, I'm your doctor now,' or, 'I'm sorry, I can't comment because I don't know all the factors that went into that decision.' I haven't ever seen them say, 'You're kidding. He didn't see this?' or whatever If s very true that you don't know all the factors that were presented to the other doctor, so I don't criticize other people's decisions.. .. People have to trust their doctor to do something, and it doesn't help the therapeutic process if they don't feel they can trust it 1 know how important it is for [patients] - they don't know all the facts, they don't know the anatomy, they don't know the problem - for them to feel like they're with somebody competent. So I would be quite reluctant to destroy that confidence they have. Some students, then, had fairly entrenched understandings that you never criticize another doctor. To my mind this indicates an important component of becoming a professional. . 8 5 . Though the professions are self-policing, there is also often an unspoken "code of silence" as Janis put it. Speaking ill of a professional colleague may entail risk to yourself, may put your professional judgment on the line, and/ or may weaken the shared understanding of professional autonomy. Janis: Thaf s the first rule, never talk bad about other doctors.... If s just something you don't do. 'Cause it can come back to you, you know. Especially as a student. Valerie: I would hope that if I ever saw something blatantly sexist or racist or wrong I would hope that I would say something. But, you get so caught up in basically clamming up, shutting up, and just taking it.... Is it going to ruin my career, am I gonna end up known as the fink, am I gonna not get the [residency] spot that I want because I told...? Mark: As students we all critique the professors and our attendings.... But, at the same time, I don't think we'd ever do that in front of a patient. If s never been told to us not to. But most of us get the feeling that we wouldn't do that. Or even if a patient describes something their doctor has prescribed to them or a treatment they've recommended which you know is totally wrong, maybe even harmful, I think most of us just, unless it was really harmful, would tend to ignore it and just accept this is the doctor and his patient. What happens between them is okay. I think. This seems to be a key aspect of developing a professional identity, a sense of self as aligned with the other members of the profession rather than with other laypeople and patients. To return to Goffman briefly, this may be the process of learning to maintain the performance of the team in front of an audience. He suggests (1959:89) that when a team member makes a mistake, the other members of the team must suppress their desire to immediately correct until the audience is no longer present. Finally, though the students indicated that the hierarchical structure affected all of them in the same ways, faculty suggested there may be some gender differences. In particular, though the men implied - by their silences as much as their comments - that when students reach full professional status the nature of the hierarchy levels off, two of the women indicated that their struggles with the hierarchy internal to medicine are ongoing. Both are well-established in their fields, known and respected by colleagues .86. internationally. One talked about being dismissed at a conference because she identified too much with her women research "subjects," despite her clear scientific credentials. The other woman described continually being treated differently from the men: Dr. R.: I would go to these big symposiums and I was invited 'cause I was this brilliant scientist. And [we'd be introduced as] Dr. John Smith, Dr. Joe Black, Sharon Rose, Dr. Frank Clark3- I kid you not!... All the men got treated one way and I did not get treated the same way. So there is a gender issue. Hierarchies among health care staff In keeping with the team concept discussed earlier, students on their way to becoming full-fledged medical professionals need to learn where they fit in relation to other health care workers, including nurses, dietitians, pharmacists, technicians, physiotherapists, counsellors, receptionists, and so on. Dr. D. called hospitals "very complex social hierarchies," where "subtleties are important." Several faculty discussed the importance of medical students' learning to get along in these complex hierarchies. Dr. L: I believe in medical school we should teach our students how to approach nurses, to watch from a distance, see if they have the time, be very polite, be very nice, be very receptive, be very conscious, you know, and, and see if they have time or something. Find the time when you can talk to them and so on and so forth. So it's all part, probably, of that process. Dr. I. suggested that all medical students should have to spend time in the role of social worker or nurse or pharmacist or mopping floors, to learn what the other essential hospital work entails. Dr. I.: If you clean up an operating room once then you know what's involved to clean up an operating room. You know whaf s involved in taking a patient up there. Then you never scream at people, 'Why does it take so long...?' You would know how long the elevator takes, you know how to clean, change the sheets and clean things-... All medical school students should have a summer job doing sanitation or whatever.... 'Cause most of the time we don't know whaf s involved there. Thaf s why most of the time we don't appreciate the work of other people because we None of these are actual names. .87. don't know how much is involved in the work of other people.... It would solve a lot of interaction problems. Students were clear that there were differences between their roles in the hospital and those of other health workers. But this was of less concern to them at this point in their training than was establishing their relationships to other medical staff and to patients. As Erin said, "We're not expected to do nurse things" - but she connected this primarily to how students should relate to patients. Relationship to patients One of the most contested topics that came up in the faculty interviews was about the relationship medical students should strive toward vis-a-vis their patients. In particular there were widely diverging views on the degree of professional authority that physicians - and by extension student-physicians - should display. Some faculty drew a very clear connection between professionalism and the "emotional distancing" that Renee Fox documented in 1957. They believe it essential that students learn an appropriate distance from patients. The relationship between a physician and patient is different from the ones other health care staff have with patients, and is based on specific skills and knowledge. Dr. E.: Unfortunately with professionalism also has to come a distancing. . . . I'm not my patients' friend, I'm not their neighbour, I'm their doctor. Within the professional job that you have to do, one can be very nice to patients but there's a distancing that says you're not their friend and you're their doctor. [...] I mean nurses and doctors have an entirely different body of knowledge [Nurses] are not taught differential diagnostic skills. The patient develops chest pain they call the doctor. Meantime the nurses try to deal with the patienf s discomfort themselves, but the doctor has to come and deal with the chest pain. I think the medical students just can't see through it. They just can't see their eventual role will be appropriate. Another clinician described this professional distancing as a "veneer," a "hard shell" that is adopted by physicians and by students, "as a necessary way of dealing with feelings they don't have other ways to deal with." She does not advocate it, but does .88. understand it. Another female clinician recalled her first realization of a need for professional distancing. She felt herself being drawn into the hysteria of a parent of a very ill child, and realized, "I'm not gonna be any use whatsoever if I cry." She described it as "a total click of I'm not of any use to this family if I get involved with them. I want to be sensitive... [but] I only become of use if I can put some distance so that I can function." Several faculty members rejected this approach to medicine in favour of one based in egalitarianism. Dr. V.: Thaf s [professional-distancing's] the easiest way to deal with it. But I reject that way of dealing with it. As much as possible the patienf s concerns are more important than my medical concerns, in other words when I'm seeing a patient I have to try to get into understanding whaf s bothering them. And in fact if s a harder job, I mean my concept is I need to understand well enough so I can help them to understand. 'Cause thaf s the process of healing is their self-understanding. They raised the issue of power, talking about recognizing and leveling or sharing power with patients. They emphasized that clinicians need to be able to hand-hold, to care, to know their patients as something more than "The liver in Room 207." They stressed the importance of communication skills, not as secondary to good clinical skills, but as "a matter of life and death." Patients visit a doctor with one complaint as a way of feeling them out. If they feel comfortable, they may raise the more serious concerns they are afraid to mention. In short, these faculty members rejected the image of distant professional. Dr. J.: [This university] is obsessed with prestige, this is the mark of our excellence is how prestigious we are. So we try to create medical students who look successful. Well for many patients thaf s a problem. If you're having to explain to your physician things that involve admitting you've really made a mess of your life, if s very hard to do that to somebody who looks like they'd never make a mess of anything. If s much easier to do that to someone who looks a little more relaxed who doesn't look like they're trying to impress you.... The idea that the dress of the business community is somehow better than the dress of the labouring community [is] simply bigotry. .89. The issue of power between doctors and patients is a crucial one, and one that came up surprisingly little in the interviews. Only five faculty members talked about such power, and none of the students did. As students are learning their place in a complex series of hierarchies, their focus is on the hierarchy within medicine, the hierarchy which will determine whether they pass or fail, whether they become doctors. In that hierarchy they are at the bottom. With all of their attention on their performance in front of their superiors, they lose sight of the fact that within another simultaneous hierarchical relationship, that between medical staff and patients, they already have considerable power. Students told me story after story of their own powerlessness, their inability to confront their own humiliation or the humiliation and ill-treatment of patients at the hands of clinicians. They told almost no stories of the powerlessness of patients. As I said, only a handful of faculty talked about power in the physician-patient relationship. It is tempting to read more into an apparent gender difference than my sample size warrants. Four of the five women faculty mentioned power issues. But one woman undermined her comments about the need for mutual respect between a patient and doctor and the need to recognize that knowledge is power, by talking scathingly about some pregnant women as "real granolas who have no idea whaf s good for them" and have ideas that "are frankly quite unsafe for both them and their babies." Another woman was by far the most adamant person I interviewed in her belief in the need for clear professional distancing and an authoritative relationship to patients and other health care staff. So three of the five women had a sustained critique of power-over relationships to patients, compared with two of eighteen men; while not conclusive evidence of a gender difference, it is suggestive. I will look more at how gender affected students' relationships to authority in Chapter 6. What seems to make this issue complex is the interrelationships among power, prestige, elitism, authority, specialized knowledge, and responsibility. Students clearly .90. acquire increasing amounts of knowledge and responsibility, and that brings with it a certain degree of authority, at least in relation to laypeople. The line between that professional authority and elitism or power-over is less clear and seems to be drawn differently by different professionals. Overall, the degree of authority, status, prestige and power a budding-physician adopts in his or her interactions with patients seems to be a complex decision.4 The standards are widely different from one practitioner to another, and even for one physician may vary according to the patient; it is little wonder students find this difficult. It seems likely there is no right answer for everyone. It may depend on individual personality. It may depend on gender, with men granted authority readily while women need to gain and secure it for themselves using white coats and titles alongside their specialized knowledge and skills. Dr. R.: If you need a white coat to get respect then you've got some insecurities and some other problems. And I do believe if there were a bunch of women of my generation we really, they had to be really hard as nails to get respect. That was the way they learned to get it and I don't particularly want to see us model for the future but that is how they functioned. And if s hard for me to judge that.... Medical students need many different models. What seems clear is that it is a difficult balance to strike. Clinicians may believe strongly in egaktarianism, but still find it painful to work that way - though differently damaging not to. Dr. R. confesses she doesn't always know the answer, how to find a balance. Dr. V.: If s very hard though. To allow yourself to feel is to make yourself vulnerable. And that's a hard way to be. Yeah. I: Easier to learn the veneer? Dr. V.: Oh yeah, yeah. And the veneer gets very thick. In fact it gets so thick that family and friends can't break through it. You know and which is one of the reasons partners of physicians have a really rough time. 4 I did not have a specific question on this in the interview guide. The theme emerged after about 5 faculty interview; after that I raised the issue of hierarchy when faculty members did not bring it up themselves. .91. Because they don't really know who their partner is anymore if you don't watch out. So veneer once it gets up is really, really hard to let go of. Dr. R.: I think you're most effective when you intuitively do understand where that person's coming from. You have to somehow open yourself up enough but protect yourself from being overwhelmed. If s a very fine balance. The reason so many doctors become callous is because if s a very hard balance to find If s really a fine balance. I don't know the right answer. Dr. W. argues that clinicians should dispense with professional distancing, but only when that is in the interest of the patient - which takes practice to determine. 