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Degree of commitment and patterns of change; a sociological study of first year medical students Stolar, Grace Elaine (Culley) 1960

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DEGREE OF COMMITMENT AND PATTERNS OF CHANGE A Sociological Study of F i r s t Year Medical Students by GRACE ELAINE CULLEY STOLAR B.A., University of B r i t i s h Columbia, 1957 B.S.W., University of B r i t i s h Columbia, 1959 A Thesis Submitted i n P a r t i a l Fulfilment of the Requirements f o r the Degree of MASTER OF ARTS i n the Department of . Anthropology and Sociology We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, I960 In presenting t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree th a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I f u r t h e r agree that permission f o r extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . I t i s understood tha t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n permission. Department of Anthropology & Sociology The U n i v e r s i t y of B r i t i s h Columbia, Vancouver 8, Canada. Date September 2 6 , I 9 6 0  ABSTRACT This study i s directed toward learning more about intervening variables, or s o c i a l mechanisms of change, within the process of s o c i a l i z a t i o n . I t focused upon one s o c i a l mechanism: "degree of commitment". The contention of the thesis i s that "degree of commitment", within the s o c i a l i z a t i o n process, i s d i r e c t l y connected with (a) the experiences of learning during the process of becoming a member of a s o c i a l system; and (b) the " s o c i a l i z e d " resultant when the learning process i s complete. The concept of "degree of commitment" i s to be understood i n i t s r e l a t i o n to three other s o c i o l o g i c a l concepts: decision-making, s o c i a l i z a t i o n , and social-change. Each of these bears d i r e c t l y upon the concept of "degree of commitment". The factors which work together to r e s u l t i n a decision, at the same time re s u l t i n a'tiegree of commitment". Once a "degree of commitment" i s established, i t can not only be estimated at a point i n time, but i t can be examined as a s o c i a l mechanism -effe c t i n g change. Of course, both decision-making and s o c i a l i z a t i o n involve "change" and, th i s concept as a d i s e q u i l i b r a t i n g force, s i m i l a r to the f a m i l i a r physics concept, i s of paramount importance. Five d i f f e r e n t stated "degree of commitment" groups were analyzed, f i r s t , whether or not t h e i r stated commitment changed over a period of time; and second, according to d i f f e r e n t responses to factual and a t t i t u d i n a l questions by commitment group. Data v©re gathered and examined, according to commitment group, i n areas such as: performance, age, socio-economic c l a s s , students' self-image and career choice, conceptions of medicine as a career, a t t i t u d e s toward f a c u l t y , peers and toward competition. The c o n s t e l l a t i o n of groups and the patterns of change vary by commitment group. As a s o c i a l mechanism, degree of commitment r e s t r i c t s and governs a c t i o n . From t h i s study, i t i s submitted t h a t degree of commitment i s an i n t e g r a l p a r t of the s o c i a l i z a t i o n process and, t h e r e f o r e , i t i s one of the s o c i a l mechanisms th a t must be studied i n any a n a l y s i s of s o c i a l i z a t i o n as a s o c i o l o g i c a l concept. The f i r s t year medical students at the U n i v e r s i t y of B r i t i s h Columbia, i n the u n i v e r s i t y year 1959-60, comprised the sample. A que s t i o n n a i r e was the main source of data. I wish to acknowledge my indebtedness to Pr o f e s s o r B. R. B l i s h e n f o r h i s d i r e c t i o n ; to Dr. K. D. Naegele f o r h i s s t i m u l a t i n g teaching; to my husband, J e r r y , f o r h i s constant encouragement; and to Miss Inge Paulus f o r her conscientious t y p i n g . I am indebted also to the f i r s t year medical students a t the U n i v e r s i t y of B r i t i s h Columbia 1 9 5 9 - 6 0 who served as my sample, as w e l l as to the many medical students and phys i c i a n s who t a l k e d to me and expressed t h e i r o p i n i o n s . I am g r a t e f u l , too, f o r a grant from the Canada Council which g r e a t l y f a c i l i t a t e d the w r i t i n g of t h i s t h e s i s . TABLE OF CONTENTS CHAPTER Pagj ABSTRACT i i ACKNOWLEDGEMENT i v TABLES v i I . INTRODUCTION 1 I I . PROBLEM AND PERSPECTIVE 8 Decision-Making 10 Process of S o c i a l i z a t i o n 12 S o c i a l Change 14 S o c i a l Mechanisms 15 Degree of Commitment 16 I I I . THE DATA 23 D e s c r i p t i o n of the Sample 26 IV. COMMITMENT DIFFERENTIALS AND COMMITMENT COMPONENTS 34 M i n o r i t y Groups W i t h i n the Sample 39 Performance 41 Age and Socio-Economic Class 45 V. STUDENTS' SELF-IMAGE AND CAREER CHOICE 55 VI. CONCEPTIONS OF MEDICINE AS A CAREER S i V I I . FACTORS IN SOCIALIZATION 95 F a c u l t y 95 Peers 97 Competition 104 V I I I . DEGREE OF COMMITMENT AND PATTERNS OF CHANGE 110 IX. CONCLUSIONS AND SUGGESTIONS FOR FURTHER STUDY 127 APPENDIX A: The Questionnaire 139 BIBLIOGRAPHY 157 v i TABLES Table No. Page I . PERCENTAGE DISTRIBUTION OF THE SAMPLE BY AGE, SEX, AND MARITAL STATUS. 28 I I . PERCENTAGE DISTRIBUTION OF THE SAMPLE BY OCCUPATIONAL CLASS. 30 I I I . PERCENTAGE DISTRIBUTION OF CHANGES IN DEGREE OF COMMITMENT BETWEEN FALL, 1959 AND SPRING, I960. 36 IV. ABBREVIATIONS FOR STATEMENTS OF COMMITMENT. 3& V. FIRST YEAR MEDICAL STUDENTS, PERCENTAGE DISTRI-BUTION OF FINAL EXAMINATION RESULTS ACCORDING TO CHANGE IN EXPRESSED DEGREE OF COMMITMENT. 43 VI. EXAMINATION AVERAGES BY COMMITMENT GROUP. 44 V I I . FIRST YEAR MEDICAL STUDENTS, AGE OF DECISION TO STUDY MEDICINE, ACCORDING TO CHANGE IN DEGREE OF COMMITMENT AND CLASS. 47 V I I I . PERCENTAGE DISTRIBUTION OF FIRST YEAR MEDICAL STUDENTS' EXPECTED ACHIEVEMENT. 6 l IX. PERCENTAGE DISTRIBUTION OF STUDENTS' EXPEC-TATIONS COMPARED TO THEIR ACHIEVEMENT BY COMMITMENT GROUP. 64 X. PERCENTAGE DISTRIBUTION OF FIRST YEAR MEDICAL STUDENTS' PREFERENCE FOR THE WORK SITUATION IN WHICH THEY WOULD LIKE TO CARRY OUT THEIR PROFESSIONAL ACTIVITY. 68 XI. FIRST YEAR MEDICAL STUDENTS' AVERAGE ESTIMATES OF YEARLY INCOME AT PEAK OF CAREER, BY COMMITMENT GROUP. 70 X I I . PERCENTAGE DISTRIBUTION OF STUDENTS' RANK-ING OF INFLUENCES ON DECIDING HOW WELL THEY ARE DOING. 77 X I I I . PERCENTAGE DISTRIBUTION OF STUDENT CHOICES OF THE BEST DESCRIPTION OF THE MEDICAL PROFESSION. 8 2 V l l Table Mo. Page XIV. PERCENTAGE DISTRIBUTIONS, FALL AND SPRING, OF STUDENTS' CHOICES OF WHAT THEY WILL LIKE BEST ABOUT BEING A DOCTOR. 85 XV. ORDER OF PREFERENCE OF WHAT STUDENTS THINK THEY WILL LIKE BEST ABOUT BEING A DOCTOR, BY COMMITMENT GROUP. 85 XVI. FIRST YEAR MEDICAL STUDENTS' CHOICES OF THE TWO CHARACTERISTICS MOST IMPORTANT IN MAKING A GOOD PHYSICIAN. 88 XVII. PERCENTAGE DISTRIBUTION OF FIRST YEAR MEDI-CAL STUDENTS' OPINIONS AS TO WHETHER THE FACULTY GIVES MEDICAL STUDENTS ENOUGH DIRECTION IN WHAT TO EMPHASIZE IN THEIR STUDIES. 96 X V I I I . PERCENTAGE DISTRIBUTION OF HOW MUCH COMPET-ITIVENESS FIRST YEAR MEDICAL STUDENTS FOUND AMONG THEIR CLASSMATES IN MEDICAL SCHOOL. 99 XIX. PERCENTAGE DISTRIBUTION OF THE HELPFULNESS THE FIRST YEAR MEDICAL STUDENTS EXPERIENCED FROM ONE ANOTHER. 101 XX. PERCENTAGE DISTRIBUTION OF FIRST YEAR MEDI-CAL STUDENTS' FEELINGS ABOUT COMPETING WITH OTHER PEOPLE-FOR HIGH STAKES, BY COMMITMENT GROUP. 105 XXI. PERCENTAGE DISTRIBUTION OF CHANGE IN SAMPLE'S FEELINGS ABOUT COMPETITION. 105 XXII. PERCENTAGE DISTRIBUTION OF FIRST YEAR MEDI-CAL STUDENTS ACCORDING TO THEIR FEELINGS ABOUT COMPETING WITH OTHER PEOPLE FOR HIGH STAKES, FALL AND SPRING. 107 CHAPTER I INTRODUCTION Medical sociology i s now an established area of s p e c i a l i z a t i o n within the d i s c i p l i n e of sociology. This i s a comparatively new area and, although accepted as "legitimate" by s o c i o l o g i s t s themselves, i t more often arouses scepticism than enthusiasm i n the majority of those within the medical milieu. Much of t h i s pessimism seems to be based on apprehension about what a s o c i o l o g i s t w i l l "do" when he gets "i n s i d e " the medical sanctuary or on unmet ex-pectations when a s o c i o l o g i s t does not "do" whatever an i n d i -vidual or c o l l e c t i v i t y expected him to do. However, i t i s i n the t r a d i t i o n of medicine to take heed of the developments i n other s c i e n t i f i c d i s c i p l i n e s and to assimilate t h e i r "new" knowledge into the medical frame of reference. The science of biology i s a good example. Medicine has not been a f r a i d to adopt and adapt what might be useful f o r i t . In fact , the medical f r a t e r n i t y gives encouragement to other d i s c i p l i n e s to continue t h e i r "basic" research. In t h i s sense, medicine has the most open and supportive attitude toward other d i s -c i p l i n e s while maintaining a most exclusive and covert a t t i -tude toward i t s e l f as a d i s c i p l i n e . The s o c i a l sciences are coming to maturity as " s c i e n t i f i c " d i s c i p l i n e s . Medicine i s aware of i t s need f o r "knowledge" regarding the s o c i a l side of the human organism. 2 I t i s w i l l i n g to meet s o c i a l s c i e n t i s t s "half-way" by pro-viding the raw data f o r s o c i a l science research. The co-operation between medicine and sociology has been extremely productive - p a r t i c u l a r l y i n the l a s t ten years. As medical sociology has developed, s p e c i f i c seg-ments have congealed within t h i s f i e l d . I One of these i s the sociology of medical education. What i s the sociology of medical education? Super-f i c i a l l y , i t i s a study of the processes, and a l l the elements of those processes, through which a medical student becomes a physician. One of the f i r s t , and perhaps best known, attempts to bring together studies on the sociology of medical educa-t i o n i s The Student Physician edited by Robert K. Merton (Soc i o l o g i s t ) , George G. Reader (M.D.), and P a t r i c i a L. Kendall (S o c i o l o g i s t ) . In terms of s o c i o l o g i c a l research, i t i s a beginning and has been a source of further ideas and studies. Why are medical educators p a r t i c u l a r l y interested i n the processes of medical education? Robert K. Merton l i s t s 2 f i v e " p r i n c i p a l " sources of t h i s i n t e r e s t : 1. The great and possibly accelerated advances of medical knowledge which raise new problems 1. I t i s not the intention here to summarize, or l i s t , the problem areas of medical sociology. Such an attempt would be s u p e r f i c i a l i n t h i s paper because of time and space. For an excellent overview of the f i e l d see the sourcebook: E. Gartly Jaco, editor, Patients, Physicians and I l l n e s s , Glencoe, 111., Free Press, 19W. 2 R.K. Merton, George G. Reader and P a t r i c i a L. Kendall, eds., The Student Physician, Cambridge, Harvard University Press, 1957, pp. 35-36. 3 of how to make t h i s knowledge an e f f e c t i v e part of the equipment of medical students; 2. Stresses on the a l l o c a t i o n of the l i m i t e d time available in.the curriculum which lead.to continued review of the bases f o r one rather than another arrangement; 3. Renewed recognition of the importance of the s o c i a l environment both i n the genesis and the control of i l l n e s s together with growing recognition of the role of the s o c i a l sciences i n providing an understanding of that environ-ment; 4. A commitment to s c i e n t i f i c method which c a l l s f o r replacing howsoever s k i l l e d empiri-cism by the beginning of more systematic and r a t i o n a l analysis of the process of education; and 5. As a p r e c i p i t a t i n g factor, substantial innovations i n medical education which require systematic comparisons of the objectives of these innovations with t h e i r actual outcome. Accepting the above as f a i r reason for the medical profession to be interested i n the sociology of medical edu-cation, the next question i s : Why are sociologists i n t e r -ested i n the processes of medical education? To answer t h i s question, medical sociology must be seen i n r e l a t i o n to the primary d i v i s i o n s of sociology out of which medical sociology has developed. The sociology of occupations and professions i s one of the'~"major f i e l d s of s o c i o l o g i c a l inquiry drawn upon by medical sociology. Work, as i t i s carried on by s o c i a l beings, has increasingly been an area of study f o r sociolo-g i s t s . The f a c t s , that work occupies such a large percentage of any individual's l i f e i n an i n d u s t r i a l society and that the economic arrangements are most s i g n i f i c a n t points of organization i n a society, make t h i s an important area i n the study of human behavior. Who choses - or i s chosen by -which occupation, how neophytes learn to become f u l l members of a p a r t i c u l a r occupation, and how candidates are selected and rejected by an occupation are f o c a l points of study for s o c i o l o g i s t s . Professions, because of t h e i r more e x p l i c i t boundaries and terms of reference which make them more v i s i b l e for study, at least i n the beginning, have been a p r i n c i p l e target f o r these studies. Also, the professions themselves are anxious to turn out a p a r t i c u l a r kind of "professional person" from t h e i r schools. Consequently they are interested i n the ways t h e i r environments and teach-ings are related to t h e i r " f i n i s h e d " product - and whether or not they are producing what they intend to produce. The medical profession as a complex s o c i a l struc-ture i s i d e a l f o r s o c i o l o g i c a l study because: ( 1 ) i t has a c a r e f u l l y formalized set of relationships with other pro-fessions, with c l i e n t s , with the community, and f o r medical colleagues; ( 2 ) these relationships are set down and, there fore, are e x p l i c i t ; ( 3 ) the medical profession i s "accepted by others - professional and l a y ; and ( 4 ) i t i s w i l l i n g to be examined within l i m i t s . In short, the profession of medi-cine provides the nearest so c i o l o g i s t s can get to a v i s i b l e , " i d e a l type" of work complex i n terms of recruitment, selec-t i o n , t r a i n i n g and s o c i a l structure. In the development of theory and the testing of hypotheses such a prototype i s invaluable to the s o c i o l o g i s t . 5 Another major area of sociology which the sociology of medical education draws upon - and f o r t h i s study the most c r u c i a l - i s the process of s o c i a l i z a t i o n . ^ This i s the study of how individuals learn to become members of a society or any subsystem of a society. In Merton's words: " I t involves the a c q u i s i t i o n of attitudes and values, of s k i l l s and behaviour patterns making up s o c i a l roles established i n the s o c i a l structure."^ This includes the adult a c q u i s i t i o n of s o c i a l roles as w e l l as those acquired by children i n the process of "growing up , r. Therefore, medical students are engaged i n "learning how" to be t e c h n i c a l l y and s o c i a l l y acceptable as doctors. Acceptable not only i n t h e i r community but - and perhaps most importantly - acceptable to the established medical profession. Again, as the medical profession has r e l a t i v e l y clear-cut objectives f o r i t s students, i t , there-by, provides so c i o l o g i s t s with a comparatively v i s i b l e model fo r developing and testing hypotheses. Merton l i s t s " f i v e coordinate developments i n sociology (which) have brought about concerted beginnings of s o c i o l o g i c a l research on medical education: 1. The marked and cumulating interest i n the sociology of professions which includes, as a major component, studies of professional schools; 2. The growing u t i l i z a t i o n of s o c i a l science as composing part of the s c i e n t i f i c basis f o r the provision of health care i n contemporary society; 3 This i s an important aspect of the theorectical per-spective of t h i s study and we s h a l l return to i t l a t e r i n some d e t a i l . 4 Merton, et a l , p_p_. c i t . , p. 41 • 6 3. The considerable recent growth i n the empirical study of complex s o c i a l organiza-t i o n , among which schools constitute an im-portant special class; 4. The s i m i l a r growth of interest i n the process of adult s o c i a l i z a t i o n i n general which, i n application to the f i e l d of medicine, i s concerned with the processes by which the neophyte i s transformed into one or another kind of medical man; and 5. The recent advances i n methods and techniques of s o c i a l inquiry which make i t possible to examine these subjects and prob-lems by means of systematic inquiry." 5 The studies to date i n the sociology of medical education concentrate on the medical school, that i s ; i t s s o c i a l structure, what i t i s tr y i n g to teach and what i t i s teaching, and on the experiences and changes of values and attitudes that the medical students undergo during t h e i r four years i n medical school. There are studies on the ecology of the medical student but there are no published studies which trace ecological background and subsequent medical school ex-periences. There are studies which discuss the i n t e n s i t y of pre-medical students' feelings about becoming a member of the medical profession, but th i s "degree of commitment" or "dedication" or "degree of emotional investment" has not been systematically followed through to determine i f i t changes or i f i t affects other areas of the medical students' experiences. Many studies have followed a class or classes of medical students through a year or the f u l l four years of medical school i n d i c a t i n g the students' feelings on p a r t i c u l a r matters 5 I b i d . , p. 52. 7 at the beginning of tr a i n i n g and p e r i o d i c a l l y thereafter. However, most of these studies have taken the class as an ent i t y and regarded change i n a group or sub-group as being homogeneous. That i s , f o r example, i f i n a class of t h i r t y -s i x medical students at Time 1, ten students gave the same answer to one p a r t i c u l a r question and then at Time 2, ten students answered that same p a r t i c u l a r question the same way as i t was answered at Time 1, there was no i n d i c a t i o n whether or not these were the same ten students, a l l d i f f e r e n t students, or some combination of the two. Using an admittedly small sample of f i f t y students, t h i s thesis intends to take account of some of these heretofore unexplored aspects of the medical student as a s o c i a l being undergoing change. CHAPTER I I PROBLEM AND PERSPECTIVE This study i s directed toward learning more about "intervening variables" i n a s o c i a l s i t u a t i o n where the ob-je c t i v e i s to change - s o c i a l i z e - selected individuals from "something'1', e.g. children or students, into ''something" else, e.g. adults or medical doctors. In t h i s thesis the i n t e r -vening variables within the process of s o c i a l i z a t i o n s h a l l be called " s o c i a l mechanisms of change". The hypothesis of t h i s paper i s that the s o c i a l mechanism "degree of commitment" i s d i r e c t l y connected with (a) the experiences of learning during the process of be-coming a member of a s o c i a l system; and (b) the " s o c i a l i z e d " resultant when the learning process i s "complete". "Degree of commitment", therefore, has to be exam-ined i n two d i f f e r e n t respects: f i r s t , as a resultant and, second, as a s o c i a l mechanism of change. In the f i r s t i n -stance, when a candidate f o r s o c i a l i z a t i o n arrives at the door of a s o c i a l i z a t i o n agency, he brings with him a l l the many things that he has experienced up to t h i s time: the manner i n which his parents taught him, his relationships and experiences with other human beings, and so on. A p a r t i c u l a r c o n s t e l l a t i o n of these "many things" can be regarded as an in d i c a t i o n of the "degree of commitment" to become a graduate of the s o c i a l i z a t i o n agency. This can be estimated at a point i n time. 9 The "degree of commitment" to wanting to be a graduate of a learning experience, at any one point i n time, however, i t s e l f w i l l influence the experiences that follow. How "much" t h i s need i s f e l t w i l l determine the amount of energy and the perseverance;that a so c i a l i z e e w i l l put into the learning endeavour and the r e l a t i v e pain and pleasure he w i l l endure, and demand, to see the experience through to completion. I f the degree of commitment of an i n d i v i d u a l i s s l i g h t , i t i s assumed that high demands on energy and perse-verance and high deprivation with r e l a t i v e l y few rewards w i l l r e s u l t i n withdrawal from the painful s i t u a t i o n . A s i m i l a r experience to a person with a high degree of commit-ment would not l i k e l y r e s u l t i n withdrawal. In f a c t , he might f i n d pleasures where the less committed did not, and he might take pride i n overcoming the d i f f i c u l t i e s of the experience. These are two extremes on a continuum. There are "degrees" of commitment a l l along t h i s continuum. In t h i s l a t t e r instance, "degree of commitment" i s not a resultant, i t i s a "cause" - a s o c i a l mechanism. The "degree" of commitment w i l l make a difference to the experi-ences within the learning ( s o c i a l i z a t i o n ) process and to the f i b r e of the f i n a l s o c i a l i z e d product. The available i n s t r u -ments of measurement i n the s o c i a l sciences cannot "measure" t h i s "degree" of commitment with appreciable accuracy. How-ever, d i f f e r e n t degrees of commitment can be ranked i n order of i n t e n s i t y . I m p l i c i t i n t h i s analysis i s the knowledge that ( l ) the subjects under study have made the decision to study medicine of t h e i r own accord, that i s , they were not f o r c i b l y inducted into medical school, and (2) once i n medical school, the subjects were involved i n the process of s o c i a l i z a t i o n . The decision-making process and the factors of s o c i a l i z a t i o n are intimately and irrevocably wed to the process of change and consequently, to the "degree of commitment" as a mechanism of change. The three concepts involve many of the same elements: past experience, self-image, s i g n i f i c a n t others, possible alternatives of action. In f a c t , when a decision i s reached, a degree of commitment to that decision (a p a r t i c u l a r constel-l a t i o n of the aforementioned elements) can be estimated. Also, within the s o c i a l i z a t i o n process, degree of commitment i s a s o c i a l mechanism of change. S o c i a l i z a t i o n i s a process; degree of commitment i s a mechanism within that process. A p a r t i c u l a r c o n s t e l l a t i o n of the aforementioned elements equals the degree or impact of t h i s mechanism on the s o c i a l i z e e . I t i s appro-pri a t e , therefore, to s p e l l out what i s meant by the "decision-making process", " s o c i a l i z a t i o n " , and " s o c i a l change" for a more complete picture of the frame of reference of t h i s study. Decision-making: Charles Kadushin 0 has outlined the decision-making process c l e a r l y . This concept i s important i n t h i s study 6 C. Kadushin, Individual Decisions to Undertake Psycho- therapy, Bureau of Applied Social Research, Columbia University, Reprint 268, 195$. because an i n d i v i d u a l does not become a soc i a l i z e e (medical student) u n t i l he decides to do so. Every i n d i v i d u a l has a perception of a s i t u a t i o n - no matter whether i t i s a "true" or " f a l s e T \ r e a l or unreal, perception - where choice i s i n -volved. At the same time the i n d i v i d u a l has a perception of himself - a self-image - that f i t s or c o n f l i c t s with the per-ceived r e s p o n s i b i l i t i e s that go with the taking of any p a r t i -cular choice. An i n d i v i d u a l must be able to imagine himself within a s i t u a t i o n , however f a n c i f u l l y , or he w i l l have d i f f i c u l t y "deciding" to move into i t , and subsequently, he w i l l have d i f f i c u l t y remaining within the s i t u a t i o n . A person's attitude toward his decision to undertake certain r e s p o n s i b i l i t i e s makes a considerable difference i n his approach to those r e s p o n s i b i l i t i e s . Kadushin states there are four major factors which determine a decision when an i n d i v i d u a l i s i n a s i t u a t i o n which necessitates choice. F i r s t , the i n d i -vidual's orientation to a s i t u a t i o n , that i s ; his values, his standards, and his "motivational orientation" which includes his cognitions and perceived attributes of a s i t u a t i o n . A n individual's t o t a l l i f e s i t u a t i o n at the moment of decision must be i n such an order as to make t h i s or that decision f e a s i b l e . The circumstances and p o s s i b i l i t i e s of today may appear quite d i f f e r e n t from the circumstances and p o s s i b i l i -t i e s of one year ago or, l i k e l y , of one year hence. Second, the individual's evaluation of the s i t u a t i o n ; his judgment of the relevant a l t e r n a t i v e s . I t makes a marked difference when, fo r example, there i s a possible choice of f i v e d i f f e r e n t paths, of two different paths, or a choice of no other path at a l l . One's values and standards which are the customary point of reference i n the choice of alternatives constitute an additional factor. "Values", as well as rational standards, always have their part to play, although i t i s often a subtle role. Third, the individual's relationships to others.? The various human relationships one maintains - and wishes to maintain - influence decision, often directly and forcibly. Others' perceptions are often an important aspect of choice. The fourth factor i s time, i n two dimensions; how long has the choice been considered, e.g., I decided to study medicine when I was seven years old; and how soon does the choice have to be made, e.g., I have two days to decide. Process of Socialization Talcott Parsons has outlined the sociological approach to the process of socialization. The following i s a restatement of some of his ideas. The process of socialization i s a series of stages on the way to "becoming" socialized to a particular social system. The classic example of socialization i s , of course, the child 7 This i s similar to Merton's role-sets which he defines as "that complene nt of role relationships which persons have by virtue of occupying a particular social status." R.K. Merton, Social Theory and Social Structure, revised and enlarged, Glencoe, 111., Free Press, 1957, p. 369. For his example of a role-set, Merton writes: "... the single status of medical stu-dent entails not only the role of a student i n relation to his teachers, but also an array of other roles relating the occupant of that status to other students, nurses, physicians, social workers, medical technicians, etc." p. 3o9. 8" Talcott Parsons, The Social System, Glencoe, 111., Free Press, 1951, Chapter VI. 13 "becoming" an adult. Like the c h i l d , who has an "adult" to indicate the way to become a "full-member" or adult i n any p a r t i c u l a r society, the student has his "teachers". Also, l i k e the c h i l d , the student learns not only what i s taught d i r e c t l y to him, but he "picks up" the feelings, attitudes, and mannerisms of his superiors as w e l l . This not only i n -volves the p a r t i c u l a r subject matter at hand, i . e . , the rol e of a "good" son with regard to his parents, or the role of the doctor with a c l i e n t , but also involves the attitudes and pre-judices of his "teachers" (positive or negative) toward l i f e i n general. Persons i n l i n e f o r s o c i a l i z a t i o n , " s o c i a l i z e e s " , have certain c l a s s i c attributes regardless of what they are being "trained" f o r . They come to t h e i r " s o c i a l i z e r s " with a certain p l a s t i c i t y , that i s , they have the capacity to learn alterna-t i v e patterns. This implies that the s o c i a l i z e r s can select a pattern of t h e i r own choice (which may not be the "best" choice from someone else's point of view) and the so c i a l i z e e w i l l attempt to learn i t i n his role of s o c i a l i z e e . This p l a s t i c i t y suggests how i t may be possible to "teach" dogma which "goes against the grain". The so c i a l i z e e has the capacity to form attachments. D i r e c t l y connected with t h i s s e n s i t i v i t y f o r others, the so c i a l i z e e i s dependent upon his s o c i a l i z e r as the agent of rewards and punishments. These two l a t t e r c h a r a c t e r i s t i c s are the levers the s o c i a l i z e r s can wield as pressure i s re-quired i n order to force the s o c i a l i z e e to move onward, to learn "more", and to perform as requested. I t i s clear that there are two s o c i a l systems i n -volved i n the s o c i a l i z a t i o n of a neophyte. One i s a super-ordinate system which i s composed of f u l l y s o c i a l i z e d persons, i . e . , adults, parents, teachers, or medical representatives. These persons have acquired what those persons i n the subordinate system, i . e . , children, students, "learners" i n a l l forms, wish to acquire. Members of the subordinate system have t h e i r own norms which they follow i n int e r a c t i o n with one another and with others, just as those i n the superordinate system have t h e i r own norms which they follow i n int e r a c t i o n with one another and with others. However, those i n the subordinate system wish to move out of t h e i r present system and to become what those i n the superordinate system are. They wish to take on the norms of the superordinate system. S o c i a l Change Inherent i n decision-making and s o c i a l i z a t i o n i s a t h i r d process: the process of s o c i a l change. Both decision-making, i n the sense of deciding upon alternative courses of action, and s o c i a l i z a t i o n involve replacing an old regime with a new regime. Change, by d e f i n i t i o n , necessitates a disruption of the pr e v a i l i n g equilibrium of an in d i v i d u a l or of a s o c i a l system. Change can only take place when there i s a re j e c t i o n or sublimation of the old, or some part of i t , i n order to assume the new, or some part of i t . A state of change, then, i s indic a t i v e of a state of disequilibrium. To disrupt a preva i l i n g status quo requires pushes and p u l l s , forces and pressures upon the changing body. Therefore, change i s always pa i n f u l and enervating. I t i s usually costly also: economically and i n terms of time expended. Socializees are undergoing a strenuous process of change as long as they are i n t r a i n i n g . Certainly, some of them derive pleasure from what they are learning. But i t i s not easy to "learn". I t takes time and e f f o r t . Therefore, a l l socializees "suffer" during t h e i r "learning". These are the points of view adopted i n t h i s t h e s i s . Social Mechanisms Social mechanisms are i n t e g r a l elements i n s o c i a l change. Talcott Parsons has given a working d e f i n i t i o n of s o c i a l mechanisms which i s employed i n t h i s t h e s i s . He writes: "A s o c i a l mechanism i s an empirical generalization about motiva-t i o n a l processes stated i n terms of i t s relevance to the func-t i o n a l problems of an action system", and, further, "accounts f o r a t y p i c a l process of t r a n s i t i o n from one s t r u c t u r a l pattern o to another." 7 This means that a s o c i a l mechanism i s an element i n s o c i a l change and an implement of s o c i a l change. I t i s the function of a s o c i a l mechanism to change a s o c i a l organism from one s o c i a l state into a d i f f e r e n t s o c i a l state, much as heat and pressure are mechanisms of change on physical states of matter. S i m i l a r l y , too, the amount or"degree" of the mechanism of change, 9 Parsons, So c i a l System, p. 6 f f . s o c i a l or physical, makes a difference to what the resultant of the applied mechanism w i l l be. Degree of Commitment "Degree of commitment" i s considered to be a s o c i a l mechanism. "Degree of commitment" i s here intended to mean the degree of importance (motivational investment) a student places on becoming a member of the medical profession. This i s a major concept i n t h i s study. We suggest that the "degree of commitment" to a learning s i t u a t i o n w i l l a f f e c t the manner i n which the subsequent learning process i s experienced. This brings us back to the e a r l i e r statements i n agreement with Charles Kadushin on the factors of decision-making. Every decision involves an assessment by the actor of (a) his orientation to the s i t u a t i o n , i t s perceived a t t r i -butes; (b) his evaluation of possible al t e r n a t i v e s ; (c) his relationships to s i g n i f i c a n t others; and (d) the length of time the decision has been pending and/or made. These considerations put 'aecision-making".into a.social as well as a psychological framework. Once the decision i s made, somewhere i n the de-c i s i o n process, a person a l t e r s his self-image and takes on a new image appropriate to his decision. That i s , when a decision i s made, a person sees himself as being compatible with the decision. I t i s " r i g h t " f o r the kind of person he i s . There-fore, when one "decides" to become a doctor, the perception of the doctor as a capable, adequate, secure, and prestigeful person, must be conceivable as one's own self-conception. I f not imme-di a t e l y , i n the r e l a t i v e l y near future. Thinking of one's s e l f as a c h i l d or as inadequate no longer makes sense. The image of the doctor and the image of the s e l f as a doctor must be i n harmony. I f these two images become too widely divergent, one of two things can happen: the image of the doctor can be changed to be more l i k e the self-image or, i f the self-image and the doctor-image are not reconcilable, the would-be doctor sees i t as an i m p o s s i b i l i t y f o r him to become a doctor. Once the decision has been made and the self-image i s appropriately i n l i n e with the decision, i f for some reason the decision cannot be carried through, e.g., poor grades, family r e s p o n s i b i l i t i e s , the self-image must adapt i t s e l f to the new set of circumstances - often r a p i d l y . Every decision i s an evaluative process, and as said before, one of the primary elements to be evaluated i s the " s e l f " . I f a decision aborts because of a miscalculation of the attributes and powers of the s e l f , an i n d i v i d u a l may be overcome with a sense of f a i l u r e . I f he cannot judge and know himself, what can he judge and know? Therefore, i n order to "hold" themselves together, i n d i -viduals are "committed" to carry out t h e i r decisions. I f they do not, they indicate to themselves and to t h e i r world that they are not what they said they were. Of course, there are major and minor decisions and some choices which are hardly regarded as "decisions" at a l l . However, i n American society to go back on a decision, espe-c i a l l y a major one which has been widely cir c u l a t e d , such as occupational or marital choice, i s regarded as a kind of fraud. To go back on a decision indicates that an i n d i v i d u a l at one time misrepresented himself as going to do a certain thing -which i s taken as an i n d i c a t i o n that he thinks he i s capable of such action. To not carry out the action i s an in d i c a t i o n that he now thinks he i s "incapable" of i t . A person who f r e -quently changes hi s mind i s regarded as irresponsible. Therefore, there are s o c i a l pressures - i n addition to personal desire - to carry out decisions. A major decision i s not taken l i g h t l y by the decider, who has a personal, s o c i a l , and emotional investment i n i t - a commitment - nor by the s i g n i f i c a n t others of his environment. I f external pressures or conditions necessitate the change or discarding of a decision, the i n d i v i d u a l concerned i s absolved from his r e s p o n s i b i l i t y to carry out his decision. Because of t h i s , there i s often a "search" from some " r a t i o n a l " extenuating external pressures when a decision i s not carried out. This search i s often by s i g n i f i c a n t others as well as the object of the decision."