4.1.4 Taking on professional ethics Faculty had surprisingly little to say about the issue of professional ethics, given that a voluntary code of ethics seems to be a cornerstone of professionalism. Psychiatrists were most likely to discuss the struggles students have to learn professional boundaries. Students on the other hand, spoke of professional ethics when discussing what it means to be a professional. Some described explicit instruction about professional ethics, fairly straightforward lectures about standards of behaviour. Students seemed to have thought most about ethics when the standards of practice they are being taught contradict their own religious beliefs - in particular Christians who feel medical secularism contradicts their ethical beliefs as Christians. Some students said they would apply the guidelines they have been taught, almost in a formulaic way, while others spoke of needing to work out their own ethical stances, set limits for themselves, and recognize their own boundaries. Cindy: Even though we may be Christians, we're living in a secular world, and we're professional, too. So you have to be careful not to -you're in a position of power, so you know, you're not supposed to, like, mislead or lead at all the patients under your care according to what you think is right, based on just your values or beliefs. It should be more of a medical direction. Like, give them the pros and cons and let them weigh them for themselves. If you want my personal opinion you can ask me. .92. I: So because you're a professional, you aren't free to express your moral convictions in the moment? Is that right? C: Yeah. Like, if someone asks you to perform an abortion on her, you can say no, and refer her to another doctor. Doug: In my last elective the doctor wanted me to do a lumbar puncture on a patient. And I'd seen it before, hadn't done it before, and he said, 'Well, if you've seen it, that's all, you know, don't worry. You go in and you're gonna do it.' He said, 'I'll be in the room, but I don't even want the patient to know that I'm a doctor. You're gonna be the doctor. You're gonna do it.' And I just said, 'No. I'm not gonna do that,' 'cause I had seen it but I hadn't seen it the day before. It had been several months before. And I wasn't comfortable doing that. And I just said, 'I wanna be able to talk to you during the procedure, if the patient consents, and say this is my landmark, this is what I feel, where should I go from there?' The most direct connection to medical socialization was expressed by two women who spoke of situations in which they would normally give casual opinions to family or friends about health concerns, but no longer feel free to do so because they are ethically bound by their medical opinions now. The 'ways of being' they are learning within medical school are spilling over into the rest of their lives, affecting their interactions with friends and family. They are becoming doctors on more than one front. 4.1.5 Identifying with 'the profession' Another aspect of a professional identity is identifying yourself as having a primary affiliation with your professional colleagues, as opposed to identifying with patients or other lay people. An important shift occurs in the clinical years as students' focus moves from exams and grades to practicing medicine: gradually the faculty and clinicians become role models to follow rather than adversaries (Coombs, 1978: 217). The students increasingly come to feel part of the medical profession. The transition from perceiving themselves as lay persons to perceiving themselves as doctors is gradual - and is central to developing a professional identity. .93. As noted in Chapter Two, the ongoing debate started by Becker (1961) and Merton (1957) has been over whether medical students are socialized into a medical identity or a student identity. As I said there, obviously elements of both are going on, and which one dominates may vary by school as well as by type of student. I will come back to this when I talk about processes of identifying, later in this chapter. Here, I simply wish to establish the presence of this element of professional identity, not to refute the presence of a student identity. About a third of the students talked at some length about concerns they have that I would classify as being concerns of the profession as a whole. In that sense I see these students as identifying with other medical professionals, as sharing the concerns of their senior colleagues around job conditions, remuneration, restrictions on locations for practice, restrictions on services allowed, relationships between the profession and the general public, and relationships with the state. As we have seen above, some students talked about not critiquing another physician because you do not know the full story, and because you would not want others to criticize your professional judgment. This notion of shared professional autonomy was extended further by some students to understandings about a shared position in the health care system. Some talked about the pressures put on physicians by drug companies. Several students discussed the unrealistic expectation by patients that they can be cured of everything, even when patients may be unwilling to tell you what you need to know to make an accurate diagnosis. Several students also expressed concern about the negative image of physicians in public perceptions, and the lack of effective representation of their interests by official professional organizations. Bruce: There's a lot of negative public perception, talk, about physicians and about the stereotype of what they are and what they're not, and what they make and how financially well-off they are. And you know, about how they're not maybe as caring and -1 feel very caught up in that, and, well, that doesn't describe me or any of my classmates. All these soft allegations about the negative parts of, of physicians.... And in a .94. different way altogether, I think... we feel shortchanged. In terms of this issue of billing and, and more restrictions as to where you can and can't be and so on The profession's changing radically. Martin: I think physicians are generally poorly organized. Nurses? They have a lot more time off, they're unionized, they're a lot more organized as a group of professionals it seems to me, and whenever they have an issue they attack it, and they get organized about it. Whereas physicians don't-1 mean we've got the BCMA which supposedly takes on that role, and the College of Physicians and Surgeons, but I just don't flunk they're as organized about things, and I wish we were. 'Cause I flunk in this society, if you're not unionized, you're not organized, you're underpaid and overworked in general. Thus far we have seen that in the process of becoming a physician, medical students take a position on whether medicine is a vocation or a job for them, they learn to become team players, and they find their way in a series of hierarchies that include other medical personnel, other health care staff, and patients. They also learn to adopt a version of professional ethics and to identify at least to some extent with the profession. The last factor I will examine here is taking on appropriately professional appearances. 4.1.6 Constructing a professional appearance Mark: As you're becoming a doctor, you feel a bit more constrained. Constrained in time, and constrained in the appropriate way for you to be presenting yourself, and the appropriate way for you to be acting and thinking about things. You just feel a bit more constrained. Another aspect of medical socialization, of becoming a medical professional, is taking on a professional appearance. Some students commented that a certain degree of concern about appearance and dress is mandated and expectations about professional appearance are conveyed to students very explicitly - "When people started to relax the dress code a letter was sent to everybody's mailbox, commenting that we were not to show up in jeans, and a tie is appropriate for men." It seems students are frequently reminded about what constitutes appropriate dress; according to one survey comment, .95. the Dean's Office sends students a notice "at least every other week about us not dressing appropriately for clinic." A few students also mentioned specific dinicians demanding a certain standard of dress on the wards, such as wearing a tie. Most students, though, do not require such mandates. From comments written in on surveys, they seem to have internalized the required standards and seem to fully accept the rationale: that 'professional' attire is respectful to patients. They want to fit in with other medical staff, and they want to be taken seriously by patients. Wearing the required attire helps in taking on the image and role of physidan. It helps to look the part. Some consdously take their cues for appropriate dress from the clinidans they are working with, deliberately mirroring the physidans around them. • I feel students should dress conservatively. We must look competent and professional at all times. • Dressing neatly and appropriately is important to convey respect to patients, other medical staff, and the profession. It probably also helps in patients taking students seriously. • When you have less than a minute or so to establish rapport with a patient, it seems to help if you appear as 'the generic doctor' with short hair, collar and tie (male). I feel this is espedally true with elderly patients - kind of what they expect. When asked whether or not they ever worried about their appearance or dress at the hospital, 40.8% of the survey respondents said they did not, while 59.2% said they did. Those of working class or poor backgrounds were slightly less likely to worry (55.6% did compared with 61.1% of upper and upper middle class students), while "minority" students were slightly more likely to worry about appearance (65.0% compared with 56.9% of non-minority students). Neither of these differences reached statistical significance, and there were no statistical differences by gender.5 5 Despite the lack of statistical significance I report these patterns because I think the open-ended questions discussed below suggest there may indeed be issues of gender and social class at work here, even though they do not show up in the closed-ended questions. Here, for class p=0.3 and for minority p=0.5. Thus there is a 30-50% chance the "pattern" is a product of random chance. .96. One concern about dressing and looking professional is cost. If students do not already have professional-looking clothes in their wardrobes, they may not have the money to purchase them. Yet the expectations about professional dress remain. • I do ensure that I am dressed formally enough. Sometimes this is a problem, as in 1st term of this year I only had 2 pairs of pants I felt appropriate, and no comfortable shoes to go with skirts. • We do have to look as professional as possible - this can be tough financially! • I don't have a lot of money for clothes, and not a very good figure either. Also, I'm usually really tired in the mornings and don't have much time for make-up/hair. I do not think it is a coincidence that all of these comments are from women. Women's clothing costs more, and more variety is expected. It goes out of fashion more quickly and the fashion standards are more rigid. Women have to buy more to keep up with social expectations, and those expectations include accessories and make-up. Lastly, women face more pervasive social messages about appearance and appropriate body type/size; a "good figure" is a mandated part of a professional image for women in a way that it is not for men. Dressing 'professionally' also raises some concerns for students who are not used to dressing that way. This may be simply personal preference, or may reflect the fact that in student environments casual clothes are often the norm and budgets permit little else. But it may also reflect differences in social class background. If a certain 'up-scale' or professional style of dress was not taken for granted in students' homes when they were growing up, they may be less likely to feel comfortable dressing that way as young adults. • I worry about not appearing 'formal' or 'professional' enough, as my background has never involved wearing dressy clothes. .97. There were important gender differences in students' concerns about appearance. Most of the men's concerns about professional appearance were satisfied by a shave and a shirt with a collar, perhaps adding a tie. • I always wear a tie - keeps things simple, no worries about being underdressed. • I do make sure that I am dressed appropriately when I see patients i.e. well-groomed, collared shirt (but no tie). Women, on the other hand, struggled with the complex messages conveyed by their clothing. It is a challenge to look well-dressed, yet not convey sexual messages. For women, 'dressed up' normally means dressed feminine - and feminine means sexual, or sexy. But professional image is intended to convey competence, not sexuality. At the same time, dothing must be practical, suited to the work students will be doing on the wards. And as one woman commented on the survey, she is simultaneously trying to convey messages about age and status. Some women found striking this complex balance a struggle. • Like to look nice, but don't want to appear too trendy or provocative. • Is it professional enough? Competent looking? Will it be too hot on the wards? (I have fainted). I do not want to appear 'sexy' on the job. • As a female I worry about whether or not something is 'too shorf or 'too low* and as a young woman I try to look older to gain respect of my patients. In one interview a student commented that both men and women sometimes violate standards of professional dress, but she finds it more problematic when done by women. Men's violations involve wearing their hair longer than average, or wearing hiking boots on the wards; women's usually involve dressing too provocatively. The former may be too informal, the latter sexualizes a doctor-patient encounter. .98. 4.2 Changes Students Go Through So how do students go from being a layperson to adopting the professional identity outlined above? What changes are apparent in students as they go through this process of medical prof essionalization? Faculty, with greater distance from the subject and ability to observe greater numbers of students over time, were better able than the students to articulate some of the changes students go through during their undergraduate training. These include developing an increased self-confidence, maturity and sense of responsibility; loss of idealism; narrowing of thought processes, loss of initial communication skills, and adoption of a medical language. 