^ 10 This section of the thesis was written before Howard S. Becker's "Notes on the Concept of Commitment", American  Journal of Sociology, July I960, Vol. LXVI, No. 1, pp. 32-40, was i n c i r c u l a t i o n . Although the expression i s d i f f e r e n t , the two pieces of work are complementary - at le a s t i n the c l a r i f i -cation of ideas. Becker regards the concept of commitment as "one s p e c i f i c s o c i a l psychological mechanism" (p. 35) i n a family of related mechanisms which operate to produce consistent human hehaviour. He outlines three major components of commitment: 1. the p r i o r actions of the person staking some o r i g i n a l l y ex-traneous i n t e r e s t on his following a consistent l i n e of a c t i v i t y ; 2. recognition of the involvement of t h i s extraneous interest i n his present a c t i v i t y ; and 3. the re s u l t i n g consistent l i n e of a c t i v i t y . There are four mechanisms which operate to enforce allegiance to following a consistent l i n e of a c t i v i t y : a. generalized c u l t u r a l expectations; b. impersonal bureaucratic arrangements; c. i n d i v i d u a l adjustment to a p a r t i c u l a r s o c i a l arrangement; and d. face-to-face i n t e r a c t i o n . To "decide" to become a doctor i s an important and consequential decision. I t denotes a large personal invest-ment. I t seems l i k e l y , therefore, that medical students would be r e l a t i v e l y self-confident and think that they had the neces-sary attributes to become a doctor. To some extent they must consider themselves to be capable, adequate, secure, worthy of prestige, and/or able to give to and serve the sick and those needing medical assistance. We assume (from observation only) that medical students do have at least some of these q u a l i t i e s . Frequently one hears i t said about a medical student: "... he w i l l make a good doctor." The speaker knows nothing about the student's medical knowledge. He makes his judgment on the apparent mannerisms, attitudes, and appearance of the student -and, of course, t h i s i s one way doctors are judged and "chosen" by t h e i r c l i e n t s . Self-images are important. They are the front pre-sented to the world. They are, however, i n a constant state of change. As one i n t r i n s i c aspect of human beings, self-images are incapable of being absolutely s t a t i c . Each experience In t h i s thesis i t i s assumed that generalized c u l t u r a l ex-pectations and face-to-face interaction are considered to be the elements of the mechanism degree of commitment operating upon the medical student sample to ensure t h e i r consistency of behaviour. That i s , these are the elements of the degree of commitment mechanism which aid a student to remain "committed" to a medical career - or at l e a s t , make i t d i f f i c u l t to con-sider withdrawing his stated commitment. In t h i s paper, Becker' four mechanisms are considered as elements and subsumed under a • concept at a higher l e v e l of generalization: "degree of commitment". of an i n d i v i d u a l adds to, dents, strengthens or weakens his conception of himself. Not that self-images are completely malleable, l i k e putty. By adulthood they are more akin to a rock: they can be chipped at or eroded by the constant flow of wind and water. Depending on the vigour and directions of the forces at work, the rock may become rough with sharp edges or smooth and even. To present oneself to the medical school for t r a i n -ing necessitates a f a i r l y p ositive view of one's s e l f . This view has been b u i l t up and reinforced by the s i g n i f i c a n t others i n one's l i f e . Once " i n " the medical school, the medical profession takes over and endeavours to further re-inforce the po s i t i v e aspects of the self-image, e.g., seeing oneself as competent, capable, i n t e l l i g e n t . This i s not the case i n some other professional schools where the f i r s t period of t r a i n i n g i s seemingly spent i n "breaking the students down" i n order that they might be b u i l t up i n a p a r t i c u l a r way. However, the medical profession, t y p i c a l l y , takes the positive approach and the students, t y p i c a l l y , have a high opinion and positive approach to a medical career. This "positive approach" on the part of the student i s an asset i n learning. Robert Merton has expressed t h i s idea i n a d i f f e r e n t context. He t a l k s of the functions of pos i t i v e orientation to non-membership groups and c a l l s i t "anticipatory s o c i a l i z a t i o n " . He writes: "For the i n d i v i d u a l who adopts the values of a group to which he aspires but does not belong, t h i s (positive) orientation may serve the twin 21 functions of aiding his r i s e into that group and of easing his adjustment af t e r he has become part of i t . " ^ Of course, medical students, l i k e any other group of students, do not have an i d e n t i c a l conception of themselves. They vary greatly. What they have i n common i s that they want to become doctors, they think they can do i t , and they have decided to t r y . This degree of desire to become a doctor and the degree to which the students are "sure" they can make the grade also varies. I t seems l i k e l y that there i s some kind of relationship between the two. The nature of t h i s r e l a t i o n s h i p i s not known: nor i s i t intended to attempt to discover i t here. This relationship i s one of the assumptions of t h i s study. The self-image, comprised of how the " s e l f " has ex-perienced the " s e l f " , and the decision to become a doctor, and a l l that that e n t a i l s as stated above, are the major orienta-tions to the actual problem of "becoming"a doctor. This i s what makes up how much a student wishes to become a member of the medical profession. The extent of t h i s desire - the degree of commitment - has been seen to make a great difference i n the approach to other learning s i t u a t i o n s , such as psychotherapy. The contention of t h i s paper i s that i t makes a difference i n approach and, consequently, a difference i n some of the ex-periences i n any learning experience. The f i r s t year medical student and the medical school w i l l serve as the test-model. 11 R.K. Merton,, So c i a l Theory and Social Structure, rev. & enlarged, Glencoe, 111., Free Press, 1957, p. 265. To sum up the problem at hand: students come into medical school with an image of themselves, an image of ''medi-cine", and the decision to become a member of the medical profession. In the terms of th i s paper, this comprises t h e i r "degree of commitment". The various degrees of commitment can be ranked at t h i s i n i t i a l point of the s o c i a l i z a t i o n process. In addition, the i n i t i a l degree of commitment which the students "bring with them" w i l l influence t h e i r approach to learning i n the f i r s t year of medical school. The degree of commitment, i n t h i s l a t e r sense, wiH.be a mechanism i n the learning process. At the end of the f i r s t year, the degrees of commit-ment, as s o c i a l facts, can again be ranked. The r e l a t i v e positions w i l l subsequently af f e c t the approach to learning during the second year of medical school, and so on. The constancy or change i n students' degree of commitment and i t s operation as a mechanism are important both p r a c t i c a l l y , to medical students and the medical school, and t h e o r e t i c a l l y , as an aspect of the learning or s o c i a l i z a t i o n process. Who are the ones who "change"? Why? CHAPTER I I I THE DATA In September 1957, the Faculty of Medicine at the University of B r i t i s h Columbia introduced a substantially re-organized program of studies to t h e i r f i r s t year medical stu-dents. In conjunction with t h i s new curriculum, and following the example of leading medical schools i n the United States, s o c i o l o g i s t s from the Department of Anthropology and Sociology were i n v i t e d to a s s i s t i n an evaluation of t h i s new program of studies. At the end of the f i r s t year of assessment, those i n -volved i n both departments agreed that further systematic assess-ment would be valuable. Up to May I960, data have been collected on the f i r s t year medical students during the university terms of 1957-58, 1958-59, 1959-60. One of the measurement tools of the sociologists was a f a i r l y lengthy, confidential questionnaire given to the medical students. Every student i n the f i r s t year of medicine at the University of B r i t i s h Columbia during the Septembers of 1957, 1958, and 1959, was asked to complete the question-n a i r e . 1 ^ Then, i n an e f f o r t to evaluate "change", every student was asked to complete the same questionnaire i n la t e A p r i l of 1958, 1959, and I960. The difference i n response 12 Cornell, Western Reserve and Pennsylvania Medical Schools were the three schools Merton et a l . concentrated upon for The Student Physician. 13 The questionnaire appears as Appendix A. between Time 1 (September) and Time 2 (April) i s the estimate of change occurring during the school term. Any 'change' bet-ween the two time periods i s attributable to a l l experiences of the f i r s t year medical students, not s o l e l y to the medical school. The questionnaire was devised to reveal students' thoughts and attitudes towards medicine. The f i r s t section i s devoted to the students' expectations and how they arrived at these expectations. In the f i r s t section, there are questions dealing with the actual decision to study medicine: how many other occupations were considered, the influence and support of others and the i n t e n s i t y of the f i n a l decision. Another series of questions deals with the student's self-image with regard to becoming a doctor. How "close" or how " f a r away" does the student f e e l himself to be from his ultimate goal at t h i s p a r t i c u l a r point of his l i f e ? What are the motivations for, and rewards of, becoming a doctor as viewed from the out-side of the medical milieu by the prospective student, and sub-sequently, by the prospective doctor? Once one i s a student, how does one handle his relations with others? That i s , how does one experience competition with other students; how does one a l l o t his time to include the piany persons one's limited time must include; how does one see the faculty and t h e i r expectations towards the student; and, very important, how does one experience and deal with the anxiety engendered by patient contact? The second section of the questionnaire concerns experiences d i r e c t l y connected with being a medical student and the opinions the medical student forms through these ex-periences. Perhaps the main concern of the student, i n the f i r s t instance at l e a s t , i s the s c a r c i t y and allotment of his time. This necessarily involves pressures which arise not only from the s c a r c i t y of time but from the very nature of the stu-dent's work. The problem of the management of uncertainty must be resolved i n one way or another by a l l students who are to become doctors. Both how pressure or uncertainty i s experienced and how i t i s dealt with comes into t h i s questionnaire. Ques-tions are also concerned with what attributes medical students believe make up a "good" doctor. Predispositions and prefer-ences towards patient types are considered. The extent to which the d i f f e r e n t d i f f i c u l t i e s a doctor i s l i k e l y to encounter have been thought about i s also looked at i n t h i s section. In the next section the prevailing professional plans of the students are questioned. These questions centered around which s p e c i a l t i e s or types of practices are presently considered as goals and what future income the students expected. The ecology of the students was also explored. Ques-tions were asked regarding age, sex, marital status, father's occupation, community background, undergraduate majors, leisure-time a c t i v i t i e s , and s o c i a l p a r t i c i p a t i o n . In i t s entirety the questionnaire was directed towards the students' decision to study medicine, t h e i r expectations, attitudes and feelings upon entry into medical school, t h e i r experiences and opinions of the f i r s t year i n medical school, t h e i r current professional plans, and t h e i r perspectives a f t e r the completion of the f i r s t year i n medical school. In addition, i n the spring of 1958, 1959, and I960, a further section was added to the questionnaire dealing with a C l i n i c a l Sessions Program. This program's aim was to i n t r o -duce the student to the " s o c i a l " side of the practice of medicine and to l a y the foundation f o r "comprehensive", medi-ca l care i n the future p r a c t i t i o n e r s . An evaluation of the impact of t h i s program was requested by the medical fa c u l t y . The. analysis of the data accumulated w i l l proceed for some time. Needless to say, the quantity of the data i s overwhelming. For the purpose of t h i s thesis, those questions which bear d i r e c t l y on the problem at hand were selected out of the questionnaire."'"'1'' These are the primary source of i n f o r -mation f o r a l l that i s to follow, supplemented only by informal interviews with doctors and students. S o c i a l s c i e n t i s t s are aware of the drawbacks and inadequacies of research using only questionnaires for sources of data. However, often that i s " a l l " there i s i n the beginning. Aware of the l i m i t a t i o n s of questionnaire questions and answers, the students' responses are, nevertheless, here considered within W.I. Thomas' theorem of the s o c i a l sciences: " I f men define situations as r e a l , they are r e a l i n t h e i r consequences." Description of the Sample - F i r s t Year Medical Students, Uni-v e r s i t y of B r i t i s h Columbia, 1959-60. For the purpose of t h i s study i t was necessary to have "paired" questionnaires f o r the two time periods, September 14 Questions used i n t h i s thesis are starred i n Appendix A. 27 and A p r i l . That i s , the September questionnaire of a student had to be matched to the A p r i l questionnaire of that same student. As previously stated the questionnaire was c o n f i -d e n t i a l and no names were required on the completed documents. In 1957-58 and 1958-59 i t was not possible to "pair" a student;1 s questionnaires. This was a d e f i n i t e drawback i n analysis. Therefore, i n 1959-60 i d e n t i f y i n g questions were b u i l t i n . These were such things as student's birthdate, sex and father's occupation. I t was then possible to "pair" the 1959-60 question-15 naires. Once paired, the questionnaires were known by symbol only. Because of the requirement of "paired" questionnaires, i t was not possible to use the classes of 1957-58 and 1958-59 for t h i s study. In A p r i l I960, there were f i f t y - n i n e r e g i s -tered f i r s t year students at the University of B r i t i s h Columbia i n medicine. A l l of these students did not complete both questionnaires because of absence at one or the other session. Thus, when the questionnaires were "paired" for f a l l and spring there were f i f t y sets which met the requirements. The authors of these sets comprise our sample. In September of 1959 the study sample ranged i n age from under twenty to over t h i r t y years of age. The average class age was 23.9 years: 24.1 years for men and 22.4 years for women. 15 I t should be stated that those persons who did the "pair-ing" did not know any of the members of the f i r s t year medical class. As soon as the questionnaires were paired, numbers were substituted for names and henceforth a l l responses were completely anonymous. 16 In The Ecology of the Medical Student, a Report of the TABLE I: PERCENTAGE DISTRIBUTION OF THE SAMPLE BY AGE, SEX, AND MARITAL STATUS.17 Age Male Female Total 16-20 years 14.0 ( 7) 6.0 (3) 20.0 (10) 21-25 years 54.0 (27) 8 .0 (4) 62.0 ( 3 D 26-30 years 12 .0 ( 6) - 12 .0 ( 6) 31-35 years 4 . 0 ( 2) 2.0 (1) 6.0 ( 3) 84 .0 (42) 16 .0 (8) 100.0 (50) M a r i t a l Status Male Female Total Single 64.0 (32) 12 .0 (6) 7 6 . 0 (38) Married 2 0 . 0 (10) 2.0 (1) 22.0 (11) Engaged - 2.0 (1) 2.0 ( 1) 84.O (42) 16 .0 (8) 100.0 (50) No member of t h i s sample was married or divorced dur-ing his f i r s t year at medical school. One young man was en-gaged when the term began, but was disengaged by the time the term ended. His was the only change of status i n the entire sample. F i f t h Teaching I n s t i t u t e , Association of American Medical Col-leges, Evanston, 111., 1958, i t i s stated that i n a representa-t i v e sampling of United States medical students, t h e i r average age was 25 years f o r males (range from 19 to 44 years) and 25.5 years for females (range from 20 to 45 years). 17 A l l tables i n t h i s thesis are set up i n percentages with the whole numbers appearing i n brackets beside the percentage. In the f a l l of 1959, twenty-two per cent (11) of the class was married. They had been married an average of 3.1 years. The range i n years married was from eight years (one male) to one year (three males). F i v e of the eleven married students had one c h i l d when the f a l l questionnaire was administered. No one had more than one c h i l d , nor was any c h i l d born during the school term. The married woman had been married two years, and had no children. Seventy-eight per cent of the students - thirty^two men and seven women,'- received t h e i r undergraduate t r a i n i n g at the University of B r i t i s h Columbia. Other undergraduate c o l -leges attended were: s i x per cent from McGill (3 men); ten per cent from United States colleges (4 men and 1 woman); and s i x per>cent from other foreign colleges (3 men). ( I f t e r r i -t o r i a l i t y makes a difference i n attitudes, i t i s probable that the questionnaire result s w i l l have a strong B r i t i s h Columbia bias.) In an e f f o r t to determine what kinds of backgrounds these medical students came from, the occupations of t h e i r fathers were rated according to a Canadian Occupational Class 1$ Scale. This scale was developed es p e c i a l l y for Canada. Occupations are ranked i n Classes from I , the highest class, to VII, the lowest class, according to combined standard scores for income and years of schooling, by sex. 1$ B.R. Blishen, "The Construction and Use of an Occupa-t i o n a l Class Scale", Can. J. of Ec. and Po l . Sc., Vol. XXIV, No. 4, November 1958, pp. 519-531. TABLE I I : PERCENTAGE DISTRIBUTION OF SAMPLE BY OCCUPATIONAL CLASS Class Male Female Total I 16.0 ( 8) 4 . 0 ( 2) 20.0 (10) I I 4 2 . 0 (21) 8 . 0 ( 4) 50.0 (25) I I I 4 . 0 ( 2) - 4 . 0 ( 2) IV - 2.0 (1) 2 .0 ( 1) V 1S.0 ( 9) - 18 .0 ( 9) VI - 2.0 (1) 2 .0 ( 1) VII 4 . 0 ( 2) - 4 . 0 ( 2) 84.O (42) 16.0 (8) 100.0 (50) The f i r s t three classes represent professional and upper-income f a m i l i e s . The "managerial" category has the largest representation. Eleven of the students' fathers are i n t h i s vocational group. Eight fathers are M.B.'s - s i x of the children are male and two are female. Other occupational groups represented i n the Classes I to I I I are school teachers ( 4 ) , accountants ( 3 ) , engineers ( 2 ) , r e a l estate agents ( 2 ) , armed services o f f i c e r s ( 2 ) , a s o c i a l welfare worker, a draughtsman, a chemist, and an unlisted professional. The Classes IV to VII are comprised for t h i s sample of farmers ( 3 ) , a transportation foreman, a plumber, a furnaceman, two o f f i c e c lerks, a metal f i t t e r , a policeman, a guard, a cook, and a longshoreman. Clearly, the backgrounds of the student sample are diverse. However, there are at least three major groupings about which some observations can be made. F i r s t , those students who are following i n t h e i r fathers' occupational footsteps have some advantages over the other students. They also may be under additional pressure to "succeed" as students, and to maintain the family's name and prestige before the father's colleagues - the child's teachers. However, doctor's children have a model to follow, presumably a l l t h e i r l i f e . They have actually watched a'.doctor at work and, i n a way, have l i v e d within the medical m i l i e u . Their expectations, therefore, are l i k e l y to be more r e a l i s t i c than those of many of t h e i r student peers. They are more orientated to t h e i r new learning s i t u a t i o n and, consequently, i t i s l i k e l y that they w i l l suffer less d i s i l l u s i o n and use up less '^energy" seeking to f i n d out just what being a doctor ( i n the widest sense) i s a l l about. Another student group that i s numerically outstanding i n our sample i s the children of managers (22$ of the sample). There are no data to explain why businessmen's children chose a medical career. However, i t might be kept i n mind that medicine always rates higher than managerial positions on occupational rating scales. Medicine might be seen by these children and t h e i r fathers as a prestigeful occupation, econom-i c a l l y and s o c i a l l y , without many of the competitive pressures of business. (Whether t h i s preconception i s true or false i s irrelevant.) I f Table I I i s a r b i t r a r i l y dichotomized to group Classes I to I I I and Classes IV to VII together, twenty-six per cent of the sample f a l l s into the bottom h a l f of the table. This i s interesting when one considers that i t i s a common public b e l i e f that doctors are primarily doctors' sons, or, at l e a s t , the sons of r i c h men. Although seventy per cent of the sample does come from the f i r s t two upper classes, approximately one quarter of the sample comes from the l a s t three categories. I t i s apparent that the main body of medical stu-19 dents at the University of B r i t i s h Columbia does not come from the families i n the middle occupational groups, but from the highest and the lowest groups according to t h i s r a t i n g . This scale correlates highly with prestige rankings. M.D.'s are rated prestige-wise and occupationally as being i n the highest group i n our society. They are, perhaps, one of the few unanimous "high" choices of the population at large. Occupational mobility i n our society has been thought to be declining but these figures indicate that, rather than s l i g h t s o c i a l mobility, one quarter of t h i s sample of medical students i s jumping up four or f i v e Class steps by going through medi-cal t r a i n i n g . A medical degree i s the surest - perhaps the only sure - manner by which one may gain prestige and s o c i a l acceptance from our entire population. 19 This d i s t r i b u t i o n of students by father's occupation was also true f o r the f i r s t year medical students i n 1957-58 and 1958-59. Another point regarding the students i n the Classes V, VI, and VII i s that they are at the opposite extreme to the doctors' children. I t i s not l i k e l y that they have had an immediate model to t r y to duplicate. Nor i s i t l i k e l y that they have been exposed to the wider, but i n f l u e n t i a l , ' s o c i a l ' aspects of being a member of the medical profession. These remarks suggest that the choice of medicine as a career by students may vary by socio-economic background. This problem w i l l not be taken up i n t h i s thesis, but i t does suggest some in t e r e s t i n g questions f o r further study. In any discussion of t h i s sample of f i r s t year medical students i t should be kept i n mind that the Faculty of Medicine at the University of B r i t i s h Columbia i s a selec-t i v e school. I t does not accept a l l applicants. A l l students who are accepted into the medical school have had good scholas t i c standing i n t h e i r u n i v e r s i t y undergraduate years. They also have been i n d i v i d u a l l y interviewed to determine t h e i r s u i t a b i l i t y f o r the medical program. I t can be assumed that a l l members of the sample are reasonably i n t e l l i g e n t , and that they have the i n t e l l e c t u a l p o t e n tial to become members of any occupation. CHAPTER IV COMMITMENT DIFFERENTIALS AND COMMITMENT COMPONENTS A degree of commitment r e s u l t s from a d e c i s i o n to ca r r y out a c e r t a i n l i n e of a c t i o n . Therefore, to examine a "degree" of commitment, i n the f i r s t i nstance, n e c e s s i t a t e s the examination of the components tha t go i n t o d e c i s i o n -making. From the statement of the t h e o r e t i c a l s e c t i o n t h i s e n t a i l s : an actor's o r i e n t a t i o n to a s i t u a t i o n , i n c l u d i n g the s i g n i f i c a n t forces which helped d i r e c t and form t h i s o r i e n t a t i o n ; h i s e v a l u a t i o n of s i g n i f i c a n t a l t e r n a t i v e s ; h i s r e l a t i o n s h i p to s i g n i f i c a n t others, such as, h i s f a m i l y , teachers, peers; and the le n g t h of time the d e c i s i o n has been pending. For a complete p i c t u r e i t i s obvious th a t a great many components should be examined. Unfortunately, the data at hand do not meet i d e a l s p e c i f i c a t i o n s . The r e -sponses to the questionnaires sometimes were too ambiguous to draw meaningful conclusions. However, the usable data do i n d i c a t e c l e a r p i c t u r e s even though the background d e t a i l cannot always be f i l l e d i n . I n the body of the t h e s i s , the q u a n t i t a t i v e data are presented f i r s t . In order to examine the concept "degree of commitment" as a s o c i a l mechanism, an estimate of va r y i n g degrees of commitment i s necessary. To determine the "degree" of commitedness of each f i r s t year medical student i n the f a l l of 1959, the responses to the following questions were tabulated: Which one of the following statements best describes the way you f e e l about a career i n medicine? (Check one) .... I t ' s the only career that could r e a l l y s a t i s f y me • .... I t ' s one of several careers which I could f i n d almost equally s a t i s f y i n g .... I t ' s not the most s a t i s f y i n g career I can think of, everything considered .... A career I decided on without considering whethe I would f i n d i t the most s a t i s f y i n g The f i r s t statement: " I t ' s the only career...", was taken as an expression of deep commitment to a medical career; the second statement as being a lesser commitment than the f i r s t the t h i r d statement as being of less commitment than the second; and the fourth statement was considered as the lea s t f o r c e f u l expression of commitment. No student during the three years t h i s question has been asked has responded i n the fourth cate-gory. The three students i n t h i s sample who responded that medicine i s "not the most s a t i s f y i n g career I can think of ..." are the only students who have so responded during the three years the questionnaire has been administered. As the primary focus of t h i s thesis i s on "change", the commitment question was tabulated for f a l l and spring, and the students were then grouped according to t h e i r combined answers for the two time periods. Table I I I indicates t h i s grouping. TABLE I I I : PERCENTAGE DISTRIBUTION OF CHANGES IN DEGREE OF COMMITMENT BETWEEN FALL, 1959 AND SPRING, I960. F a l l 1959 Spring I960 Total Only career One of several careers Not most s a t i s -fying Did not consider s a t i s -f a c t i o n Total Only career that could s a t i s f y me 70*0 (35) 5A-.0 (27) 16 .0 (8) - - 7 0 . 0 (35) One of several equally s a t i s f y i n g careers 24.0 (12) 8 .0 (4) 16 .0 (S) - - 24.0 (12) Not most s a t i s f y i n g career I can think of 6.0 (3) 2.0 (1) 2.0 (1) 2.0 (1) 6 . 0 (3) Did not consider s a t i s f a c t i o n i n career choice - - - - - -Total 100.0 64 .0 3 4 . 0 2.0 - 100.0 (50) (32) (17) (1) (50) Throughout t h i s thesis the terms "changers" and "non-changers" w i l l be employed. "Changers" are those people who stated one degree of commitment i n the f a l l and a d i f f e r e n t degree of commitment i n the spring. These are the students who are inconsistent i n t h e i r expression of degree of commitment f o r the two time periods. "Non-changers" are those people who state the same degree of commitment to medicine as a career i n the f a l l as they do i n the spring. These students are consistent i n t h e i r expression of degree of commitment for the two time periods. Who maintains a conviction or commitment i s just as important as who changes his conviction or commitment. The "changers" are represented by the eight people who state medicine i s "the only career that could r e a l l y s a t i s -fy me" i n the f a l l upon entering medical school, but i n the spring have changed to: medicine i s "one of several careers which I could f i n d almost equally s a t i s f y i n g ; " plus the four  people who state medicine i s "one of several careers which I could f i n d almost equally s a t i s f y i n g " i n the f a l l , but i n the spring have changed to: medicine i s "the only career that could r e a l l y s a t i s f y me;" and the two people who state medicine i s "not the most s a t i s f y i n g career I can think of, everything considered" i n the f a l l , but i n the spring, one changed to: medicine i s "the only career that could r e a l l y s a t i s f y me" and one changed to: medicine i s "one of several careers which I could f i n d almost equally s a t i s f y i n g . " Fourteen students, twenty-eight per cent {28%) of the sample of f i f t y students, revise t h e i r statement regarding how they f e e l about a career i n medicine during the u n i v e r s i t y school year. The "non-changers" i n the sample are the twenty-seven students who state that medicine, i s "the only career that could r e a l l y s a t i s f y me" both i n the f a l l and i n the spring; the eight students who state that medicine i s "one of several careers which I could f i n d almost equally s a t i s f y i n g " both i n the f a l l and i n the spring; and the one student who states that medicine i s "not the most s a t i s f y i n g career I can think of, everything considered" both i n the f a l l and i n the spring. T h i r t y - s i x students, seventy-two per cent (72$) of the sample of f i f t y students, remain constant i n t h e i r statements regard-ing t h e i r degree of commitment to a career i n medicine. The analysis of the data proceeds from ( l ) the "change" and "non-change" groupings, and (2) the combined f a l l and spring responses to the degree of commitment question. To make the text less cumbersome, the following terms w i l l be employed for the commitment groups: TABLE IV: ABBREVIATIONS FOR STATEMENTS OF COMMITMENT. COMBINED FALL AND SPRING STATEMENTS OF COMMITMENT ABBREVIATION PER CENT OF SAMPLE "Only career that could r e a l l y s a t i s f y me", non-change Unconditional 54.0 (27) "One of several careers which I could f i n d almost equally s a t i s f y i n g " , non-change Qualified 16.0 ( a) "Not the most s a t i s f y i n g career I can think of", non-change Conditional 2.0 ( 1) From: "One of several careers which I could f i n d almost equally s a t i s f y i n g " and "Not the most s a t i s f y i n g career I can think of" To: "Only career that could r e a l l y s a t i s f y me" Unconditional Changers 8.0 (4 ) 2.0 ( 1) From: "Only career that could r e a l l y s a t i s f y me" and "Not the most s a t i s f y i n g career I can think of" To: "One of several careers which I could f i n d almost "Squally s a t i s f y i n g Qualified Changers 16.0 ( 8) 2.0 ( 1) 3 9 Minority Groups Within the Sample I t w i l l now be apparent that there are two groups within the sample who are conspicuous because they are deviant i n some important respect from the rest of the sample. "Deviant" i s used here to mean d i f f e r e n t from the majority on a variable that might bear on the findings of t h i s thesis. The f i r s t group i s the three students who, unlike t h e i r forty-seven peers, i n the f a l l of 1 9 5 9 stated that medicine was "not the most s a t i s f y i n g carrer I can think of, everything considered". In the body of th i s essay often they are not referred to s p e c i f i c a l l y . There are two reasons f o r t h i s . F i r s t , taking the expressed commitment f o r both f a l l and spring, each of the three students stands alone i n hi s group. In the spring the three responses are a l l d i f f e r e n t from each other. One student now states medicine i s "the only career" f o r him; the second student states medicine i s now "one of several careers" he could f i n d equally s a t i s f y i n g ; and the t h i r d student remains constant i n expressed commitment and again states that medicine i s "not the most s a t i s f y i n g career I can think of". I t i s very d i f f i c u l t , as well as unre-l i a b l e , to attempt generalizations from a single case. The second reason these three young men are not always referred to s p e c i f i c a l l y , and s i g n i f i c a n t l y f o r t h i s thesis, Is that, except where indicated i n the text, they follow the patterns of t h e i r peers according to whether they ^change" i n t h e i r expression of commitment or are constant. Thus, there are two students who follow the "changers'" patterns and one student who f o l l o w s the "non-changers'" p a t t e r n s . When there i s no s p e c i f i c reference to these three students i n the a n a l y s i s of a question, i t may be assumed t h a t they have t h e i r contemporaries' c h a r a c t e r i s t i c s and f o l l o w t h e i r change or non-change p a t t e r n . The second m i n o r i t y group i s comprised of the female students. There are eigh t women i n the sample - s i x t e e n per cent of the sample. I t i s s i g n i f i c a n t that s i x of the eight women s t a t e that medicine i s the "only career" that could s a t i s f y them, both f a l l and s p r i n g . I n c r e a s i n g l y , medicine i s considered an acceptable career f o r women. However, many persons s t i l l do not consider i t e n t i r e l y appropriate. The