4.2.1 Increased self-confidence, maturity, responsibility Faculty described many - if not most - students as 'blossoming' during their four years of undergraduate medical training. They described quiet, insecure students developing increased self-confidence. Most commonly they talked about students gaining in maturity as they take on increased and serious responsibilities. Dr. N.: There is a heck of a maturity process that goes on over four years, for better or for worse. Dr. B.: They gain in maturity, that comes very rapidly. If s extraordinary how rapidly it comes They become focused on what in fact is to be their life's work. And they realize if s no game. If s a serious matter. In Boys in White Becker and colleagues argued that the idea of "medical responsibility" is one that predominates in medical culture. Students encounter this in their clinical years and construct their own student version of it (1961: 223). The notion has two sides: doctors can, through their power to act on patients, save lives; at the same time, doctors can, through failure to act or improper actions, cost patients their lives. The more serious a patienf s illness, the more substantial the weight of responsibility on the doctor - and the greater the glory should he or she pull the patient .99. through (1961: 237-8). Students structured their clinical learning around seeking out opportunities to exercise responsibility. This was less apparent in my study, probably partly because I did no observations of the students on wards. However, the pervasive belief in "medical responsibility" was clear in faculty interviews. Dr. J.: They know they're being prepared for a role in which they have a great deal of responsibility They're beginning to understand that in the very near future they would have to make some very serious decisions about people, that they're going to have to deal with very complex issues. Dr. N.: [There's] a sense of assuming increasing responsibility for one's patients. And the strong mandate there of trust, you know the patients' trust and expectation of you as an emerging physician.... Plus I think an associated kind of maturity in terms of willingness to increasingly accept that responsibility. I heard little evidence in student interviews that they sought out opportunities to exercise responsibility, as Becker and colleagues (1961) report. In fact, whereas Becker tells of students doing complex procedures they were ill-prepared for (such as a lumbar tap) in order to gain responsibility, I had three students tell me of their own refusal to do procedures (including a lumbar tap) that they did not yet feel prepared to do on their own. Here emphasis on responsibility took a different form. In my research, concern with medical responsibility was most apparent in students' concern about their own performance. Most may have been worried only about reference letters and passing grades, but a substantial number also commented in interviews and on surveys that their desire to learn it all for exams was motivated by fear that one day soon patients' lives will be in their hands. • I always wonder if I am learning enough, if I will miss something crucial that hurts a patient. I feel a tremendous sense of responsibility toward people who will put themselves in my care, and I worry a lot that I won't be up to the responsibility, that I'll make a careless or flippant or ignorant mistake. Right now I don't have responsibility for patients and my self-doubt is expressed mostly over fears of failing exams, but I can see the day when I will lie awake wondering if I made the right decision. . 100. 4.2.2 Loss of initial idealism About half the faculty I interviewed talked about students' losing the idealism they had upon entering medicine. For many, this was the biggest change they see in medical students as they go through their training. Dr. P.: Well probably the biggest change is idealism gets trampled. Thaf s probably the biggest thing. And enthusiasm... I think that students start off in the first year with idealist views about how they're going to be different. Dr. A.: What I often see is a young person totally passionate about what they are doing, totally alive, totally excited about their four years of medicine. And they're gonna be doctors, they want to go out, they want to help the world, they want to cure illness, they want to do all these incredible tilings By the time they graduate, they're not quite as excited I see a lot of disenchantment. And by the time that I see them graduate, they've grown up, they've matured. Some of them are a little jaded perhaps Perhaps their initial ideas about why they went into medicine have changed, that really if s more about themselves rather than helping others. One dinician described it more spedfically as a loss of humanitarianism. He argued that "the medicalization of people" was a loss of the caring side as students begin to emulate medical role models who "are often very highly sdentific people." Others suggested that students learn to adopt a mask or veneer of professionalism. Dr. V. made it dear that for her it is a position of superiority, an aloof distandng that protects students from their own feelings. Dr. D.: What you see in year one, you see this extraordinary, talented, happy, unsophisticated bunch of young men and women, on the whole very enthusiastic, all ears, charming lay people. And then you see a gradual transformation and sodalization of medidne They become professionals. You know, professionals means wearing a mask, the persona of professional. Which is not the totally happy-go-lucky sort of thing you see in year one. Dr. V.: I see students change sometimes from being sensitive, well-rounded, caring people into being aloof, superior professionals. Thaf s the typical trend. Get a hard shell, 'I represent wisdom, knowledge. I'm the gift of God to you the lowly patient.' That veneer, this protective thing is .101. too often adopted by both the professors and the students as a necessary way of dealing with feelings they don't have other ways to deal with. Another clinician took up this theme of superiority or power. He argued that the loss of idealism and innocence that he witnesses is not just about a necessary move toward a pragmatism. It is also about role-modeling on clinicians that embody power and enact superiority. It is about learning superiority. Finally, it may be that students do not so much lose idealism, as that their idealism was exaggerated to start with. One clinician suggested the requirements to enter medicine have become so intense that the only things distinguishing among hundreds of brilliant applicants is volunteer work. Students 'do idealism' more to get into medicine than from an inherent desire to help people or improve the world. In fact their desire to enter medicine may be based on much more pragmatic and mundane factors, which come to the fore once they have been admitted. While students did not normally talk about loss of idealism in those terms, their discussions did reflect this to some extent. One student said she had learned there was no room for naivete in medical school, that patients rarely tell you up-front why they have come to see you and you have to tease it out of them. Her thinking about patients in general, and their relationships to care-providers, had changed with experience on the wards, and she spoke somewhat scornfully about drug-dependency and indigent patients. Much more commonly, though, students' loss of idealism was expressed in terms of the profession. Most of these students had thought they were entering a profession in which they would have a comfortable standard of living, a decent life-style, social respect, and the autonomy to decide where they want to work. In Canada in the late 1990s, instead they see physicians having to go on strike for what they consider decent remuneration, physicians working excessive hours and call-shifts, wide-spread public cynicism about doctors, and an erosion of professional autonomy . 102. such that if they set up practice in an area considered 'over-served' they will only be able to bill 50% of the going rate for their services. By far the greatest amount of cynicism expressed by students was in relation to these issues. 4.2.3 Changes in language, thinking, and communication skills In their important work on the social construction of reality Peter Berger and Thomas Luckmann (1966) argued that a basic foundation of a shared or social reality is language. It allows typification or categorization of experiences and of people; this allows abstraction, in as much as the categories must be broad enough to hold more than one, they must potentially apply to the as yet unseen and unexperienced; this abstraction allows communication. At the same time though, "language builds up semantic fields or zones of meaning that are linguistically circumscribed" and those semantic fields determine "what will be retained and what 'forgotten' of the total experience of both the individual and the society" (Berger & Luckmann, 1966: 39). In other words, language helps establish particular relevances by allowing some things to matter, to register, and some not. As we saw in Chapter Two, the socialization of medical students into their new professional role includes learning two new languages: an informal medical slang, and a formal scientific language of official communication. The methods of my study did not permit observation of the former. But students did talk about the latter. Dawna: All of a sudden all I can think of is this lingo that people won't understand, but like my brother told me the other day, 'Sometimes I just don't understand what you are talking about anymore.' I don't realize it! I'll use technical terms that I didn't think that other people wouldn't know. Learning the language of medicine - what one student called "medical-ese," may have been the most obvious sign of, or may have itself facilitated a larger change in thinking, . 103. stmcturing a new reductionistic world-view (Good & Good, 1993) by establishing as valid specific relevances (Berger & Luckmann, 1966) - the relevances of medicine. As we will see later in Chapter Five, some students were quite conscious about a movement toward standardized thought processes to achieve common clinical decision-making. However a few also alluded to more subtle processes of change in how they think. The most basic change is to process things in scientific or clinical terms. Rina: My thinking sort of changed, I guess I think more in terms of science, just scientific kind of methods or something. And not even that formally, but um, I mean I was having this conversation with a friend of mine... and we were talking about HTV and she was asking me some questions and I realized, 'Oh wow! I guess I'm answering these questions in terms of sort of the pathogenesis of how this virus works in the body and replicating and stuff.' In more complex terms, though, a few students described a sort of paring away of the 'extraneous' information about a patient's life, to focus on what is clinically relevant. Though Becky believes that communicating with and relating to patients is crucial, she can also see how physicians develop a narrower focus. Becky: I sorta see how it happens.... The first day of medicine we're just people. We relate by asking everything about a person. Just like you'd have a conversation with anybody. And then that sort of changes and you become focused on the disease... because right now there's just too much. If s overwhelming. I can't do everything. I: So you don't want to know anything that is external to what you are focused on? Becky: (overlapping) Well, if s not that I don't want to, but I don't know if I have the ability to take it all in. I'm hoping that as I learn more and become more comfortable with what I know and I can apply it without having to consciously go through every step in my mind, that I'll be able to focus on the person again. And come right back full circle. Faculty members also described a kind of narrowing that occurs as medical students proceed through their training, a kind of new way of tWnking that focuses on science, clinical diagnoses, and specific skills. One man called it "deindividualization." Another told me a study of ethics among students at this medical school showed . 104. significant differences between first and fourth year, differences that he thinks mark this narrowing of thinking. Dr. G.: The first-year students' minds were quite wide open and their approach to ethics was- it was less curtailed by the science that had been heaped on the students in those mtervening years. The perspective of the fourth-year students was much more narrow. They were much more interested in the clinical aspects of things, the scientific aspects of things than the humanitarian aspects of things. There was quite a difference there. Several students also spoke of their growing intolerance for others since they have been in medical school. They identified a general impatience with casual conversation, and some spoke of a more specific condescension about lay people's health knowledge and behaviours, as well as actions with physicians. Doug: I don't have any patience for the level of conversation that goes on [in a normal social setting]. You know, sort of that make-conversation kind of thing.... I find myself really impatient with the level of conversation I think three years ago I would have played my role. Jason: My sister noted that I had become more (pause) condescending. And, in retrospect, I actually might have become, at the end of my second year.... Maybe feeling that I knew a lot more than everyone else did in the lay public. And, God, if they only knew what was happening then maybe they wouldn't smoke or blah, blah, blah, blah, blah. And almost a kind of a moralistic attitude toward people. Thinking, 'Oh, I know all this and you don't.' Whether the intolerance for small talk and impatience with laypeople's health knowledge is a situational adaptation unique to students - a product of time pressures and pride in new knowledge - or is a more generalized aspect of socialization into medical ways-of-being is not certain. One faculty member mentioned that a study in this school showed medical students' communication skills improved significantly during their first term of first year, but "by the end of fourth year they were worse than they had been before they entered medical school." Another clinician suggested the fault lies with the education . 105. process itself, that communication abilities are sacrificed to learning the "medical interviewing" style. Dr. W.: Their ability to talk to people became corrupted by the educational process. They learned the language of medicine but they gave up some of the knowledge that they had brought in.... The knowledge of how to listen to somebody, how to be humble, how to hear somebody else's words that kind of stuff. It got overtaken by the agenda of medical interviewing. She argues that students who enter medicine as empathic listeners, learn "that to do it right you have to jump in after six seconds." This, she claims, is the average time a doctor waits before interrupting a patient. This suggests that students' conversational impatience and intolerance are more than situational adaptations, that they are a (learned) part of medical culture. 4.3 Processes Of Becoming, Identifying Lance: A lotta things seemed so mysterious and so, so difficult, you know. 'Oh, man, you'd have to be a genius to know that!' or something. But really if s just a matter of sitting down and somebody explaining it to you, and then, gradually, all through the study the mysteries disappear. When students enter medical school they are simply laypeople with some science background. When they leave four years later they have become physicians; they have experienced some or all of the changes discussed above, and have to some extent taken on a new identity of medical professional. What happens in those four years? What are the processes of socialization that help students make these transformations? Obviously a huge part is simply the acquisition of specialized knowledge, knowledge exclusive to the members of this profession. What other processes go into the making of a doctor? Some faculty argued that an initial transformation occurs upon acceptance into medicine, that people develop an identity as medical students. Others thought students don't start to feel like 'real med students' until they have begun passing their exams, . 106. proving (to themselves not least of all) that they are in fact acquiring medical knowledge. Until then the sense of being an impostor lingers, at least for some students. Self-confidence begins to grow with passing grades. While a couple of students said they felt like medical students as soon as they were accepted into the program, most others talked about not really feeling they were medical students until well into their second year, or even later. In particular, while they were engaged mainly in learning basic sciences, studying books and attending lectures in their first two years, they felt like they were simply extending their undergraduate science education. Dawna: First and second year I was just like an undergrad, it wasn't that different. Interviewer: So in first year you weren't doing the things that you thought a med student would do? Cindy: At the beginning of first year if s totally orientation, you're having lots of parties, lots of fun, getting to know each other. Learning how to study and stuff. When exams come, you're really, really busy trying to cram this material, and you don't realize that what you're doing is dissecting a human cadaver. Whether it occurs earlier or later, there are some discernible elements that together compile the processes of 'becoming a doctor.' A significant one is experiencing a series of 'first times' which later become commonplace; getting used to violating personal boundaries is a major component here. Interactions with patients probably have the greatest impact on the development of a medical-student identity, but more generally the responses of others - friends, strangers, other staff, and patients - all help the student to construct a new sense of self as (almost) physician. Finally, the process clearly involves some degree of acting, role-playing. Students present themselves as if they were student-physicians, and before long they start to believe in that themselves. Finally, simply having a real job to do, having some responsibility seems to be a major part of begining to live this identity. . 107. 4.3.1 First experiences become more commonplace Several students talked about 'first times' as key moments in their transformation toward becoming doctors. They described a process in which what felt artificial and unnatural initially, came to feel natural simply through repetition. Denise in particular thought that learning to identify herself as almost-a-doctor happened through a series of emotionally powerful first-experiences. Denise: I think there are sort of seminal experiences. Like, the first cut in anatomy, the first time you see a patient die. First time you see a treatment that was really aggressive, and didn't work and probably shouldn't have been used. For me, that was a big day; when I saw something that I thought, 'This is not dignified.' First few procedures that I conducted myself. First time I realized that I really did have somebody's life in my hands- not that they gave me a lot of power, but, for example, when a person is paralyzed before an operation and they are getting the breathing tube put in their throat, if you get it in the wrong place they don't have a whole lotta time without oxygen. And that was, for me, the first time that I intubated somebody and had to check and make sure that I had it in the lungs instead of down the throat, that was a big day. Actually the first time I gave a shot to somebody with LEV was also a big day. And I had to actually leave afterwards and sit down 'cause I was shaking 'cause I'd internalized so many things about needles and FflV and the rest.... It seems like a whole lot of first times. The first time you take a history, the first time you actually hear the murmur. There are a lot of 'Ah-ha!' sort of experiences. Several students specifically named their first encounters with patients on their initial visit to a family practitioner's office, in first year, as a turning point. One student described being emotionally overwhelmed by the confidences of patients, and his feeling of inclusion in medicine. Another suggested time and repetition makes these startling firsts become more commonplace. Cheryl: I guess you kind of lose that sense of awe that you have with the patient. I don't know if you're socialized into it, but you just... I guess just being told and being taught about your role as a doctor. You kind of assume it more. Your relationship with patients and stuff becomes more familiar and you just become more and more accustomed to having a certain way with people. . 108. One faculty member also pointed out the importance of 'first times/ in particular anatomy class being for most students, "the first time that they've ever seen a dead body, and for some of them this is not a minor experience I think there's a growing experience there." A student echoed the importance of anatomy. Brendan: At the end of [first] year I started studying for the anatomy final, and it just, it was another one of those steps. Because it made me look at that whole year and all the things that I'd been exposed to. If s probably the closest I have come to crying. And not because I was sad, but just overwhelmed. I remembered that sort of wide-eyed awe that I had that first day in anatomy lab, and that sort led to the first day in the family practice office, and to the wonder of seeing some of the biology of the cadavers we're dissecting, and just the awe of the human body. That all sorta came back, that first year of study. Part of the novelty of the medical school experience is the new experience of being entitled - even required - to violate conventional social norms in terms of personal boundaries, both physically and conversationally. One of the things that clearly sets medical people apart from most lay people is being permitted to go far beyond the usual boundaries with their patients, touching their bodies, entering orifices, inquiring about bodily functions, probing emotional states, and so on. Several students found this set them apart in their own minds, distinguished them as something different from other people, something akin to a doctor. Denise: You have to master a sense that you're invading somebody. And to feel like it's all right to do that, to invade their personal space. Rina: In second year I remember we had these little clinical sessions . . . and we were all so shy\... And just feel like, 'Why am I asking all these personal questions about someone's bowel movements and their sexual history?' Like you feel really weird, especially if the person's like your mom's age or something. I guess the more you do it you just get matter of fact about it. Peggy: Putting your hands on patients. You know, listening to their heart and lungs and just, just touching people is, thaf s a boundary, you know. And just the things that these people will tell you, just by virtue of the fact that you're in the medical profession. Boy, they'll just tell you everything. And it doesn't have to be, you know, deep, dark, perverse secrets, or . 109. anything like that, but just their medical background. Which is very personal. 4.3.2 Responses from others The more students are treated by others as if they really were doctors the more they feel like (almost-)doctors. The response from family and friends, strangers, other hospital staff, and patients, is key for many students in beginning to think of themselves as doctors. In response to an open-ended survey question about the aspects of medical school students most enjoy, two wrote in the social respect their new status is afforded: "The practically automatic respect I get from strangers when they find out I'm in med school." In the interviews, too, several students talked of feeling "put on a pedestal" when people find out they are medical students. Mark: I get more respect, generally, from friends, and family. Martin: I think a lot of the friends of my parents in the neighbourhood were kind of like, 'Wow! Martin got into medical school?!' I could really sense a new respect from some of the people in the neighbourhood. Like my parents' friends who thought I was just a trouble-maker and wasn't going to go anywhere And I felt it from my friends too. Interactions with other health care staff are another possible source of confirmation of a medical self-identity. When nurses, for example, treat the students as if they really were medical people, they feel more like they are. Rina: The more the staff treats you as someone who actually belongs there, that definitely adds to your feeling like you do belong there.... If s like, "Wow! This nurse is paging me and wants to know my.opinion on why this patient has no urine output? You're kidding, you want my opinion?!" For many students though, contact with patients was the single most important source of confirmation that they are in fact medical students, even junior physicians. It is with patients that they feel most like doctors. As one survey respondent commented, "I feel good when I feel that patients are putting their trust in me and it is gratifying to . 110. be able to help them." Several students pointed out that when patients look to them as if they were physicians, and as if they know what they are doing, they realize they do know more than the average person.6 With doctors, students feel they can easily be caught out for what they don't know; with patients they feel fairly certain they will know more. Faculty, too, tend to believe patient contact is the single most important thing for helping students begin to see themselves as almost-doctors. As one man said, "First and second year I haven't noticed much of a change, but once they get into the hospitals and start their clinical training then, yeah, there is a change." That is when they truly alter their self-conceptions. Dr. B.: You're on the other side. You're no longer a layperson. Once you've got a patient confiding in you and telling you things. Dr. O.: Patients confide in them and maybe even call them 'Doctor.'... That sense of belonging, that sense of really being part of the profession and working with doctors, being treated, maybe not as equals, but as colleagues by their professors and being confided in by patients when you start taking histories. When you start sharing people's life, when they start telling you their problems, that puts you in a certain position. Students echoed this view, saying that the confidences patients entrusted in them that make the biggest difference. Brendan: For me if s not really been so much the learning of the individual skills that sort of defines my role as a physician, or as a medical student, but more the trust and the confidences that people relate to me. Part of this transition seems to be an altered relationship to knowledge. Firstly, it involves students' recognizing that they have indeed learned something. Secondly it involves recognizing that the knowledge that has seemed so abstract and possibly irrelevant has direct meaning and application. 6 At the same time some of them sometimes feel uncomfortably aware that patients believe they know more than they may actually know. . I l l . Dr. U.: When they have to really start looking after sick people and making decisions for somebody other than themselves and then it really hits home, and they make this transition from being students to being doctors.... They start realizing that everything isn't so black and white and that yeah, you really have to know that; if s not just because you have to pass an exam, if s because there's a sick person there, and if you don't know it they may not do so well. TJhirdly, it involves making what has been very abstract knowledge much more concrete. They can no longer talk in the abstract about what they would do if, when they have real patients in front of them. Dr. P.: Probably the biggest change I see in people is between the third and fourth year, because thaf s really when they start to see patients It's very easy for somebody to talk about what they would do in terms of abortion or in terms of talking about death and dying when they are doing it from an intellectual perspective, talking about a paper case. But when they're doing it from the perspective, actually knowing the person, having taken care of the person, having to deal with the emotional component, that they were never prepared for, thaf s the tough part. The importance of responses from significant others, hospital staff, and especially patients is unsurprising. Symbolic interactionists and social psychologists have clearly established the importance to identity development of seeing yourself reflected back to yourself. The classic is Cooley's (1964) concept of the looking glass self, the idea that self is based on how others respond to us. And following Cooley, George Herbert Mead (1934) argued that the construction of the social self entails the internalization of "the generalized other," the collective responses of the community of others to which one belongs. More specifically, in his study of medical socialization, Robert Coombs argues that part of the change in self-image is a matter of how medical students are viewed and treated by others (Coombs, 1978). Thus interactions with others can help cement students' self-identities as budding-physicians7. One small component of such interactions that seems to have 7 Of course interactions with others in which a student is not treated as a legitimate member of the medical community would help to destroy his or her self-identity as student-physician. I will discuss such instances more in subsequent chapters. . 