woman's place i s often thought to be " i n the home" and the long t r a i n i n g r e q uired to begin a medical career i s of t e n considered a "waste" f o r women. Therefore, i t does not seem out of place that these women should be determined and consider medicine to be the "only career" f o r them. Less determination, and they might have been d e f l e c t e d out of t h i s f i e l d . Of the other two women, one s t a t e s f a l l and s p r i n g that medicine i s "one of s e v e r a l careers I could f i n d e q u a l l y s a t i s f y i n g " , and the other changes from medicine i s the "only career" i n the f a l l to medicine i s "one of s e v e r a l careers I could f i n d e q u a l l y s a t i s f y i n g " . This l a t t e r woman i s the only female to change her expression of commitment. A l l of the women passed t h e i r f i r s t year medical school, but t h i s g i r l had the lowest standing. S i x of the eight g i r l s ' f a t h e r s rank socio-econom-i c a l l y i n Classes I or I I . Otherwise, i n terms of age at f i r s t c o n s i d e r i n g m e d i c i n e as a c a r e e r , age a t d e f i n i t e l y d e c i d i n g t o become a d o c t o r , o t h e r c a r e e r s c o n s i d e r e d and so o n , t h e y a r e s i m i l a r t o t h e i r male c o u n t e r p a r t s . I n a s t u d y o f o c c u p a -20 t i o n s and v a l u e s , R o s e n b e r g f o u n d : . . . t h a t t h e o c c u p a t i o n a l v a l u e s o f t h e c a r e e r woman a r e a l m o s t i d e n t i c a l w i t h t h o s e o f t h e c a r e e r - o r i e n t e d man . . . s ex r o l e s a r e f a c t o r s o f i m p o r t a n c e i n d e t e r m i n i n g o c c u p a t i o n a l v a l u e s b u t n o t among women who have adopted a " m a l e " a t t i t u d e t o w a r d t h e i r o c c u p a t i o n s . The c a r e e r woman t e n d s t o want t o s a t i s f y t h e v a l u e s w h i c h men choose i n work r a t h e r t h a n t h e v a l u e s s e l e c t e d by o t h e r women. These d a t a b e a r o u t t h i s s t a t e m e n t . The women i n t h e sample u sed f o r t h i s s t u d y do n o t c l u s t e r d i f f e r e n t l y f r o m t h e men. F o r t h i s r e a s o n t h e r e a r e few s p e c i a l r e f e r e n c e s i n t h e body o f t h e t e x t t o t h e women members o f t h e s a m p l e . They f o l l o w t h e same t r e n d s as t h e men. Responses t o t h e q u e s t i o n n a i r e a r e n o t s i g n i f i c a n t by s e x . P e r f o r m a n c e I t i s t h e o b j e c t o f t h i s t h e s i s t o d e m o n s t r a t e t h a t a " d e g r e e o f commitment" i s c o m p r i s e d o f many e l e m e n t s and t h a t i t o p e r a t e s as a s o c i a l mechani sm. However , a " common-sense t l e x p l a n a t i o n o f t h e commitment t h e s e s t u d e n t s e x p r e s s m i g h t be t h a t t h e y s t a t e a degree o f commitment - and change o r do n o t change - a c c o r d i n g t o how w e l l t h e y a r e a c t u a l l y d o i n g . T h a t i s , a c c o r d i n g t o t h e g r a d e s t h e y r e c e i v e . I n N o r t h A m e r i c a t h e r e i s a marked s t r e s s upon p e r -s o n a l a c h i e v e m e n t , e s p e c i a l l y o c c u p a t i o n a l a c h i e v e m e n t . T h e r e 20 M o r r i s R o s e n b e r g , O c c u p a t i o n s and V a l u e s , G l e n c o e , 1 1 1 . , F r e e P r e s s , 1957 , p . 5 0 . i s a l s o a marked s t r e s s on school achievement, and there i s a great d e a l of a n x i e t y from the very f i r s t grade, on the part of both parents and c h i l d r e n , that the c h i l d should "perform" w e l l . F i r s t on h i s l i s t of "major v a l u e - o r i e n t a t i o n s " i n America, Robin M. W i l l i a m s places "achievement and success". He w r i t e s : "The comparatively s t r i k i n g features of American c u l t u r e (with other s o c i e t i e s ) i s i t s tendency to i d e n t i f y standards of personal excellence w i t h competitive occupational 22 achievement." Within such a m i l i e u i n d i v i d u a l s seem to " l i k e b e s t " what they can do best. Therefore, i t i s a l o g i c a l p o s s i b i l i t y t hat the students who want "most" to become members of the medical p r o f e s s i o n are those students who, from t h e i r grades and achievements to date, f e e l most c e r t a i n that they are, i n f a c t , going to make the grade. The more c e r t a i n they are of t h e i r achievement, that i s , the higher t h e i r performance, the "more" committed they might be expected to be to the reward f o r t h e i r achievement. A f t e r the f i n a l examinations, r e s u l t s of the f i r s t year medical students were c l a s s i f i e d according to the 23 students' expressed degree of commitment. 21 Robin M. W i l l i a m s , J r . , American S o c i e t y , New York, Knopf, 1957, pp. 388-442. 22' I b i d . , p. 389. 23 The medical students at the U n i v e r s i t y of B r i t i s h Colum-b i a must have an average of s i x t y per cent or b e t t e r i n order to continue with t h e i r medical s t u d i e s . I f they have an average of s i x t y per cent, they can w r i t e supplemental examinations i n TABLE V: FIRST YEAR MEDICAL STUDENTS, PERCENTAGE DISTRIBUTION OF FINAL EXAMINATION RESULTS ACCORDING TO CHANGE IN EXPRESSED DEGREE OF COMMITMENT. Degree of Commitment Examination R e s u l t s Above Average Below Average To repeat or withdraw T o t a l U n c o n d i t i o n a l Q u a l i f i e d C o n d i t i o n a l U n c o n d i t i o n a l Changers: One of s e v e r a l careers Not most s a t i s f y -i n g career Q u a l i f i e d Changers: Only career Not most s a t i s -f y i n g career 4 0 . 7 ( 1 1 ) 5 0 . 0 ( 4 ) 1 0 0 . 0 ( 1 ) 4 4 . 4 ( 1 2 ) 3 7 . 5 ( 3 ) 1 4 . 8 ( 4 ) 1 2 . 5 ( 1 ) 1 0 0 . 6 ( 4 ) 1 0 0 . ; . 0 ( 1 ) 7 5 . 0 ( 6 ) 2 5 . 0 ( 2 ) 1 0 0 . 0 ( 1 ) 1 0 0 . 0 ( 2 7 ) 1 0 0 . 0 ( 8 ) 1 0 0 . 0 ( 1 ) 1 0 0 . 0 ( 4 ) 1 0 0 . 0 ( 1 ) 1 0 0 . 0 ( 8 ) 1 0 0 . 0 ( 1 ) up to three subjects i f the medical f a c u l t y agrees that the student i s capable of the work. The obtained average f o r t h i s student sample was 7 4 * 1 3 per cent, w i t h a standard d e v i a t i o n of 5 . 6 4 . Nineteen students i n the sample were above the average. The median score f o r t h i s sample was 7 2 per cent. Members of the sample who f a i l e d (obtained l e s s than 6 0 per cent) or d i d not w r i t e f i n a l examinations were not taken i n t o account i n the percentage compilations of c e n t r a l tendency because marks were not a v a i l a b l e f o r a l l students who are to repeat or withdraw from the f i r s t year ; of- medicine. Seven students i n the sample were required to w r i t e supple-mental examinations, f i v e of the u n c o n d i t i o n a l l y committed, and two of the q u a l i f i e d changers (only c a r e e r ) . 44 TABLE VI: EXAMINATION AVERAGES BY COMMITMENT GROUP. Degree of Commitment Average i n Percent Standard Deviation No. of Students Not most s a t i s f y i n g career (grouped f or anonymity) 79.0 3.6 3 Qualified 74.0 3.1 7 Unconditional 71.4 4.9 23 Unconditional Changers (one of several careers) 69.3 2.8 4 Qualified Changers (only career) 67.3 2.3 6 Obviously, from these figures, there i s no simple correlation between statements of the ''greatest* commitment and performance. The top f i v e students come from a variety of expressed commitments: Rank Degree of Commitment 1 Q u a l i f i e d Changer (not most s a t i s f y i n g career) - male 2 Unconditional - female 3 Unconditional - male 4 Qualified - female 5 Conditional - male Although there i s no d i r e c t correlation between state ments of the greatest commitment and marks received, there i s some connection between statements of commitment and marks received. The range of marks does d i f f e r by commitment group. The highest group marks are achieved by those three students who stated i n the f a l l that medicine i s "not the most s a t i s f y -ing career I can think of". This group i s followed by the two non-change groups, who are followed by the change groups. The same pattern i s apparent for i n d i v i d u a l students. F i r s t i n achievement i s a student who said medicine was "not the most s a t i s f y i n g career I can think of" i n the f a l l . He i s followed by non-changers. The student who stood twentieth i n the medical class i s the f i r s t changer to appear on the l i s t . The nine-teenth student i s i n the middle of the class standings. Changers, then, with the exception of the three "not most s a t i s f y i n g career" students, a l l stand i n the bottom half of the class . This i s so even though one group of students becomes more com-mitted between f a l l and spring. Degree of commitment i s not simply an expression of the students' expected performance l e v e l . Age and Socio-Economic Class In seeking to discover the basis of ind i v i d u a l s ' ideas and attitudes, sociologists have often, and frequently p r o f i t -ably, examined s o c i a l and economic fa c t s . Therefore, the group-ings by "degree of committedness" have been tabulated with socio-economic factors pertaining to the student sample. The c l a s s i f i c a t i o n of the students' fathers' occupations by Blishen's Canadian-occupation scale was explained previously. In t h i s thesis the f i r s t upper three classes are grouped together and the l a s t four classes are also grouped together. This clustering serves the purpose here where the interest is to determine whether or not coming from a "higher" or "lower" economic and social background has any influence on f i r s t , the likelihood of one's becoming a medical student and, second, students' expectations of, and their experiences in, medical school. There is no particular interest here in the specific "class" the students represent. Rather, the interest is in their general orientation to their "world'* arising out of their environment to date.^ In order to determine the length of time the deci-sion to study medicine has been settled in the students' minds, they were asked: "At what age did you definitely decide to study medicine?" The answers to this question were tabulated against the stated "degree of committedness" and students' fathers' occupations. The present age of the students is also set out in Table VII. By "present age" is intended the age given by the student upon entry into f i r s t year medical school. In this way i t can be estimated how long i t has taken students to reach their goal to enter medical school. This length of time, as stated previously, is directly related to the depth or committedness of a decision. 2A As the sample size is small, grouping also faci l i t a t e s analysis. Therefore, when "upper" and "lower" classes are referred to i t i s not intended in the usual categorical socio-logical sense. The reference w i l l be to the arbitrary dichotomy employed for this study of classes I - III as "upper" and classes IV - VII as "lower". This w i l l make the text less cumbersome. TABLE V I I : FIRST YEAR MEDICAL STUDENTS, AGE OF DECISION TO STUDY MEDICINE ACCORDING TO CHANGE IN DEGREE OF COMMIT- . MENT AND CLASS. Degree of Commitment Per cent of Students Class Mean Age at ' f i n a l ' D e c i s i o n Present Age ( F a l l 1959) Unconditional Q u a l i f i e d Changers (only career) Q u a l i f i e d U n c o n d i t i o n a l Changers (one of s e v e r a l careers) (not only career) Q u a l i f i e . d Changers (not only career) C o n d i t i o n a l 42.0 (21) 12.0 ( 6) 14-0 ( 7) 2.0 ( 1) 6 .0 ( 3) 10 .0 ( 5) 8 . 0 ( 4) 2 .0 ( 1) 2.0 ( 1) 2.0 ( 1) upper lower upper lower upper lower upper lower upper upper 18 . 1 yrs, 18.2 " 19.1 19.0 22.0 20.8 tt tt tt tt 20.0 " 19.0 " 19.0 " 22.0 " 23.0 yrs, 23.8 " 22.2 " 23.6 " 24.7 25.0 24.3 23.0 23.0 23.0 tt tt Taken as groups, the students i n classes I - I I I are younger upon e n t r y to f i r s t year medical school than those i n cla s s e s I V - V I I . However, those who come from the lower classes (IV-VII) made t h e i r " f i n a l " d e c i s i o n to study medicine at an e a r l i e r age than those who come from the upper classes ( I - I I I ) . This g e n e r a l i z a t i o n holds t r u e both f o r comparisons w i t h i n each commitment group and w i t h i n the c l a s s as a whole. Taking the c l a s s as a whole, on the average, members of the lower classes make t h e i r d e c i s i o n to study medicine nine months (at 19.0 years) before t h e i r upper c l a s s classmates. Time strengthens a decision. That i s , the longer a person has held a decision, the more often he i s l i k e l y to have verbalized t h i s decision to others and thought about i t himself. In our society occupational choice probably i s re-garded as the individual's major l i f e t i m e decision - at least for boys, marriage may be f o r g i r l s . A recurring question put to children and young people i s : "What are you going to be when you grow up?" Therefore, there i s ample opportunity to verbalize and to think about one's occupational choice. The more often the same choice has been stated, the more l i k e l y one i s to maintain and carry out that decision. I t should also be kept i n mind that medicine i s re-garded with high esteem and prestige i n our society, therefore, those who aspire to become members of the medical profession are given every encouragement by r e l a t i v e s , friends, and even strangers who hear of t h e i r s o c i a l l y acceptable and s o c i a l l y 'Worthy" int e n t i o n . A s children we 'learn'' i n our society to earn the love of relevant others by doing what they consider "acceptable", therefore, the would-be medical student, i n being ''encouraged'' i n a certain behaviour, goes through a patterned sequence that i s f a m i l i a r to him. H e ''knows'' the rewards (praise) and punishments (disappointment, withdrawal) that relevant others w i l l give to him for his performance. There-fore , i n t h i s case, there i s f a i r l y strong pressure and r e i n -forcement to help the lower class student to achieve his ambition. I t i s an honour to him, his family, his friends, and sometimes to his community, f o r him to become a medical student. I t i s l i k e l y that the student from the lower classes has to overcome many obstacles - economic and s o c i a l - and that many who wish to, do not make i t as f a r as the f i r s t year of medical school. However, i t i s also l i k e l y that those who do are f a i r l y determined and committed to succeed - both for themselves and for others. Thirteen students i n the sample come from classes IV-VII. Only two of these students are 2 5 "changers" i n t h e i r expression of commitment. While the lower class group has pressures to '"help" them develop a degree of committedness and, thus, a desire to learn to become a doctor, the upper class group has di f f e r e n t "aids" to a s s i s t t h e i r selection and achievement of a goal. F i r s t , i f a father i s i n the upper socio-economic classes of our society, i t i s l i k e l y that he can "give" his children, i n the f i n a n c i a l sense, what they want i n the way of an education -i f they have the i n t e l l e c t u a l p o t e n t i a l . Second, there i s pressure on children from the upper classes to choose a s u i t -able profession. Suitable from the point of view of t h e i r family's s o c i a l p o s i t i o n . For upper classes, as f o r the lower, medicine i s an acceptable career. Managerial positions may be preferred i n some upper-families over medical positions; s t i l l , medicine i s a "good" choice and one that i s l i k e l y supported. Children of upper class parents l i k e l y have less pressure on them to choose a career before i t i s almost time to a c t u a l l y embark upon a chosen path. In lower classes, 25 One student changed from "not most s a t i s f y i n g " to "only career" and one changed from "only career" to "one of several". Therefore, only one lower class student becomes less committed. choosing an occupation i s a major decision because i t deter-mines the s t y l e of l i f e one w i l l be able to achieve. There i s l i k e l y more and e a r l i e r tension around t h i s decision for lower classes. In the upper classes i t i s a question of maintaining, rather than having to achieve, a s t y l e of l i f e . The st y l e of l i f e of the upper classes prepares a c h i l d more adequately than the s t y l e of l i f e of the lower classes for entry into any of the professions. The upper classes provide t h e i r children with an environment that i s f i l l e d with learning s t i m u l i and know-ledge. They have the means to obtain books, music, a r t , t r a v e l and have greater access to mass communication media. Also, the family associates are l i k e l y l a r g e l y from the upper classes. These people often have had wide experience i n t h e i r learning endeavours and they are able to communicate t h e i r experiences to others. Coming from an upper class background implies that an i n d i v i d u a l has had greater opportunities f o r experience and learning, and, importantly, ''understands" the language of his teachers and professors because th i s i s the language he has grown up with. In short, the student from an upper class back-ground has the s o c i a l background to ready him fo r learning and to f a c i l i t a t e that learning. For him, learning to be a professional involves learning a professional body of knowledge For a lower class student of a profession i t may include much more: the s o c i a l attributes of the role ( i n the widest sense, how to t a l k , give orders to subordinates, and so on) being more d i f f i c u l t to master than the actual body of knowledge. To sum up, when the f i r s t year students presented themselves to the medical s c h o o l , the members of the lower s t r a t a had decided a t an e a r l i e r age than the members of the upper c l a s s e s to become doctors and are l i k e l y , i n t h i s regard, to be more deeply committed to become doctors because of the pressures of time and the reinforcement of the choice from s i g n i f i c a n t others. On the other hand, the members of the upper c l a s s e s w i l l have chosen medicine as a career when a l l careers are r e l a t i v e l y open to them and when they have known about d i f f e r e n t kinds of o p p o r t u n i t i e s , e.g., academic professions -although they might know of fewer jobs - that the lower classes might not know e x i s t . They w i l l a l s o have the s o c i a l background to f a c i l i t a t e l e a r n i n g . Although the members of the lower c l a s s e s decide ' d e f i n i t e l y to study medicine" at an e a r l i e r age than t h e i r upper c l a s s contemporaries, t h e i r c h r o n o l o g i c a l age, on the average, when they f i r s t enter medical school i s o l d e r . Although they decide sooner, i t takes them longer to get there. This suggests that the lower c l a s s e s have more "to overcome" -although i t may only be time. From Table V I I i t can be seen t h a t the o l d e s t group, at entry i n t o medical school, segregated by degree of commit-ment, are the q u a l i f i e d committed. The age d i s t i n c t i o n a p p l i e s f o r both upper and lower c l a s s groups. They were a l s o the old e s t when they made t h e i r f i n a l d e c i s i o n to study medicine. From these f a c t s alone i t appears that perhaps the most r e a l i s t i c assessment of a medical career has been made by the q u a l i f i e d committed group. They ''decided1' on t h i s career a f t e r 7 6 considering other careers. ° As they are older than t h e i r classmates, presumably they had a chance f o r a longer look,at, and exposure to, more occupations. Their decision, therefore, i s more l i k e l y to be supplemented by, or even based on, a more r a t i o n a l , r e a l i s t i c appraisal of what would be involved i n the choice of medicine as a career than the decision of t h e i r younger classmates whose decisions were made at an age of less experience. The group that made t h e i r " f i n a l " decision to study medicine at the e a r l i e s t age are the unconditionally committed. Numerically they are the largest group: twenty-seven students which represents over half (54 per cent) of the t o t a l sample. S i g n i f i c a n t l y , twenty-one of these students, forty-two per cent of the sample, come from backgrounds where t h e i r father i s i n one of the upper three classes. Six students come from back-grounds where t h e i r father i s i n one of the lower four classes. Generalizing, those who make t h e i r decision to study medicine "early" and come from the upper classes, express the greatest degree of commitment to a medical career. As Oswald H a l l has written, commitment to a career choice such as medicine i s reinforced through time and the example of "professional" parents. 26 A l l members of t h i s commitment group considered at l e a s t one other occupation seriously. Some of the unconditionally com-mitted stated that they did not consider any other occupation seriously. Of those fourteen students who change i n t h e i r ex-p r e s s i o n of commitment, twelve are from upper c l a s s backgrounds and two are from lower c l a s s backgrounds. Those who express more committedness i n the s p r i n g than i n the f a l l are younger both i n a t t a i n e d age and age at f i n a l d e c i s i o n than thenon-changers who, l i k e them, stated medicine was "one of s e v e r a l e q u a l l y s a t i s f y i n g careers". Those who express l e s s committed-ness i n the s p r i n g than i n the f a l l were older a t age of f i n a l d e c i s i o n but are now younger i n a t t a i n e d years than those non-changers who, l i k e them, s a i d medicine was the "only career" f o r them i n the f a l l . The students who are youngest upon entry i n t o medical school are the q u a l i f i e d changers (only c a r e e r ) . Seven of thes e i g h t students come from the upper c l a s s group. From t h i s evidence i t seems that age and c l a s s do i n f l u e n c e degree of commitment. The younger students are more apt to s t a t e a g r e a t e r commitment to a medical career but they are a l s o more apt to change t h e i r statement during the school year than the o l d e r students. A l l change groups are younger than the group which they were a f f i l i a t e d w i t h i n the f a l l . Seventy-four per cent of t h i s sample comes from the upper c l a s s e s . An examination of degree of commitment by c l a s s i n -d i c a t e s t h a t , p r o p o r t i o n a t e l y , the upper c l a s s students s t a t e a g r e a t e r commitment to t h e i r proposed medical career, but they change t h e i r statements during the ensuing year twice as o f t e n as t h e i r lower c l a s s peers. In t h i s section degree of commitment has been analyzed i n connection with some s o c i a l f a c t s : performance, age, and socio-economic class by father's occupation. I t i s apparent that degree of commitment varies with these f a c t s . A certain arrange-ment of these facts comprises a certain degree of commitment. Soci a l facts have been the data so f a r . They are s p e c i f i c , tangible, and they can be "measured'' according to some standard. Quantitative measurement i s less attainable for conceptions, attitudes, and experiences. The next sections deal with' these less s p e c i f i c s o c i a l e n t i t i e s and degree of commitment as a s o c i a l mechanism. CHAPTER V STUDENTS' SELF-IMAGE AND CAREER CHOICE The r e l a t i o n s h i p between self-image and choice has been d e l i n e a t e d p r e v i o u s l y . I n t h i s s e c t i o n the d i s c u s s i o n focuses on the self-image and the choice of a medical career. Every i n d i v i d u a l has an image of himself, a preconception of the v a r i o u s a t t r i b u t e s and drawbacks of a p a r t i c u l a r choice, e.g., a medical career, and a conception of how he would f i t i n w i t h a p a r t i c u l a r choice. , Here the i n t e r e s t i s on how the students view themselves i n r e l a t i o n to medicine and to medical t r a i n i n g , w i t h the emphasis on how these conceptions vary by commitment group. To become a medical doctor r e q u i r e s a long, concen-t r a t e d p e r i o d of t r a i n i n g . To become a medical s p e c i a l i s t r e q u i r e s even longer. Many p r o f e s s i o n a l d i s c i p l i n e s r e q u i r e a s i m i l a r l y long period of t r a i n i n g from t h e i r s o c i a l i z e e s ; but t h i s i s not a g e n e r a l l y acknowledged f a c t . The m a j o r i t y of people today have personal contact w i t h medical personnel. However, many never meet a PhD. Of the occupations most people are f a m i l i a r w i t h , medicine r e q u i r e s the longest most sustained t r a i n i n g p e r i o d . I t seems l i k e l y t h a t medical students, i n the beginning at l e a s t , would have a conception of medicine s i m i l a r to the p u b l i c image. They would l i k e l y consider medicine to r e q u i r e a longer p e r i o d of t r a i n i n g than most occupations and consider i t t o be "tough" course. To t e s t these assumptions, the sample was asked whether they expected medical school to be a " b a s i c a l l y tough" or a " b a s i c a l l y enjoyable" experience. In the f a l l , twenty-four per cent of the group expected t h e i r medical t r a i n i n g to be " b a s i c a l l y tough"; s e v e n t y - s i x per cent of the group expected t h e i r medical t r a i n i n g to be " b a s i c a l l y enjoyable". By s p r i n g , eighteen per cent of the group expected the remainder of t h e i r medical t r a i n i n g to be " b a s i c a l l y tough" and eighty-two per cent expected i t to be " b a s i c a l l y enjoyable". However, eight per cent of the group who, i n the s p r i n g , expected t h e i r t r a i n -i n g to be " b a s i c a l l y tough" expected i t to be "enjoyable" i n the f a l l . Only ten per cent of the sample s t a t e d t h a t i t would be " b a s i c a l l y tough" both f a l l and s p r i n g . Degree and constancy of commitment have no obvious r e l a t i o n to the enjoyment - or l a c k of enjoyment - expected during medical school, except i n one category. The uncondi-t i o n a l changers (only career) are evenly d i v i d e d i n September as to whether or not medical school i s going to be a " b a s i c a l l y enjoyable" experience. By s p r i n g a l l of t h i s group expect the remainder of t h e i r medical s c h o o l i n g t o be " b a s i c a l l y enjoyable". Although the sample g e n e r a l l y expects medical school to be a " b a s i c a l l y enjoyable" experience, they do not consider i t to be an easy course. The sample was asked to " r a t e " medi-cine w i t h law, engineering, d e n t i s t r y , o f f i c e r i n the army, physics PhD., and a psychology PhD., according to whether medical s t u d i e s ' are more d i f f i c u l t , l e s s d i f f i c u l t , or about 57 the same i n degree of d i f f i c u l t y as s t u d i e s i n these other f i e l d s . The m a j o r i t y of the medical students considered the study of medicine t o be more d i f f i c u l t than s t u d i e s i n the above-named f i e l d s , except a physics PhD., which they con-si d e r e d to be "about the same" i n degree of d i f f i c u l t y to o b t a i n . This s u b s t a n t i a t e s the contention that medical s t u -dents t h i n k medical t r a i n i g i s more d i f f i c u l t compared to other t r a i n i n g courses. This statement should be put along w i t h the previous statement t h a t the m a j o r i t y of medical s t u -dents expect t h e i r s c h o o l i n g to be " b a s i c a l l y enjoyable". I t would seem th a t t h i s sample of medical students i d e n t i f i e s w i t h t h i s " s e l e c t i v i t y " aspect of medicine. Medicine i s the most d i f f i c u l t to " l e a r n " ; that which i s more d i f f i c u l t to a t t a i n *Ls b e t t e r t h a n " t h a t which i s a c c e s s i b l e t o a l l , and, f u r t h e r , those t h a t are capable of undertaking the l fbest" and the "most d i f f i c u l t " are somehow b e t t e r than, or at l e a s t d i s t i n c t from, those t h a t do not. This r e l a t e s back to student self-image, and the d e c i s i o n to undertake the study of medicine. Students who e n r o l i n medical school consider medicine to be the "most d i f f i c u l t ' * of t h i s s o c i e t y ' s occupations, except physics which i s equal i n d i f f i c u l t y , and they t h i n k they are capable of surmounting t h i s b a r r i e r to become members of the "most d i f f i -c u l t " and, consequently, according to our s o c i e t y ' s values, the best occupation. Further, they expect to enjoy t h i s d i f f i -c u l t experience. Therefore, i t seems reasonable to propose t h a t , as a group, medical students are the most s e l f - c o n f i d e n t s o c i a l i z e e s of any v o c a t i o n a l t r a i n i n g group. This s e l f - c o n f i -dence i s r e i n f o r c e d i n t h i s area by the medical students' know-ledge that not only d i d they choose medicine as a career, and not only do they t h i n k they can succeed, but others, who belong to t h i s p r e s t i g e f u l p r o f e s s i o n , chose the students to become members of t h e i r p r o f e s s i o n because they a l s o t h i n k the students can succeed i n t h i s endeavour. An examination of the sample by degree of commitment h i g h l i g h t s the d i f f e r e n c e s , r a t h e r than the s i m i l a r i t i e s , among the medical student group. The u n c o n d i t i o n a l l y committed i n d i -cate the g r e a t e s t discrepancy between t h e i r conception of the d i f f i c u l t i e s i n v o l v e d i n medical t r a i n i n g and other t r a i n i n g programs. They consider medicine to be more d i f f i c u l t than any other d i s c i p l i n e , except physics which f o r t y per cent of t h i s commitment group consider to be equal i n d i f f i c u l t y , while twenty-three per cent consider medicine more d i f f i c u l t and t h i r t y - t h r e e per cent consider medicine l e s s d i f f i c u l t ( f o u r per cent "don't know"). The u n c o n d i t i o n a l changers (only career) and the q u a l i f i e d changers (one of s e v e r a l careers) f o r every occupa-t i o n have more r e p r e s e n t a t i v e s s t a t i n g medical t r a i n i n g i s " l e s s d i f f i c u l t " than other t r a i n i n g s i n the s p r i n g than they had i n the f a l l . This i s part of a general p a t t e r n on the part of a l l commitment groups to devaluate the " d i f f i c u l t y ' ' of medical t r a i n i n g i n the s p r i n g compared to t h e i r f a l l statements. The q u a l i f i e d committed consider medical t r a i n i n g to be of the same d i f f i c u l t y as other t r a i n i n g s more o f t e n than t h e i r peer groups. This i s p a r t i c u l a r l y so f o r d e n t i s t r y and physics. Although i n the spring a l l groups see medical t r a i n i n g as being more l i k e other t r a i n i n g , there i s a higher percentage of t h i s movement among the "changers" and the less committed (the q u a l i f i e d committed) than among the more committed ^lon-changers". This may be in d i c a t i v e of 1. a decline i n the idealism surrounding medical school when i t i s found to be much l i k e the pre-med years i n content and study-drudgery, and 2. i f medicine i s considered as "one of several careers" from the beginning, i t i s l i k e l y that i t i s not thought to be so very d i f f e r e n t from other careers one can imagine himself engaged i n . When t h i s idea i s confirmed through course content during the experience of the f i r s t year, more students state medicine i s of the same d i f f i c u l t y as other t r a i n i n g . As stated before, t h i s decline i n the image of medi-cine as being "better than" because i t i s "harder than" other careers i s general. I f "something" i n the learning process i s not substituted f o r t h i s damage to the self-confidence, one would expect 1. the students to be less enthusiastic, 2. less confident, 3. something i n the learning process happening to buoy or substitute for t h i s loss, or 4« some combination of the f i r s t three. This point s h a l l be considered again l a t e r . In the f a l l the students were asked what t h e i r ex-pectations were regarding several possible stress situations inherent i n the learning process. Exactly f i f t y per cent of the students f e l t they would f i n d i t d i f f i c u l t to keep up with the other students during the f i r s t year of medical school. The other f i f t y per cent expected no d i f f i c u l t y i n t h i s regard. Seven of the eight women i n the c l a s s expected to have t r o u b l e keeping up. Only one of the three students who stated medicine was "not the most s a t i s f a c t o r y career I can t h i n k of", ex-pected to have d i f f i c u l t y . The only commitment group whose m a j o r i t y expected to have d i f f i c u l t y was the q u a l i f i e d changers (only career) group. F i f t y per cent of the members of the non-change groups do not expect to have d i f f i c u l t y l e a r n i n g what i s expected of them. However, the m a j o r i t y of the changers do expect to ex-perience d i f f i c u l t y i n t h i s area. "Learning to t h i n k f o r your-s e l f was not considered to be a problem by the l a r g e m a j o r i t y of students ( e i g h t y per cent - two students d i d not answer the q u e s t i o n ) . Ten per cent of those who d i d expect to have d i f f i -c u l t y l e a r n i n g to t h i n k f o r themselves were changers. F i f t y -e i g h t per cent of the students d i d expect to have d i f f i c u l t y not a l l o w i n g themselves t o become o v e r l y tense or nervous about t h e i r work. Of the remaining forty-two per cent, t h i r t y - t w o per cent were non-changers and f o u r per cent d i d not answer the question. The u n c o n d i t i o n a l l y committed were the only group whose m a j o r i t y d i d not expect to have d i f f i c u l t y . They were d i v i d e d i n t o twelve students who expected t r o u b l e and t h i r t e e n who d i d not. Therefore, the s t r e s s was f e l t more s t r o n g l y i n the change groups. I f the above s i t u a t i o n s are considered as s t r e s s s i t u a t i o n s , i t i s f a i r l y c l e a r t h a t , f o r some reason, the non-changers experience l e s s s t r e s s than the changers. I n a d d i t i o n , the u n c o n d i t i o n a l l y committed experience p r o p o r t i o n a t e l y l e s s s t r e s s than the q u a l i f i e d committed. There i s no gross d i f f e r e n c e between the u n c o n d i t i o n a l and q u a l i f i e d changers. Students were a l s o asked how w e l l they expected to do i n t h e i r s t u d i e s compared to the r e s t of t h e i r c l a s s . The object of t h i s question was to assess whether or not t h i s was a l s o experienced as an a r e a of s t r e s s . TABLE V I I I : PERCENTAGE DISTRIBUTION OF FIRST YEAR MEDICAL STUDENTS' EXPECTED: ACHIEVEMENT. Expected Achievement FALL SPRING B e t t e r than average 48.0 (24) 42.0 (21) Average 30.0 (15) 44.0 (22) Below average 2.0 ( 1) 4.0 ( 2) Don't know 20.0 (10) 100.0 (50) 10.0 ( 5) 100.0 150) Of the twenty-four students i n the f a l l who s t a t e they expect to do " b e t t e r than average", seventeen students (69.7 per cent) are u n c o n d i t i o n a l l y committed. T h i r t e e n s t u -dents (61.8 per cent) i n the s p r i n g are from the same commit-ment group. 