112. tremendous impact is being called doctor by others. Despite the fact that legally medical students are not doctors and should not be referred to as doctors, it is nonetheless a reality that they are - either mistakenly by patients, or by hospital staff seeking to allay the concerns of patients who might be alarmed to be examined by a mere student. In virtually all of the first-hand personal accounts of medical training the authors discuss the first time they were called doctor as a highly transitional point (Klass, 1987; Konner, 1987; Reilly, 1987; Shapiro, 1987). In my survey, 66.2% (n=47) of students had been called doctor at least occasionally, by people other than family or friends (see Table 4.1). Of the 66 students who had been called doctor, fully 64 recalled the situation and/ or how they felt about it. This indicates that being called doctor for the first time in the context of medical school carried some significance for these students. Most students were first called doctor by patients, though a significant proportion were first called doctor by a clinical instructor or preceptor. The vast majority of students felt uncomfortable or uneasy when called doctor, knowing they do not yet warrant that title. T A B L E 4.1 Ever Cal led Doctor Frequency (#) Percentage (%) Never 5 7.0 Once or twice 18 25.4 Occasionally 47 66.2 Regularly 1 1.4 Total 71 100.0 Students expressed more mixed feelings when the label of doctor came from a patient than when it came from a physician. While several did talk of feeling uncomfortable, fraudulent, or anxious, some also added that they simultaneously felt proud or pleased. • I felt that the expectations that this person had of a doctor could not be met by my present skill level so I was surprised, a little embarrassed and I corrected the patient. I must also admit that I was proud of myself for appearing professional. . 113. Students were more uniformly uncomfortable with the label doctor when it came from a physician, partly because they felt they were being misrepresented to patients, which raised ethical questions, and partly because they felt unable to cope with the accompanying expectations and responsibility. Those who had mixed feelings or felt good about being called doctor by a physician felt respected or included. T A B L E 4.2 Feelings About Being Called Doctor by Various People H o w did you feel about it? M i x e d / Uncomfortable/ W h o called you Dr? # % G o o d neutral uneasy Nurses 2 3.1 1 0 1 Doctors 19 29.7 2 2 15 Patients 31 48.5 2 9 20 Medical association 2 3.1 0 1 1 Friends/ family 5 7.8 2 1 2 Other/ don't know 5 7.8 1 1 3 Total 64 100.0 7 15 42 (10.9%) (23.4%) (65.6%) The personal accounts of medical education also mark the significance of not being called doctor, especially when your peers around you are. There have been many accounts of male students being called doctor while women were not (Bickel, 1994; Dickstein, 1993; Lenhart, 1993; Mendelsohn, Neiman, Isaacs, Lee & Levison, 1994;), and of students of colour being taken for nurses, orderlies, maids or cooks, while their white peers are taken for doctors (Gamble, 1990; Rucker, 1992). Here survey results showed that social class background, age and having English as a first language make no difference to whether or not students have ever been called doctor, nor to how frequently that happens. But significantly more men than women are regularly called doctor, and significantly more women have never been called doctor.8 8 Never been called doctor, 14% of women, 0% of men; occasionally or regularly 57% of women, 78% of men (Cramer's V=0.32, p=0.06; A N O V A F=6.6, p=0.01). . . . 114. 4.3.3 Playing a role gradually becomes real In his study of medical socialization, Robert Coombs argues that the change in self-image is partly a matter of playing the role of doctor, complete with white coat and stethoscope (1978: 222). Jack Haas and William Shaffir (1987) expand on this describing professional socialization as learning to manipulate symbols and manage impressions. They argue that medical students are given an "identity kit" consisting of the symbols that mark them off as distinct from lay persons and other hospital staff: a white jacket, a stethoscope, a name tag, a clipboard, and a language Haas and Shaffir term "med-speak" or "McBabble" (1987: 70). Thus begins the important differentiation between We and They. The symbols and props of doctors do not simply allow students to present a desired image to fool others; this manipulation of image gradually changes students' perceptions of themselves. What begins as a kind of role-playing becomes a more thorough identification with the role (1987: 77-78). This is exactly the way students described their experience of the process in interviews. They spoke of coming to feel like 'real' medical students as playing a role at first that gradually comes to feel more genuine. Erin: In third year it was really role playing. You were doing all these examinations on these patients which were not going to go into their charts, were not going to ever be read by anybody who was treating the people so it really was just practice. Just play acting. Cheryl: I remember the very first interview we had with a patient It was like a joke. 'Cause I was asking this patient about blood pressures I knew nothing about, but I was just taking on this role.... It seemed like I was a total fraud. I can't be doing this. Rina: Our first real clinical exposure's in second year and if s not a lot. And I remember that was like, 'Wowww! Okay, I'm wearing the white coat, this is weird but if s cool, but what the hell am I doing wearing the white coat!?' Major impostor syndrome again! (laughter) And then third year, for sure by halfway through the year, sort of like, 'Yeah, okay, I'm a med student, and I kinda belong here. Kind of.' Definitely by this year. . 115. They even affirmed the importance of the "identity kit" (Haas & Shaffir, 1987) of white coat, stethoscope, clipboard and ID tag to successful accomplishment of their role-play - even as it enhanced the feeling that this is an act. Maureen: Even last year I hated going in all those Staff Only places.... If s a lot better this year because we have I.D. tags so we are somewhat legitimate. Erin: The little white coat actually made a difference. The times that I went in third year without my little white coat I would always sort of feel a little bit nervous. Peggy: We had to wear the little white coats. And the stethoscope, 'Do I put it in my pocket or on my neck or- ?' If s just comical. And then in second year when we first start going around in little groups of students, again, comical is the word. You've got these four medical students with their little white coats, their pockets are just stuffed with everything, and they're following a staff person around in a little group up to the patient. Martin: It was during third year when we got to put the little white coat on and carry some instruments around the hospital, have a name tag.... It definitely felt like role-playing As we saw in Chapter Two, a central part of the image projection engaged in by medical students is the donning of a "cloak of competence" (Haas & Shaffir, 1987). The daily lives of clinical students consist of proving to faculty, preceptors, clinical instructors, nurses and patients that they do know something and are competent. They quickly learn to at least look competent (Haas & Shaffir, 1987: 59). Several students thought confidence was central to being a good medical student or physician. Nancy: I think patients need to feel that you are confident. And thaf s part of it, you know. One of the doctors said, 'You can't just know what you're doing. You have to look good doing it.'... You go in and see a doctor who could ask you all the right questions, but they ask you in such a way you think, 'This person's an idiot. They don't know what they're doing. I'm leaving.' Where somebody who asks it in a confident way, they might not get everything but you feel comfortable. . 116. But for the majority of the students their confidence in their own skills and knowledge was not as high as they felt they needed to portray to patients. They described pretending confidence while gradually their skills, experience and knowledge base caught up. Nancy: Even if I don't know what I'm doing I can make it look like I know what I'm doing.... It was my acting in high school. I don't know what I'm doing but I can make it look like I do. So in a way I get the trust of the patient and I feel really good about it. Maureen: I think [patients] actually assume that we know more and are able to do more than we really are in a lot of cases. I think we look a certain part and I'm not sure that we're actually up to that part.... Like if I didn't know any better, I could see myself and think well that person's doing- they know a lot... Martin: You try to look confident, and you try to feel confident, and I think I did that right off the bat, as soon as I got in the hospital.... Your knowledge base goes up and you actually do have some competence in assessing the patients and making the decisions that you do. But still, most of my cases I am not completely confident about and I have to play a bit of a role in looking confident I think it is important to look confident, and not have the patients doubt you or your abilities. Most students assumed the role-play was temporary, giving way to a gradual sense of themselves as 'the genuine article' as they acquired more experience and knowledge. One suggested the role-play continues. Martin: I think the role-playing goes on and on. I don't know if the role-playing ever actually ends, (laughter) Certainly during their training, the role-play continues, since the roles and settings are constantly changing. Just as students start to get over their initial discomfort and feel they belong in one part of the hospital in one capacity, they move on to a new rotation and start all over again feeling like they do not belong and are in everyone's way. And as students progress through the program the expectations of them change, so that even in the same ward they may be in a new capacity, thus still feeling initially uncertain and out of place. . 117. Finally, several faculty members pointed out that a major part of the process by which students become medical professionals is through role-modeling, fashioning themselves after other medical professionals. As an apprentice-type training, role modeling is a central aspect of training. Some of the modeling can be negative - faculty described other clinicians teaching students by example to be disrespectful to patients, and to enact an attitude of power-over in their interactions with patients. Others described dinicians modeling how to create positive interactions with patients and their families, as well as how to balance their own lives in terms of medidne and family life. And they model how to take on responsibility appropriately. Dr. R.: What we're talking about here is helping them learn the responsibility. I'm completely convinced that that is not head work if s heart work. And you learn heart work by osmosis. You see people who are for real doing it It is not intellectually taught They will osmose from the people they're working with. And of course you'd like to give them the best models (laughing sort of) but it isn't always possible. One student echoed the importance of role-modeling in helping students learn the roles they need to play. Mark: I think a fair amount would probably be modeling after doctors that you know and respect or have spent time with in the clinics. And you sort of model yourself and your persona to be something like that. 'Cause you see it as being effective with the patients, so you kind of wanna have the same effect I think unconsdously you develop a tone of voice that asks the questions and gets the replies that you want. Or at least creates the effect that you want. 4.3.4 Being in the hospital, responsibility, having a job to do While interacting with patients can be a huge affirmation of a students' developing self-identity as budding-physidan, even more important is doing things that feel like medical things and taking on what feels like medical responsibility. Some faculty stressed that what matters most is not just patient contact, but making a difference to patients, taking responsibility for patient care. . 118. Dr. I.: When they come into contact with the patients then they feel like, 'Oh, I'm somebody. I'm doing something.' But thaf s a kind of a false feeling . . . you still do not feel comfortable examining that patient because you don't have enough skills to do that The next level of maturity, the real maturity as a medical professional, thinking that you belong to the system, comes when... they are given some degree of freedom on examining the patient on their own.... If s the independence, independent evaluation of patients. The more responsibility students face the more they begin to identify as almost-doctors. Some students had begun fourth year by the time I interviewed them. They noted that having a job to do, specific responsibilities that are theirs, makes a big difference. In third year, as one student said, "We didn't know anything. We have nothing to contribute. Thoughts are grasping at anything medical, but it's like your mind's still on your science - all you have are basic sciences behind you. If s like you could be anybody in the hospital." In fourth year, when they are medical student interns (MSIs) they are expected to accomplish specific tasks; it actually matters whether they do their jobs or not, and that gives them a sense of entitlement - they have a right to be there, they belong. Rina: Since this MSI year's been going, if s like 3 months I guess, I am sort of developing like more of an identity of like, 'Okay, I am this professional.'