12.3 per cent i n the f a l l and 14*3 per cent i n the s p r i n g of the students who expected to do " b e t t e r than average" come from the q u a l i f i e d commitment group. The commitment groups are most i n t e r e s t i n g when examined w i t h regard to how they changed. By s p r i n g , none of the q u a l i f i e d changers (only career) expects to do b e t t e r than average. A l l other commitment groups haye some r e p r e s e n t a t i o n i n t h i s category. By s p r i n g , the three students who i n the f a l l s a i d medicine was "not the most s a t i s f y i n g career, I can t h i n k of", a l l s t a t e they expect t o do b e t t e r than average i n t h e i r s t u d i e s . The u n c o n d i t i o n a l changers (one of s e v e r a l careers) are outstanding f o r the consistency of t h e i r expectations. There i s a great d e a l of movement i n the other commitment groups among the expectation c a t e g o r i e s . This as not so f o r the aforementioned group. These students tend to remain i n the same category f a l l and s p r i n g . Twenty per cent of the sample begin by saying they "don't know" how they w i l l do compared to the r e s t of the c l a s s . When the f a l l q u e stionnaire was administered, students had l i t -t l e b a s i s f o r comparisons between themselves and t h e i r c l a s s -mates except the previous year's performance, about which there was d i f f e r e n t i a l knowledge. I t might be suggested that the twenty per cent who d i d not wish t o commit themselves i n the f a l l were w a i t i n g to see how they a c t u a l l y were going t o compare i n performance. Although t h i s might be regarded as a " r e a l i s t i c " approach, i t might a l s o be regarded as an index of i n s e c u r i t y , or at l e a s t a p r o t e c t i v e mechanism. Once one has v e r b a l i z e d what one expects t o do then others have a b a s i s f o r judging whether or not one, i n f a c t , "makes i t " . I t i s more d i f f i c u l t to be pleased w i t h doing l e s s than one expected to do than i t i s to be pleased w i t h doing as w e l l as was done when no previous g o a l was set up. I n t e r e s t i n g l y , i n the f a l l f i v e students ( f i f t y per cent) of the"don't knows" are from the u n c o n d i t i o n a l l y committed, none i s q u a l i f i e d committed, f i v e are changers i n commitment. I n the s p r i n g there are f i v e per-sons who s t a t e they "don't know" how they expect to do. Only one of these students was i n t h i s category i n the f a l l . The responses to t h i s question i n d i c a t e t h a t i n the area of achievement-expectations, the three students who begin s t a t i n g "not only career t h a t can s a t i s f y " are the most o p t i m i s t i c group; the q u a l i f i e d changers (only career) are the l e a s t o p t i m i s t i c ; the u n c o n d i t i o n a l changers are the most c o n s i s t e n t ; the q u a l i f i e d committed are the most de-l i b e r a t e ; and the u n c o n d i t i o n a l l y committed are h i g h l y o p t i -m i s t i c but p r o p o r t i o n a l l y most undecided of the commitment groups. I t would seem th a t a n t i c i p a t e d achievement was an area of s t r e s s , but that t h i s s t r e s s was experienced d i f f e r e n t i a l l y by commitment groups. Students' expectations were compared to t h e i r 2 7 a c t u a l achievement to see how r e a l i s t i c they were. 2 7 The top one-third of the c l a s s i s considered to be " b e t t e r than average"; the middle t h i r d i s considered to be "average"; and the bottom t h i r d of the c l a s s i s considered to be "below average". 64 TABLE IX: PERCENTAGE DISTRIBUTION OF STUDENTS' EXPECTATIONS COMPARED TO THEIR ACHIEVEMENT BY COMMITMENT GROUP. Commitment Group Marks B e t t e r than average Average Below average Don't know F a i l -ure's Exp. Ach. Exp. Ach. Exp. Ach. Exp. Ach. Nos. U n c o n d i t i o n a l 4 8 . 1 ( 1 3 ) 3 7 . 0 ( 1 0 ) 4 4 . 4 -( 1 2 ) 1 4 . 3 ( 4 ) 3 . 7 ( 1 ) 4 8 . 1 ( 1 3 ) 3 . 7 ( 1 ) — 4 U n c o n d i t i o n a l Changers: from one of s e v e r a l careers 5 0 . 0 (2) — 5 0 . 0 ( 2 ) 7 5 . 0 ( 3 ) — 2 5 . 0 ( 1 ) from not most s a t -i s f y i n g 1 0 0 . 0 ( 1 ) 1 0 0 . 0 ( 1 ) Q u a l i f i e d 3 7 . 5 ( 3 ) 3 7 . 5 ( 3 ) 2 5 . 0 ( 2 ) 5 0 . 0 ( 4 ) 1 2 . 5 ( 1 ) 1 2 . 5 ( 1 ) 2 5 . 0 ( 2 ) — 1 Q u a l i f i e d Changers: from only career — — 7 5 . 0 (6) 5 0 . 0 ( 4 ) — 5 0 . 0 ( 4 ) 2 5 . 0 ( 2 ) — 2 from not most s a t -i s f y i n g 1 0 0 . 0 ( 1 ) 1 0 0 . 0 ( 1 ) C o n d i t i o n a l 1 0 0 . 0 ( 1 ) 1 0 0 . 0 ( 1 ) The three students who stated i n the f a l l t hat "medi-cine was not the most s a t i s f y i n g career I can thi n k of" are a l l accurate i n t h e i r p r e d i c t i o n s t h a t they w i l l do " b e t t e r than average". Of the two major non-change groups, the Q u a l i f i e d committed group p r e d i c t s most a c c u r a t e l y . The u n c o n d i t i o n a l changers (one of s e v e r a l careers) are somewhat c l o s e r i n t h e i r expectations than the other major change group. Except f o r the three students mentioned and the q u a l i f i e d committed, a l l other groups over-estimated themselves. They expected to place higher i n t h e i r c l a s s than they d i d . No one s t a t e d they expected to f a i l , but seven students d i d . There were no f a i l u r e s among the u n c o n d i t i o n a l changers (one of s e v e r a l c a r e e r s ) . I n the three groups where there were f a i l u r e s , p r o p o r t i o n a l l y , the higher percentage was among the q u a l i f i e d changers (only c a r e e r ) . The students' a c t u a l achievement turns out to be r e f l e c t i v e of the g e n e r a l i z a t i o n s regarding the achievement-expectations. The three students who s t a t e d medicine was "not the only career t h a t could s a t i s f y " were the most o p t i m i s t i c w i t h good reason: t h e i r "better than average" expectations were r e a l i z e d . The q u a l i f i e d changers (only c a r e e r ) , who were l e a s t o p t i m i s t i c , had the highest p r o p o r t i o n of f a i l u r e s . The u n c o n d i t i o n a l changers (one of s e v e r a l c a r e e r s ) , who were c o n s i s t e n t i n t h e i r expectations, a l l passed. The q u a l i f i e d committed, the most d e l i b e r a t e and d e l i b e r a t i n g , p r e d i c t e d most a c c u r a t e l y of the two non-change groups. The uncondi-t i o n a l l y committed, h i g h l y o p t i m i s t i c but undecided, place both high and low on the achievement l i s t . The d i f f e r e n t commitment groups are i n d i c a t i v e of d i f f e r e n t degrees of r e a l i s m . Students were a l s o asked to p r o j e c t themselves i n t o the f u t u r e i n order to r e v e a l how they conceptualized them-selves as p r a c t i s i n g p hysicians i n t h e i r chosen career of medicine. I n the f a l l , f i f t y - e i g h t per cent of the c l a s s t h i n k they w i l l " t h i n k of themselves as doctors" by t h e i r i n t e r n year. Twenty-two per cent expect to th i n k of themselves as doctors before t h e i r i n t e r n year, and twenty per cent do not expect to have t h i s s e l f - c o n c e p t i o n u n t i l a f t e r t h e i r i n t e r n year. By s p r i n g , f o r t y - s i x per cent of the c l a s s expect to t h i n k of themselves as doctors during t h e i r i n t e r n year, t h i r t y - t w o per cent expect to have t h i s s e l f - c o n c e p t i o n e a r l i e r , and twenty-two per cent expect to have i t l a t e r than t h e i r i n t e r n year. S i g n i f i c a n t l y , the u n c o n d i t i o n a l l y committed expect to t h i n k of themselves as doctors e a r l i e r than the other s t u -dent groups. The movement, i n the s p r i n g , of some students to expecting to t h i n k of themselves as doctors sooner than they had expected i n the f a l l , comes p r i m a r i l y from two groups: the u n c o n d i t i o n a l l y committed and the u n c o n d i t i o n a l changers (one of s e v e r a l c a r e e r s ) . No q u a l i f i e d changer (only career) expects to t h i n k of himself as a doctor before h i s i n t e r n year. I n the sp r i n g of I960, there were f o u r students i n the sample who expected to t h i n k of themselves as doctors w i t h i n the next two years: three non-changers, two who are u n c o n d i t i o n a l l y committed and one who i s q u a l i f i e d committed; and one uncondi-t i o n a l changer (one of s e v e r a l c a r e e r s ) . From the foregoing i t i s apparent that the more intense the v e r b a l a l l e g i a n c e to the p r o f e s s i o n of medicine, the sooner one expects to t h i n k of himself as a member of that p r o f e s s i o n . A l l students would l i k e to have s u b s t a n t i a l p a t i e n t contact i n t h e i r t h i r d year or before. This was i n d i c a t e d both f a l l and s p r i n g . However, the m a j o r i t y of changers ( 6 6 . 7 per cent) would l i k e s u b s t a n t i a l contact i n t h e i r next year (second year of medical s c h o o l ) . In c o n t r a s t , 4 5 . 8 per cent of the non-changers s t a t e they would l i k e to wait u n t i l t h e i r t h i r d year f o r t h e i r f i r s t s u b s t a n t i a l p a t i e n t contact. T h i r d year i s the year when students are given s u b s t a n t i a l p a t i e n t contact. The students know t h i s before they enter medical school. This response seems to be an expression of t h e i r general impatience. Impatience i s more l i k e l y to be held i n check when things are going w e l l r a t h e r than when they are not P r o j e c t i o n i s a common defense mechanism against f r u s t r a t i o n . I n t h i s instance the students - p r i m a r i l y the changers - seem to be saying that the medical school i s not doing things " r i g h t " , they withhold p a t i e n t s from students too long. This may be e a s i e r to say than: "Medical school and my expectations of medical school are not the same - I'm having a f r u s t r a t i n g time of i t . " This f r u s t r a t i o n could be i n any one or a number of areas - d i s p a r a t e expectations regarding course content, p a t i e n t contact, s c h o l a s t i c performance, and so on. The s i g n i f i c a n t d i f f e r e n c e s i n response to t h i s question i s by change and non-change groups, r a t h e r than by commitment groups. The change groups are the more impatient. Looking even f a r t h e r ahead, students were asked what kind of a working s i t u a t i o n they would p r e f e r . TABLE X: PERCENTAGE DISTRIBUTION OF FIRST YEAR MEDICAL STU-DENTS' PREFERENCES FOR THE WORK SITUATION IN WHICH THEY WOULD LIKE TO CARRY OUT THEIR PROFESSIONAL ACTIVITY. F a l l Spring. Own p r o f e s s i o n a l o f f i c e w i t h h o s p i t a l a f f i l i a t i o n 6 0 . 0 ( 3 0 ) 6 0 . 0 ( 3 0 ) Own p r o f e s s i o n a l o f f i c e without h o s p i t a l a f f i l i a t i o n - 4 . 0 ( 2 ) Large p r i v a t e c l i n i c or h o s p i t a l 1 8 . 0 ( 9 ) 1 2 . 0 ( 6 ) Small group c l i n i c 1 2 . 0 ( 6 ) 1 4 . 0 ( 7 ) Medical s c h o o l 6 . 0 ( 3 ) 6 . 0 ( 3 ) Other 4 . 0 ( 2 ) 4 . 0 ( 2 ) 1 0 0 . 0 ( 5 0 ) 1 0 0 . 0 ( 5 0 ) Although the percentages f o r f a l l and s p r i n g are f a i r l y s i m i l a r , f o r t y per cent of the sample gave a d i f f e r e n t response i n the s p r i n g than they d i d i n the f a l l . I n q u a n t i t y of movement, the non-changers are l e s s a c t i v e than the changers. One quarter of the u n c o n d i t i o n a l l y committed and one h a l f of the q u a l i f i e d committed changed t h e i r mind during the school term about the kind of work s e t t i n g they p r e f e r r e d . Over one h a l f of each of the change groups gave d i f f e r e n t responses f a l l and s p r i n g . Again, the changers are more u n s e t t l e d than the non-change groups. The choices revolve p r i m a r i l y around three a l t e r n a t e s e t t i n g s : own o f f i c e w i t h h o s p i t a l a f f i l i a t i o n , a l a r g e private c l i n i c or h o s p i t a l , and a small group c l i n i c . I t i s not surprising that s i x t y per cent of the students i n the f a l l and againihthe spring chose as t h e i r preference "own professional o f f i c e with h o s p i t a l a f f i l i a t i o n " . This i s the usual image of the doctor: a man i n a white coat i n his own o f f i c e . Like asking students what specialty f i e l d they would prefer to prac-t i c e , t h i s question, involves an issue to which they may have not given much thought and which requires no immediate answer. Also, students do not know the advantages and disadvantages of one setting over another, The choice at t h i s time, therefore, has l i t t l e d i r e c t significance for the future. However, there i s a tendency f o r proportionally more of those who belong to some other group than the unconditionally committed to indicate at one time or the other a preference f o r group and c l i n i c practice. In c l i n i c practice there can be a "sharing" of time and r e s p o n s i b i l i t y . Also, a number of s p e c i a l i s t s can locate under one roof for speedier r e f e r r a l s and l i k e l y more e f f i c i e n t communication of information regarding patients. On the other hand, the man who practices alone, bears the f u l l r e s p o n s i b i l i t y f o r his patient himself. However, his work - triumphs and errors - are much less v i s i b l e to others than they might be i n a group practice. This "weighing" of settings against one another could go on. For the purpose of t h i s thesis, however, i t i s indicated that the unconditionally committed have a greater wish to do i t " a l l alone", a greater s e l f - r e l i a n c e , and are more constant i n t h e i r choice with regard to themselves as medical p r a c t i t i o n e r s . The u n c o n d i t i o n a l l y committed are more sure of t h e i r place i n the medical m i l i e u x than t h e i r peers. They have thought out - or at l e a s t i d e n t i f i e d w i t h -the e x t e r n a l and v i s i b l e symbols of the medical doctor. To estimate the rewards the students expected from medicine i n terms of f i n a n c i a l r e t u r n s , the students were asked "What y e a r l y income do you r e a l i s t i c a l l y expect at the peak of your career?" TABLE X I : FIRST YEAR MEDICAL STUDENTS' AVERAGE ESTIMATES OF YEARLY INCOME AT PEAK OF CAREER BY COMMITMENT GROUP Commitment Group F a l l Estimate Spring Estimate U n c o n d i t i o n a l l y committed $ 1 5 , 9 2 3 # 1 6 , 8 8 4 Q u a l i f i e d committed 1 5 , 6 2 5 1 4 , 3 7 5 Q u a l i f i e d changers (only career) 1 7 , 5 0 0 1 5 , 3 1 3 U n c o n d i t i o n a l changers (one of s e v e r a l careers) 1 7 , 5 0 0 1 7 , 5 0 0 Not most s a t i s f y i n g career i n f a l l (three students) 1 9 , 1 6 6 1 4 , 1 6 6 The average expected income at the peak of t h e i r careers f o r the sample as a whole i n the f a l l was $ 1 7 , 1 7 2 and i n the s p r i n g was $ 1 5 , 2 2 5 . A c r o s s - s e c t i o n of United State f i r s t year medical students i n 1 9 5 6 s t a t e d they expected to be making $ 2 2 , 3 4 0 a year at the peak of t h e i r careers. 2$ D. Cahalan, P. C o l l e t t e , and N.A. Hilmar, "Career I n t h i s sample, those students who, i n the s p r i n g , s t a t e medicine i s the "only career" f o r them, rate t h e i r f u t u r e earnings higher.than do t h e i r contemporaries , who do not see medicine as the "only" s a t i s f y i n g career they can t h i n k o f . In f a c t , the u n c o n d i t i o n a l l y committed are the only group t h a t t h i n k s by s p r i n g t h a t they w i l l earn more than they had p r e v i o u s l y prophesized i n the f a l l . 2Q The Canadian Department of N a t i o n a l Revenue i n 1959 published the t o t a l "earned income assessed" of medical doctors and surgeons i n Canada who "work f o r themselves f o r g a i n " as #157,240,000. This i s an average y e a r l y income, of #13,376. The average t o t a l earned income assessed f o r medical doctors and surgeons i n B r i t i s h Columbia was $16,133 i n 1959. From these f i g u r e s i t would appear t h a t the students i n the sample have a r e a l i s t i c p i c t u r e of t h e i r f u t u r e income according to present standards. The estimates by commitment group, however, i n d i c a t e that the group which so f a r has shown the g r e a t e s t d e l i b e r a t i o n , the q u a l i f i e d committed, expect to earn l e s s than t h e i r c l a s s -mates. I n the spring,the three "not most s a t i s f y i n g career" i n the f a l l students made a s i m i l a r l y low estimate. L i k e the I n t e r e s t s and Expectations of U.S. Medical Students", J . of  Medical Education, Aug. 1957, V o l . 32, No. 8, p. 560. 