... I think part of it is just 'Okay, this is my job and I have to get this information for the sake of hopefully helping the person, for their health and stuff.' Erin: Now we are actually writing in the real charts. And people really read it and so you feel - ifs not, they're not actually really relying on you to do it, somebody else could do it a lot faster probably [Laughter] But you feel like you're somehow playing some sort of important role in the system. Rina: The more they let you do the more you feel like you belong there. So, I started with psychiatry, they let you book your own appointments with patients and see patients on your own. Like 'Whoa, these are my patients?! Really?' And you're writing progress reports in the charts, and you're doing dictations, you're writing into these cool dictation machines every day. So maybe a question of just the more you do, the more you really feel like you belong. In third year obstetrics [it was like] you have no place here. Whereas fourth year if s like, 'Yeah, we're gonna page you . 119. to come to the delivery and you're gonna help out and help deliver babies.' So then you just feel like 'Well I must belong here, cause I work here. I actually write in the charts and everything.' The notion of having "my patients" is a key transition pointed out by some of the faculty. Students' responsibility shifts in the clinical years from being responsible solely for themselves to taking responsibility for patients. Dr. U.: [Before third year] I would say the majority are concerned about their own performance evaluated by the instructor. In other words, the patient is kind of a inanimate object. They're polite and everything but they really aren't thinking I've got to care for this patient or I can help this patient 'cause they don't feel they have the skills at that point. Even if they did feel the empathy They're not indifferent, they're very kind to the patients but it doesn't mean the same thing. They don't feel the responsibility. They have a responsibility for themselves and thaf s, thaf s pretty well it. To come back full circle to the team concept discussed at the beginning of this chapter, some students feel that having real responsibility finally makes them full-fledged members of the health care team. The work they do matters, contributes. Josh: Now you're having more decision-making power and you're getting to do things this time.... Only now we are starting to develop a professional identity, because before we were students Last year was more in hospitals, but we weren't part of any kind of team at all... you never sort of actually were involved in patient care Now we're part of teams.... Now you're expected to do doctor kind of things. And so now you have to develop the professional identity. 'Cause you couldn't still walk around as a student and feel comfortable with what you were doing 'cause there's no one there to really spoonfeed you and pat you on the shoulder and now you have to take your own initiative and do the things that they taught you in the last three years. 4.4 Summary - Constructing a Medical-Student Identity Thus far we have seen that a medical professional identity, at least as understood and articulated by the participants in this research, includes an understanding of medicine as a calling (though this conflicts with a growing orientation toward more . 120. balanced lifestyles); being a 'good team player'; and taking up a prescribed position in the medical hierarchy, the larger health care hierarchy, and an appropriate relationship to patients (though the definition of appropriate is contested). In addition, medical professionalism involves adopting some version of professional ethics, identifying with the concerns of one's professional community, and fashioning and maintaining an appearance that instills confidence in one's professional abilities. On the way toward acquiring such a professional identity, students go through many changes. These include developing an increased self-confidence, maturity and sense of responsibility; loss of idealism; narrowing of thought processes; and loss of their initial communication skills in favour of adopting a new medical language. The process of medical socialization is one in which students encounter a series of transformational 'first experiences' which help them realize an altered world view. Their emerging sense of self as medical professionals is bolstered by interactions with others in which they are treated as if they really were medical people. Interactions with patients have a particular importance, as does being called 'doctor' in medical settings. The label sets them on their way toward playing the role of medical-person, a role which through repetition, suitable props, growing skills, and appropriate role models gradually comes to feel more real. Finally, though I did not find responsibility had the same significance in being a medical professional that Becker et al. (1961) and Sinclair (1997) found it does, it certainly is a major factor in the process of becoming a doctor. Being granted increasing responsibilities for patient care is a key aspect of developing a sense of self as a medical professional. Virtually all of the research findings reviewed in Chapter Two have been borne out in this study. Medical students do learn a position of "detached concern" toward their patients, though this position is not uniformly accepted by medical practitioners. Some struggle against its dehumanizing effects; as we shall see in subsequent chapters, so too do some students. Medical students do learn to present themselves to patients . 121. and clinicians as competent, whether or not they are. They do learn a new language, one which scientizes and reduces their world to component objective factors, and one which may limit their communication abilities with patients, even as it facilitates communication with other medical people. They do seem to lose idealism, though that is clearer to faculty than to students, except in the arena of career prospects. Finally, they do learn, to some extent, to balance an ambiguous status as simultaneously lowly student and elevated medical professional. Part of that lesson is balancing different parts of one's life, and learning not to make waves. I will explore those themes more in the next chapter. The experiences of students in medical school are not unique, in that they reflect more generalized processes of social interaction, socialization and identity formation. As I have indicated above, the importance of role-playing as part of how we all function in our daily lives was thoroughly examined by Erving Goffman (1959). Identity, according to Goffman, is not so much a matter of being as of doing. "To be a given kind of person, then, is not merely to possess the required attributes, but also to sustain the standards of conduct and appearance that one's social grouping attaches thereto" (1959: 75). We must enact "doctor" in order to be a doctor. "A status, a position, a social place is not a material thing, to be possessed and then displayed; it is a pattern of appropriate conduct, coherent, embellished, and well articulated [It] must be enacted and portrayed" (1959: 75). But in playing those roles, the self is also altered: "By playing roles, the individual participates in a social world. By internalizing these roles, the same world becomes subjectively real" (Berger & Luckmann, 1966: 69). For Goffman identities are negotiated through interactions. Individuals present an image of self for acceptance (or not) by others. The interaction is dialectical, and requires the art of impression management - which as we have seen medical students are immersed in. The part of the performance intended to impress Goffman called the "front." It includes the setting, the "personal front" (dothing, gender, appearance and . 122. manner). And "when an actor takes on an established social role, usually he finds that a particular front has already been established for it" (1959:27). Most roles also involve a larger performance team, as well as an audience. In medical settings, the health care team must maintain disdpline and loyalty to the collective performance if they are not to give it away as performance to the audience - the patients. The team, and individual members of the team, must conceal actions or aspects of self that are incompatible with the performance and even cover evidence of the covering. "Audience segregation" facilitates this concealment. If the audience (patients) or any other non-team-members (such as family, friends) are allowed "backstage" they will see the work of produdng the finished performance. I will explore in the next chapter how such segregation can make it easier for students to stay in role as medical professionals. The other component of sodal identity formation that is apparent in the account of medical school above that fits well with existing theory is the importance of responses of others to an emerging self. First noted by sodal psychologists such as Cooley (1964) and Mead (1934), as mentioned above, it was later taken up by theorists such as Berger & Luckmann (1966). Mead (1934) argued that the development of the self is only possible through sodal interaction. Individuals learn to reflect on themselves by watching the reactions of others. They eventually absorb the responses of the community around them, allowing them to become functioning members of a sodety. If those around you fairly consistently respond to you as if you were a medical person, chances are you will come to see yourself as one. If those around you fairly consistently express the belief that to be a medical professional means to be X, Y and Z, chances are you too will come to believe medical professionalism consists of traits X, Y and Z. Sodal psychology often implies that sodalization ends in childhood. But of course sodal interactions continue, and consequently so do sodalization processes. Because primary sodalization is particularly entrenched, secondary sodalization and re-sodalization must always contend with an individual who has an already formed . 123. self which has a tendency to persist (Berger & Luckmann, 1966). In other words, Rina was someone before she entered medical school. She was a woman, Jewish, daughter of a physician. She had a degree in anthropology, had worked in NGOs, and considered herself a "Lefty radical." She had a boyfriend, and a community of friends. All of that was still there when she entered medical school. All of that was part of her prior self-identity. As Berger and Luckmann (1966:129) state, "Whatever new contents are now to be internalized must somehow be superimposed upon this already present reality. There is, therefore, a problem of consistency between the original and the new internalizations." The process may be eased by the ability of the individual to view a part of the self as relevant only to a role-specific situation, to detach that part from his or her total self. Or such secondary socialization may entail a deeper transformation. Which occurs depends in part on the role of significant others. The 'old' others help the student retain connections to those parts of self; new 'others' help the student switch worlds, adopt a new identity. The latter requires "an intense concentration of all significant interaction within the [new social] group" (Berger & Luckmann, 1966:145). It may also require minimal contradictions between the world of the 'old self and the world of the 'new self.' Maintaining the plausibility structure requires ongoing contact with a community. The extent to which medical students manage to integrate differing aspects of self during their training will be taken up in the next chapter. . 1 2 4 . Chapter V: Producing Homogeneity and Neutrality In his book Getting Doctored, Martin Shapiro (1987: 27-66) suggests that the medical school cultural norms of incredibly hard work, pressure to study at every available moment, and competition to work the longest hours, mean that students have no time left for extra-curricular activities and involvements. To the extent that your identity is connected to your activities and interpersonal interactions, ii you are not doing anything but medical school and you are seeing no one but medical people, you are likely to see yourself as little other than a medical student. This is most intense during clinical years and internship when students spend the majority of their time in the hospital. Even the social lives of medical students tend to include only other medical students, nurses, physiotherapists and other health care workers (Shapiro, 1987: 61). Not surprisingly, research has shown that the socialization of students in professional education programs such as medicine and law (Guinier, Fine & Balin, 1997; Kennedy, 1982) leads to a considerable degree of homogeneity among the students, as well as an increase in conservatism. Values, attitudes, beliefs tend to coalesce around a central norm. Students become more similar in their outlooks than they were before they began the intense training process. In law school, for example, women students seem to "become more 'like men'" particularly in terms of career aspirations as they lose initial interest in labour or public interest law (Guinier et al., 1997: 46).1 In medicine there is a documented intensification of political conservatism among undergraduate students (Coombs, 1978). Jane Leserman found that women students were more humanitarian and liberal in their professional orientations upon entering medical school (1983:141). While still more liberal than men by graduation, 1 Kennedy argues that in law school "there is no purchse for left or even commited liberal thinking on the smooth surface of legal education. The issue in the classroom is not left against right but pedagogical conservatism against moderate, disintegrated liberalism" (Kennedy, 1982:43). . . .125 . . . both men and women had become more conservative in their attitudes. Shapiro argues that even students who enter with "progressive" politics are relentlessly socialized toward a common professional outlook. Many do not even try to resist the gentle depoliticization (which is really politicization into a different ideology). For those who do make an effort to remain involved, the isolation from people of like mind and the lack of time to be politically active are obstacles that may prove impossible to overcome (Shapiro, 1987: 59). In this chapter I show that the incredible time pressures on students restrict their lives to medical school activities and medical school people such that it becomes increasingly difficult to maintain those parts of their lives that are external to medicine. I argue that this time pressure, the structured lives of the students, and the tendency for the medical student identity to dominate self-identity combine to construct a certain degree of conformity or homogeneity among the students. I also argue that this tendency toward homogeneity is compounded by a predisposition in medical education toward a liberal individualism that encourages students to see themselves as neutral in terms of their social characteristics, and to see their patients as almost neutral. This, I conclude, elides recognition of the impact of membership in relevant social categories, particularly those categories which enjoy dominant or hegemonic status. 5.1 Time Pressures and Absence of Balance Students who responded to the survey spent an average of 60 hours that week on activities related to medical school - studying, being in classes, being on the wards. There was a wide range, from as little as 25 hours to as much as 110 hours. Just under half the respondents (43%) fell within 10 hours of the mean, between 50 and 70 hours. School took more of their time than did anything else in their lives, by a wide margin. All other activities definitely took a back seat.2 While about half the students spent 60 See Appendix V, Table A. l for a complete breakdown of the activities and time spent on each. .126. hours or more that week on school, fully half the respondents spent 4 hours or less with friends, two-thirds spent 2 hours or less with family other than spouse or partner, and about three-quarters spent 2 hours or less on music/arts/ movies, restaurants/bars, religion, housework, or reading for pleasure. About three-quarters spent 6 hours or less on sports or watching television - the two most common pastimes. Virtually no one spent more than 2 hours on racial/ethnic/cultural activities; volunteer activities; or social/political activism. T A B L E 5.1 Hours Spent on Medical School the Previous Week (N=70) Hours on school Frequency V a l i d % Cumulative % 40 hrs/ wk and under 17 24.3 24.3 41-55 hrs /wk 11 15.7 40.0 56-65 hrs/ wk 15 21.4 61.4 66-75 hrs/ wk 16 22.9 84.3 76-90 hrs /wk 8 11.4 95.7 91-110 hrs /wk 3 4.3 100.0 So, students are spending their time on school, with brief episodes of TV and sports, occasional time out to read, visit friends or family, go out for a meal, a drink or a movie. Not surprisingly, the aspect survey respondents reported as most difficult about being in medical school was time pressures. The time pressures, of course, were connected to the amount of work students had to cover. The vast majority of students indicated they found the amount of work, and the consequent shortage of time, by far the most stressful (see Table 5.2). T A B L E 5.2 Degree of Stress Associated W i t h Various Aspects of Students' Lives (N=72) Fairly to very Neutral Fairly unstressful to not stressful at all stressful Amount of work 84.7% 15.3% 0.0% Shortage of time 80.6 13.9 5.6 Balancing school and life 78.6 12.5 8.9 Dealing with patients 18.1 34.7 47.2 Family 17.4 24.6 58.0 Being a "minority" 7.1 9.5 83.3 Gender 4.2 6.9 88.9 Sexual orientation 4.3 1.4 94.2 . . . 1 2 7 . . . As a result of the time pressure students have difficulty balancing school and the other parts of their lives - and as we have seen, most simply don't balance their lives. Medicine takes over most of their time. This then negatively affects their relationships with friends, partners and family, which adds stress and guilt. Virtually all the students interviewed mentioned constant guilt, whether they are "sacrificing time with partner, friends and family for study," or taking time from their studies and "worrying about the consequences." In comments written on the survey, ten students mentioned strain on their relationships, eight students isolation from friends and family, and eleven students difficulty balancing school and personal lives. A few talked about their entire lives being overtaken by medical school, and some of putting the rest of their lives on hold. • Medical school has swallowed me up and has not left any time for pursuing other interests and activities. I feel that medical school has made me more unidimensional. The stress of trying to balance school and everything else. Most students clearly feel they are making considerable sacrifices to be in medical school. When asked what they would like to spend more time doing after medical school two-thirds or more of the survey respondents indicated they would like to develop other skills and interests, read more, build relationships and spend more time with loved ones, take better care of themselves and travel - among other things.3 Not surprisingly, students feel large parts of their lives are 'on hold' while they are in medical school. Relationships and marriage are the key things, cited by more than half the respondents. Second was travel, followed in order of frequency by creative and artistic interests, having children, spending more time with friends, and sports and outdoor leisure activities. Significant numbers of students mentioned the fact that major financial planning, and even the ability to be financially independent, are on hold. Some 3 See Appendix V, Table A.2 for the complete list and frequencies. ...128 . . . felt that most big life plans, the ordinary aspects of adulthood, were held in abeyance at least until they knew where they would live. The lists of things they have put on hold indicate that these students had been incredibly well-rounded people, engaged in music, writing, art, sports, and so on - before they entered medical school. However, very few of them were still engaged in those activities. 5.2 Striving for Balance Research has shown consistently that medical students have higher than average rates of depression and substance abuse, especially excessive drinking (Firth-Cozens, 1990; Sinclair, 1997). Not surprisingly, several students told me about episodes of serious depression during their years of undergraduate training.4 On the other hand, many students found concrete ways of building balance into their lives that helped stave off frustration, stress, guilt and anxiety. They scheduled their lives to allow activities other than school. They found stress releases that worked for them. They found sources of support for their values and interests within school. They carefully maintained outside contacts and interests. They changed their expectations of school and of themselves, and they clarified their own priorities to keep school in perspective. One of the most common strategies for maintaining a balanced life was carefully scheduling time off. Students varied in the extent to which they did this consciously and deliberately. Cheryl: You have to come to a point where you just decide to do other things, just block off time where you're not thinking that this is medicine time. 'Cause if you don't do that, then it just kind of permeates everything.... Like I didn't really exercise in undergrad very much, and now I do quite regularly. And thaf s something that I just do.... Even though I think, "Thaf s another hour I could be studying,' but I just do it... . With my boyfriend, too, we have certain nights. Like, Tuesday night and 4 Most of them were very reluctant to tell anyone at the medical school about their depressions. Though there are support services available, students tended to believe that if they sought help through those channels it would go on their records that they had had psychological difficulties; it would be a black mark against them and could hurt their future opportunities. ...129 ... Friday night - sounds kind of rigid - but we just kind of blocked off time. And some of my friends thought, 'Oh, that's really spontaneous!' (laughs) Another thing students found central for mamtaining balance was finding effective means for releasing stress. Several students run regularly, or do other physical activities. Many participate in medical intramural sports. Some talk things out with partners or spouses. Some alluded to a 'work hard, party hard' ethic. For a few students, just doing the necessary studying, getting it out of the way, was their best stress release. Finding the time for stress-releasing activities can be a challenge. Becky: I'm a runner. I run five times a week. So thaf s my survival.... Just even taking an hour and going for a run has caused me extraordinary agony many times.... To be honest I used to skip classes all the time and go running. In the winter when you're sitting in lecture all day and I couldn't go home and run because it would be dark.... Thaf s how I survived. I know my own balances and I know my own thresholds.... You just gotta know your own limits. Finding people in medicine with whom they could be totally themselves was another important aspect of striving for balance. A handful of students talked about Bible study groups within the medical school as a place where they can discuss medical school experiences with others who will be able to relate to them but who will also respond from a common set of values and beliefs. Some students also mentioned the significance of finding even a few kke-minded friends in medicine who shared their values and perspectives. One of the most important sources of stability and balance for many students is their connections to people and activities that are completely unrelated to medical school. On the survey 89% of respondents agreed strongly or very strongly with a statement to that effect. Though most find it very difficult, they also find it essential to maintain these links. Cheryl: I think the main way to prevent, like, losing parts of yourself is just having time and people who aren't medicine.... If you don't have other things or other people to help you keep an even keel and get perspective, it can be probably very deadly. .130. Having roommates, partners, spouses who are not in medicine maximizes the potential for spending time with non-medical people - and for enabling reality checks with someone outside medicine. Of course maintaining outside connections may mean not making many school-based connections. Doug: With some of my friendships, I made a conscious choice to not go to this barbecue and not go to that party and not hang out at Weepers on Friday night and drink with other medical students.... I made some choices about things that I wouldn't get involved with in medical school because it has the potential to be so all-consuming. In contrast, having primary relationships with other people in medicine may make dealing with time conflicts easier, but the cost may be the loss of stabilizing outside connections: "I've been able to maintain a good relationship with my girlfriend and even thaf s been difficult at times. And my family Everybody beyond that who I was very close to . . . most of those people have fallen by the wayside." Many of the students I interviewed had learned that one way to hang on to what matters when school could easily engulf their entire lives was to scale down their expectations about what they could accomplish while in school. Their involvement in sports was reduced. Housedeaning standards slid a little. A few of the women had relinquished any unease they felt about hiring someone else to clean for them. The most common adjustment, though, was lowered self-expedations concerning grades. Students simply had to learn to accept lower marks than they were used to, if they were going to maintain any sort of balance in their lives: "Does it matter whether I get 80% or 85%? If it means that I get to do the things that I want to do as well?" One student had devised a "70% solution" that allowed her to maintain a life outside of medicine. Denise: You have to follow the policy of doing enough and not more. I think that's whaf s worked for me. Don't try to be the best I dedded that 70% was an acceptable mark. Called it 'the 70% solution.' Like if I got 70% at school I could probably still manage 70% at home. It wasn't easy. .131. (laughs) I'd never before thought of 70% as an acceptable mark.... [But] this is a practical field. I'm no longer an academic and 70% is enough.5 This is clearly the sort of "situational adaptation" the Becker et al. (1961) found medical students engage in as a pragmatic response to the impossibility of ever learning it all. Several students had gone through a difficult adjustment accepting that they will never be able to learn everytliing. 5.3 A Push Toward Homogeneity Answering open-ended survey questions, a few students expressed concern that the intensity of their training and the lack of time for any interests or activities outside of school resulted in a tendency toward a kind of homogeneity among the students. • I'm not myself; I can't be. The vigorous training forces all 120 of us, regardless of age, ethnicity or other factors, to become essentially identical people. So much of our time is spent in medicine that we don't have a lot of time to explore other interests. About two-thirds of the students I interviewed agreed that there is a great deal of pressure to think, act and be in certain ways. As Dawna said, "I think that you're expected to think a certain way, you're expected to act a certain way, and it's pretty hard to be anything but that." Faculty also indicated they see an increased uniformity among the students as they proceed through the four years, especially in terms of appearance and manner. Dr. H.: They respond the way that you would expect them to respond. You know what I mean? There's almost a deindividualization of the student. 5 To be clear, she qualified this by saying that her standards for emergency procedures, or any "drug that has a very narrow therapeutic window, so that I could kill somebody" were 100%. She expects herself to know those things perfectly. A n d in topics related to her chosen specialty she has higher expectations for herself. However, she found her 70% solution helped her to accept the fact that you cannot learn everything. .132. Clinicians referred to students' becoming "almost like automatons," or "one of the rest of the cattle." Dr. Q. kept returning to the image of a cookie cutter, producing identical cookies. Dr. Q.: I think the training tends to streamline and produce sort of a cookie cutter as you come out the end and basically you could be a lesbian feminist and come out as sort of a heterosexual white male in your attitudes (laughing).... You [are] being fit into a mold very much. This type of language was echoed by some students. About a quarter of those interviewed compared medical students to robots: "You just become kinda like a robot, I think, kind of an automaton." Part of this pressure toward homogeneity is the development of clinical diagnostic thinking. Students are expected to think in standardized ways, to follow the same thought processes to reach the same diagnosis. And most do not see this as problematic in any way. Lance: Medical training trains you to think in a certain way. I mean, every doctor should think clinically and follow the same path. If s important, if s the best pathway. But the pressure toward homogeneity is more than just clinical thought-processes. Some students identified a much broader homogenizing socialization that "forces you to kind of follow this pathway like sheep," including the way you dress, walk, speak and so on. As indicated in the previous section, part of this homogenizing is simply lack of time for things outside of school. Sean eloquently described the intensity of the tiaining and the homogenizing implications for both students and their loved ones. Sean: I think there is a force in that direction, that we're pushed to be the same person. And I think that probably we're more alike now than when we started. Yeah. I think that we're all held to one standard, we're all after the same thing. And in the end you all have to get through the same hoops to get there, so you all study the same material and spend the same time in the same libraries, reading the same things. And then, at the same time, it does kind of take away the things that made you individual to .133. begin with, like your outside interests and stuff start to disappear. And your families and friends go through the same things in terms of you, so that kind of makes them the same. You know, the same issues crop up for everybody. So I think that by the end you've all had essentially the exact same experience for four years. In every aspect of your lives. Because most of your life outside of medical school is taken away, kind of. The things that made us real individuals when we started, like our outside interests and our outside experiences are removed, kind of. And you're given a substitute set of experiences that are all exactly the same. A few faculty members described the intensity of medical training as analogous to military training and boot camp, with strict dress code, rigid learning style, and near-total isolation from people outside the institution. One dinician said it "is much the same process as any brainwashing." At the same time some students described a tremendous pressure, espedally in the first two years, to be involved with medical school activities and friends. This peer pressure further isolates them from the lives they led prior to and outside of medicine. Some students argued passionately that while thought processes and some behaviours might tend toward conformity, fundamental values and personality would never change. However, fully 44% of survey respondents agreed that they sometimes feel they have lost touch with who they are during medical school,6 and 49% disagreed with the statement that "I am more or less the same person I was before I entered medical school." Older students were most likely to think they are much the same as they were upon entry to medical school (the age difference is not significant, ANOVA F=1.48, p=0.2; T-test of the difference in means between 25-26 year olds and 36+ p=0.07). Only a few students talked about their own values changing in significant ways. Janis spoke of having gone through an extended period of wanting to be like "them" -other medical students and doctors - of losing her own reasons for entering medicine, becoming "money-grubbing," status oriented, image-consdous, competitive: "To stay 6 There were no significant differences by gender, minority-status, age, class background, or having a religious affiliation. ...134 ... in medical school... you have to be very focused on yourself. And thaf s not my nature. You have to say, 'No, I have to study. Get lost.' You have to be very selfish about your time." Rina felt she was becoming "way more conservative." Rina: Going from traveling around India working in NGOs worrying if you're going to get funded, to having to shop at The Gap now for my little clinical outfits, 'cause you don't want to wear hippy-dippy dresses and stuff.... If s sort of vaguely disturbing. Like . . . I just bought a second-hand car, and I've never had a car before.... I guess I have to face it: I'm just this bourgeoisie middle class person with liberal values. I don't know, (laughs) Her (ex)boyfriend first pointed out how she was changing, becoming more conservative. But then she too wondered, "Whoa, who am I? This is kind of strange." She went on to say, "I know my-1 mean I think my politics are still very Left... in theory anyway, but then I drive this nice car, and I want to go to Hawaii on holiday..." Despite the fact that students tend not to think their own values have changed significantly7 during medical school, there is evidence of some convergence among students - whether it reflects permanent or situational attitude change. One clinician described what he called students' "natural attitude," the set of shared assumptions held in common so pervasively that to even question these assumptions disrupts everything.8 He argues that students who are new to medicine witness or participate in things they think are wrong and feel shocked. When no one around them seems shocked, they learn to let it go, and eventually to accept it as normal. Ji they question it, it is usually with their peers, other medical students who are witnessing similar things. This cements the notion that what they have witnessed is normal and not in need of questioning. 7 Fully 38% of survey respondents agreed with the statement, "I feel my values have changed while I have been in medical school." Another 46% disagreed. So there appears to be a split among the students on this. 8 I interpret his "natural attitude" as the establishment of a hegemonic social order (Bocock, 1986), a particular social arrangement or set of social rules that become naturalized, seen as 'just the way it is,' such that it becomes virtually impossible to question that order. .135. Dr. P.: They share some of the stories, but... they share them in a kind of way that reinforces the behavior.... [Builds on] the 'natural attitude' and sort of all the assumptions that we make about things so that we don't question. And that people who question the natural attitude or the assumptions are actually shit disturbers and not liked. This can occur around fairly minor things or more serious ones: not taking the time to treat a patient respectfully because you need to get a history quickly. Calling a patient 'the liver in 207/ Seeing a clinician not telling a patient the whole truth and saying nothing. Or as Dr. P. suggests, helping someone re-insert a needle into a bottle "to get more fluid after they've had the needle inside an ELTV positive patient." One of the central natural attitudes seems to be the importance of conformity. Among the faculty, three people used the phrase "don't rock the boat" when talking about undergraduate medical students: "I think that over a period of time students go from feeling uncomfortable with certain aspects of the culture, to not wanting to rock the boat, to identifying with it, to perpetuating it" (Dr. P.). One clinician described medical school as making sure students have "good blinders on," staying focused on school unable to even see injustices going on around them. Students also described a desire not to rock the boat. Robin: I would characterize probably about 75% of medical students, and thaf s a conservative guess, as being afraid to stand out in any way. Except perhaps as a brilliant person in terms of knowledge. You know, no one's afraid to be especially knowledgeable. One faculty member suggested this desire to conform is strongest in the clinical years: "You want to be same, you don't want to be 'Other.' And what we do is we justify and explain away a lot of stuff in order to be able to be part of the group right?" Part of what gets justified and explained away in the face of what I am calling a pressure toward homogeneity or conformity is the conflicts students experience between what is expected of them as a good medical student and what they expect of themselves as "a decent human being." Virtually every student told me stories about feeling compelled to ignore basic human needs that they would normally meet with .136. common courtesy or human kindness, in order to be a "good med student." For example, one student told me about having to do a physical on an elderly woman: "I was trying to put her through the physical thinking, 'Damn, I gotta present you tomorrow. Move it!' You know?" Then, realizing what the woman really wanted was to have someone just listen to her, talk to her, be with her, the student decided to brush and braid the woman's hair. "I'm tWnking, what kind of medical student am I? You know? You're supposed to be in and out, write it up, and present it. And here I was, like, braiding, you know, stuck!" It took this student much longer than it should have to do the physical, and she felt like a 'bad med student.' Another instance: A group of students is doing rounds with a resident. They all stop to feel an older woman's enlarged abdomen. The woman starts crying and asking whether she will be okay, whether her husband is okay at home without her. The resident says, "Okay, let's go. Next patient." One student, frantically thinking, "I gotta go or else I'll look bad," stays behind anyway, risking the wrath of the resident to comfort the patient. Another instance: A group of students in a room with a young man their age who has a bowel problem. "And the surgeon just said, 'Oh some of us are going to do a rectal exam on you,' and didn't really ask his permission and all of us were in the room." This student felt very uncomfortable but said nothing. My argument here is not that medical students are particularly heartless people, but rather that there is a 'natural attitude,' or hegemony, with which they learn to conform, and which dictates certain appropriate responses to situations like this. In part they are governed by a desire not to stand out in a highly hierarchical setting where shame-based teaching is still common. In part they are governed by a strong sense of their own powerlessness vis-a-vis clinicians, a powerlessness they confirm by talking with their classmates who feel equally powerless. They share with one another stories of 'What could I do, I need a reference from him?' together building a joint understanding that it is not safe or wise to confront things you see that may disturb .137. you. But in part they also come to believe that these responses to patients are appropriate, that this is what doctoring is. This is the process of building the natural attitude, or hegemony, which then provides guidelines for future behaviour. What students described is the adoption of a new or altered social reality. (Most) students who enter medical school with typical social attitudes about human kindness and caring learn to see these automatic responses to pain and suffering as abnormal, unacceptable in medical professionals. They are resocialized. Berger and Luckmann (1966) explain that the internalization of social reality hinges on everyday conversations with the significant others in a person's life; this is key to the ongoing maintenance, modification and reconstruction of the individual's social reality (1966:140). Casual conversation is the means by which people establish and share in a taken-f or-granted world - or what Dr. P. calls a natural attitude. Adoption of a new social reality requires adoption of a new set of significant others. Together with these new people the individual establishes a new "symbolic universe," a way of understanding and making sense of the world (1966: 88). To maintain the new social reality, though, requires "an intense concentration of all significant interaction within the group that embodies" that symbolic universe, or "plausibility structure" (1966:145). The plausibility structure must become the individual's world, displacing all other worlds, especially the world the individual 'inhabited' before his alternation [resocialization] This requires segregation of the individual from the 'inhabitants' of other worlds, especially his 'cohabitants' in the world he has left behind [0]ne must be very careful with whom one talks. People and ideas that are discrepant with the new definitions of reality are systematically avoided (Berger & Luckmann, 1966:146, my emphasis). Eventually the new plausibility structure takes on the weight of history and of the institution. It becomes 'the way things are done' and is no longer questioned. Let me be clear what I am arguing here. As we saw in the previous section, the time pressures and intensity of medical training cause students considerable difficulty .138. balancing the demands of school with the rest of their lives. Many students let go of, or put on hold, aspects of their lives that were important to them before they entered medicine. Most of their time is spent with other medical people, largely segregated from non-medical-school friends and connections. Their community of significant others gradually becomes a narrower one; their "worlds" outside of medicine are gradually "displaced" and they seldom encounter views that are discrepant with the new definitions of reality they are adopting. As Dr. P. stressed, resisting conformity to "the natural attitude" requires external reality checks that time pressures make difficult. Dr. P.: What I tell them is how important it is to compare their experience and talk to their friends - not their medical friends, 'cause their medical friends are only going to reinforce the one perspective - but to talk to and to maintain friendships and relationships outside so that when you tell these stories you have an outsider's perspective to remind us that our perspective is simply one perspective. The extent to which students have access to such external reality checks depends in part on the extent to which their new medical student identity has displaced the rest of their lives - or, in contrast, the extent to which they have maintained outside connections. As I discuss below, students displayed a range of degrees of integration between their medical students selves and the rest of their lives. 5.4 Degrees of Separation / Integration In Robert Broadhead's (1983) study of how medical students put together their identities as spouses, parents, and so on with their developing identities as physicians, he insists that medical student identities do not totally displace all other identities such that individuals become nothing other than medical students. He stresses that identities are always multiple and always mteracting. Individuals must find ways of "articulating" their various identities to one another, sorting out the convergences and divergences of attitudes, assumptions, activities and perspectives that accompany different subjectivities. Whether the development of a professional identity is .139. experienced as an unproblematic integration of the new identity with prior ones, or a drastic change that may entail negation of some former identity and may result in "a new or different person,"9 the process inevitably requires students to find some way to "relate, integrate, and align their emergent professional identity with all others" (1983: 37). In my research students displayed varying degrees of integration between their their medical school selves and the rest of their lives. For a few students all aspects of their lives seem fully