29 Taxation D i v i s i o n , Taxation S t a t i s t i c s , 1959. Queens P r i n t e r , Ottawa, 1959. q u a l i f i e d committed, these three students made an accurate estimate of t h e i r performance - which was high. From these estimates i t would seem that the more single-minded one i s about a career i n medicine, the more f i n a n c i a l returns one expects. That i s , for this sample, the greater the verbal en-dorsement of a medical career, the higher the expected f i n a n c i a l returns. There has been some conjecture equating occupational choice and personality, e.g., pediatricians are persons who suffered s i b l i n g r i v a l r y - they want to work with children because they are, at l a s t , biggest and strongest (vis - a - v i s a patient). This presumably could be one basis f o r a student's preference for one specialty f i e l d or another, or i n the early stages of t r a i n i n g p a r t i c u l a r l y , students might chose f o r them-selves the career they considered most p r e s t i g e f u l within the profession, or, perhaps, a student might be drawn to the s p e c i a l -ized subject matter of a specialty. In an e f f o r t to uncover patterns of choice, students were asked which f i e l d of medicine they would prefer to enter. No outstanding patterns emerged. The choices were scattered both f a l l and spring with no apparent connection. In the f a l l , surgery was chosen by twenty-six per cent of the sample - twenty-two per cent being from the unconditionally committed group. In the spring, surgery was chosen by twenty-two per cent of the sample -fourteen per cent from the unconditionally committed group. Pediatrics was mentioned by fourteen per cent of the class i n the f a l l , eighteen per cent i n the s p r i n g ; medicine by s i x per cent i n the f a l l , eighteen per cent i n the s p r i n g . These three s p e c i a l t i e s are p r e s t i g e f u l w i t h i n the medical p r o f e s s i o n . Surgery, p a r t i c u l a r l y , has an aura of glamour surrounding i t . An unexpected choice of t h i s sample, however, was made by the two per cent of the sample i n the f a l l , but twenty-two per cent i n the s p r i n g , who stat e d p u b l i c h e a l t h was t h e i r career choice. This was unexpected because p u b l i c h e a l t h as a medical career 30 r a t e s low on the p r e s t i g e s c a l e . Neophytes g e n e r a l l y i d e n t i f y w i t h the most p r e s t i g e f u l p o s i t i o n or person. Sixty-two per cent of the students gave a d i f f e r e n t choice i n the s p r i n g from t h e i r f a l l c hoice. Of the remainder, twenty-four per cent were from the u n c o n d i t i o n a l l y committed. This would seem t o i n d i c a t e t h a t , f i r s t , g e n e r a l l y the students are not s e t t l e d i n t h e i r choice of s p e c i a l t y w i t h i n the f i e l d of medicine and, second, w i t h i n an unstable area, the uncondi-t i o n a l l y committed are r e l a t i v e l y s t a b l e . F o r t y - f o u r per cent of t h i s l a t e r group do not change i n s p e c i a l t y choice during t h e i r f i r s t year i n medical school. I t seems that not only d i d the u n c o n d i t i o n a l l y com-mitted group decide to become doctors at an e a r l i e r age than t h e i r contemporaries, but they have a l s o decided on what kind of doctor they want to become. This suggests that t h e i r i d e n t i f i c a t i o n with a career i n medicine i s i n t e n s e . 30 In the A.A.M.G.'s, The Ecology of the Medical Student, where students and medical f a c u l t y rated s p e c i a l t i e s , p u b l i c h e a l t h appears only i n the " l e a s t l i k e d " column, p. 177. For most medical students i n t h e i r f i r s t year the question of s p e c i a l t y choice i s i r r e l e v a n t , ^hey do not know enough about the var i o u s s p e c i a l t i e s to make a choice. That members of t h i s sample s t i l l s t a t e a s p e c i f i c choice, i s not out of character. As c h i l d r e n , they responded when asked: "What are you going to be when you grow up?" C h i l d r e n go through v a r i o u s phases when they respond to t h i s a d u l t "game" w i t h an " I don't know". U s u a l l y , however, the c h i l d has an answer - o f t e n v a r y i n g w i t h the day. I t i s simpler to s a t i s f y the a d u l t s and "play the game". Medical students, l i k e a l l students, have had '^practice" s t a t i n g o c c u p a t i o n a l choices. These are forced choices - made without considering - or o f t e n knowing - the a l t e r n a t i v e s . They are i n no way regarded as bi n d i n g u n t i l the choice i s repeated o f t e n and over a length of time. Then, both the asker and the respondent, begin to take the answer s e r i o u s l y . So f a r , i t would seem tha t the m a j o r i t y of our sample have not s e t t l e d to one response. The data at hand do not continue t o the time when students graduate and have to make a d e c i s i o n of consequence regarding t h e i r f i e l d of s p e c i a l t y y This would be a f t e r the required year of i n t e r n s h i p . For t h i s question consistency of answers between two time periods p e r t a i n s to only the one group of non-changers The q u a l i f i e d committed may be i n c o n s i s t e n t i n t h e i r response to t h i s question, but they are a c t i n g c o n s i s t e n t l y i n accordanc w i t h t h e i r general p a t t e r n . I f t h i s group " d e f i n i t e l y decided" to study medicine a t a l a t e r age than the other groups, then i t i s i n character t h a t they should d e f i n i t e l y decide upon t h e i r choice of s p e c i a l t y a t a l a t e r age. This <gives them an oppor-t u n i t y to look around, to see where there are o p p o r t u n i t i e s , what appeals and what does not, where one would f i t i n and where one would not. Why do medical students s t a t e the p a r t i c u l a r s p e c i a l t y they do, when asked? A medical student pondering t h i s question s a i d t h a t students gave a s p e c i a l t y because "people are always a s k i n g . . . you don't know y e t * , , i t develops as you go along." T h i s student s t a t e d f u r t h e r t h a t "choices" were a r r i v e d a t s i m i l a r l y to c h i l d r e n ' s choices. The most recent s t i m u l a t i n g r e p r e s e n t a t i v e or v i s u a l p r e s e n t a t i o n of an occupation (or s p e c i a l t y ) i s the c l e a r e s t model at hand, so that i s "what 1 want to do." Even fewer students remain constant i n t h e i r s t a t e -ments of the f i e l d s they would l e a s t l i k e to enter. Seventy-f o u r per cent of the students g i v e a d i f f e r e n t choice i n the s p r i n g than they d i d i n the f a l l . Again, the u n c o n d i t i o n a l l y committed have the only s i g n i f i c a n t segment remaining constant. Seventeen per cent of t h i s group (Ten per cent of the sample) s t a t e they would l e a s t l i k e to be a p s y c h i a t r i s t . An a d d i t i o n a l e i g h t per cent from other commitment groups share t h i s d i s l i k e f o r p s y c h i a t r y . Dermatology i s the only other s p e c i a l t y t h a t any number of students say they would not l i k e to p r a c t i c e -s i x per cent of the sample i n the f a l l , twelve per cent i n the s p r i n g (four per cent are constant on t h i s choice, both xfomen). L i k e t h e i r s p e c i a l t y preference, but to an even greater degree, i s i n character t h a t they should d e f i n i t e l y decide upon t h e i r choice of s p e c i a l t y at a l a t e r age. This gives them an oppor-t u n i t y to look around, to see where there are o p p o r t u n i t i e s , what appeals and what does not, where one would f i t i n and where one would not. Why do medical students s t a t e the p a r t i c u l a r s p e c i a l t y they do, when asked? A medical student pondering t h i s question s a i d t h a t students gave a s p e c i a l t y because "people are always aski n g . . . you don't know y e t . . . i t develops as you go along." This student s t a t e d f u r t h e r t h a t "choices'' were a r r i v e d at s i m i l a r l y to c h i l d r e n ' s choices. The most recent s t i m u l a t i n g r e p r e s e n t a t i v e or v i s u a l p r e s e n t a t i o n of an occupation (or s p e c i a l t y ) i s the c l e a r e s t model at hand, so that i s "what I want to do." Even fewer students remain constant i n t h e i r s t a t e -ments of the f i e l d s they would l e a s t l i k e to enter. Seventy-four per cent of the students give a d i f f e r e n t choice i n the s p r i n g than they d i d i n the f a l l . Again, the u n c o n d i t i o n a l l y committed have the only s i g n i f i c a n t segment remaining constant. Seventeen per cent of t h i s group (Ten per cent of the sample) s t a t e they would l e a s t l i k e to be a p s y c h i a t r i s t . An a d d i t i o n a l e i g h t per cent from other commitment groups share t h i s d i s l i k e f o r p s y c h i a t r y . Dermatology i s the only other s p e c i a l t y t h a t any number of students say they would not l i k e to p r a c t i c e -s i x per cent of the sample i n the f a l l , twelve per cent i n the s p r i n g (four per cent are constant on t h i s choice, both women). L i k e t h e i r s p e c i a l t y preference, but to an even greater degree, 76 i t seems that the m a j o r i t y of students have not " d e f i n i t e l y decided" on t h e i r s p e c i a l t y of l e a s t preference. Again, a l l students make a choice - they do not say, "don't know", or r e f r a i n from answering. This seems to be part of the l e a r n i n g process: what i s l i k e d best - or l e a s t - or the development of n e u t r a l i t y . To begin to answer t h i s dilemma requires data f o r at l e a s t the f o u r medical school years. Seventy-eight per cent of the student sample i n the f a l l a n d • e i g h t y - s i x per cent i n the s p r i n g express l i t t l e or no a n x i e t y regarding whether or not they w i l l be able to have the kind of medical career they d e s i r e . Of the remaining t h i r t y -two per cent i n the f a l l , ten per cent are women. P r o p o r t i o n a t e l y , the non-changers express more anxiety than the changers. How-ever, by sp r i n g there i s l i t t l e expressed a n x i e t y from any group. For a l l students, the a c t u a l p r a c t i c e of medicine seems f a r d i s t a n t at t h i s p o i n t . There are many p r e s s i n g problems which have to be taken care of immediately, not f o u r or f i v e years hence, such as passing term examinations. G e n e r a l l y , the questions d e a l i n g w i t h the futu r e seem to e l i c i t r a t h e r tenuous responses from many students. Dealing w i t h the present, each student rated the im-portance of 1. f e l l o w students' comments, 2. informat i o n from the f a c u l t y , and 3. personal s e l f - e v a l u a t i o n i n determining how w e l l he thought he was doing i n f i r s t year medical s c h o o l . No student i n the sample ranked himself t h i r d ( l a s t ) i n importance f o r s e l f - e v a l u a t i o n i n the f a l l . In the s p r i n g , f o u r students ranked the sequence 1. f a c u l t y , 2. students, 3. s e l f . TABLE X I I : PERCENTAGE DISTRIBUTION OF STUDENTS' RANKING OF INFLUENCES ON DECIDING HOW WELL THEI ARE DOING Influences • F a l l S pring S e l f - f a c u l t y - other students S e l f - other students - f a c u l t y F a c u l t y - s e l f - other students F a c u l t y - other students - s e l f Other students - s e l f - f a c u l t y No answer 18.0 ( 9) 3 0 . 0 (15) 3 0 . 0 (15) 12 .0 ( 6) 10.0 ( 5) 38.0 (19) 3 6 . 0 (18) 18.0 ( 9) 8 . 0 ( 4) 100.0 (50) 100.0 (50) At both p o i n t s i n time, the s e l f i s the most important source of e v a l u a t i o n f o r t h i s sample; f o r t y - e i g h t per cent i n the f a l l ranked !'self" f i r s t , and seventy-four per cent d i d s i m i l a r l y i n the s p r i n g . T h i s , again, points to the s e l f - c o n -f i d e n c e of the sample. They are not l o o k i n g to others f o r a p p r a i s a l - which i s oft e n accompanied by the search f o r p r a i s e , or at l e a s t , support. G e n e r a l l y , the medical student considers h i m s e l f the best judge of how w e l l he i s doing. Examining the d i s t r i b u t i o n by commitment group, f o r the non-changers the " s e l f " i s t h e i r main e v a l u a t o r . However, the second most important i n f l u e n c e i n e v a l u a t i o n are f e l l o w students f o r the u n c o n d i t i o n a l l y committed, and the f a c u l t y f o r the q u a l i f i e d committed. One group seems to r e l y more on i t s peers, the other group more on i t s s u p e r i o r s . Among the changers, a l s o , the " s e l f " was overwhelm-i n g l y the major evaluator of performance. However, other students' opinions d i d not rank high f o r any of the change groups. From the data i t seems that the medical student i s a f a i r l y s e l f - r e l i a n t s o c i a l i z e e . Compared wi t h t r a i n i n g f o r other p r o f e s s i o n s , the f i r s t year medical students t h i n k that medical t r a i n i n g i s more d i f f i -c u l t - except f o r a Ph.D. i n p h y s i c s , which they consider to be equal or s l i g h t l y more d i f f i c u l t than medicine. The extent of t h i s d i f f e r e n c e narrows between f a l l and s p r i n g . A l s o , the co m p a r a b i l i t y of medicine to other careers d i f f e r s by commit-ment group. Those students who begin with an u n c o n d i t i o n a l commitment to medicine, see the career as having more unique aspects than do the students who begin w i t h a q u a l i f i e d commitment. While the students t h i n k of medical t r a i n i n g as a "tough" course, at the same time, the m a j o r i t y of t h i s sample expect t h e i r medical t r a i n i n g to be b a s i c a l l y an enjoyable experience. In s t r e s s s i t u a t i o n s the changers expect to have more d i f f i c u l t y than the non-changers. In e s t i m a t i n g what t h e i r a c t u a l achievement l e v e l w i l l be, there i s a f a i r amount of movement between f a l l and s p r i n g f o r a l l commitment groups except f o r the u n c o n d i t i o n a l changers. However, only two students i n the sample estimate that t h e i r performance w i l l be "below average". In f a c t , eighteen per cent of the sample f a i l , and an a d d i t i o n a l f o r t y - f o u r per cent score below the c l a s s average mark. 79 The -majority of the sample expect to th i n k of them-selves as doctors by t h e i r year of i n t e r n s h i p or before. How-ever, the u n c o n d i t i o n a l l y committed, on the average, expect to th i n k of themselves as doctors sooner than t h e i r contemporaries. The f i r s t s u b s t a n t i a l p a t i e n t contact i s hoped f o r during the t h i r d year of medical school by most students. I t i s common knowledge among the students t h a t i t i s during t h e i r t h i r d year that they are scheduled to be in v o l v e d w i t h p a t i e n t s . There-f o r e , i t i s s i g n i f i c a n t t h a t two t h i r d s of the changers s t a t e t h a t they would l i k e s u b s t a n t i a l p a t i e n t contact before the t h i r d year of medicine. The students are q u i t e u n s e t t l e d as to what k i n d of a work environment they would l i k e to enter i n t o upon graduation. There i s a great d e a l of movement between f a l l and s p r i n g . This seems to be one of those questions whose answer i s not important to the students j u s t now. This i s one d e c i s i o n that can be put o f f f o r at l e a s t f o u r years. However, the ma j o r i t y i n d i c a t e d t h a t they could l i k e an o f f i c e of t h e i r own wit h a h o s p i t a l a f f i l i a t i o n . The u n c o n d i t i o n a l l y committed were the most con-s t a n t i n t h i s statement, while the other groups were more i n c l i n e d to consider group p r a c t i c e set-ups. As a group, the sample has r e a l i s t i c f i n a n c i a l ex-pe c t a t i o n s . The students' estimate of t h e i r expected f i n a n c i a l income at the peak of t h e i r careers coincides w i t h the present income of doctors i n B r i t i s h Columbia. The estimates d i f f e r , however, by commitment group. The gr e a t e r the v e r b a l endorse-ment of a medical career, the higher the expected f i n a n c i a l r e t u r n . P r o j e c t i o n of career plans s e v e r a l years i n t o the f u t u r e i s not f i n a l i z e d i n t h i s sample. There i s a great d e a l of change between f a l l and s p r i n g preferences and d i s l i k e s of s p e c i a l t y f i e l d s . At t h i s stage i n t h e i r t r a i n i n g , few s t u -dents express a n x i e t y t h a t they w i l l not be able to have the kind of medical career they d e s i r e . In the e v a l u a t i o n of how w e l l he i s doing i n medical school to the end of the f i r s t year, of most importance to the student i s h i s s e l f - e v a l u a t i o n . The second most important i n -d i c a t o r d i f f e r s by commitment group. The u n c o n d i t i o n a l l y com-mitted value t h e i r f e l l o w - s t u d e n t s ' opinions next to t h e i r own, while the other groups value the f a c u l t y ' s opinions next to t h e i r own. CHAPTER VI CONCEPTIONS OF MEDICINE AS A CAREER To see oneself i n r e l a t i o n to a p a r t i c u l a r career e n t a i l s not only a conception of oneself i n r e l a t i o n t o the career, but a l s o a conception of what i s involved w i t h i n the career i t s e l f . A p o t e n t i a l candidate assesses not only h i m s e l f . He "assesses" the career. I f a career i s embarked upon w i t h a f a l s e impression of the s e l f , i t appears to make a d i f f e r e n c e . I n the l a s t s e c t i o n there i s a c o n s i s t e n t d i f f e r e n c e i n response according to whether or not one changes one's "degree of commitment" or remains constant i n "commitment". Change i m p l i e s a reassessment of a formerly held c o n v i c t i o n . I n t h i s s e c t i o n , change, non-change, and "degree of commitment* groups are examined with the focus on the conception of medicine as a career r a t h e r than, as i n the l a s t s e c t i o n , on the conception of the s e l f i n a medical career. The students were asked: "In your op i n i o n , which one of (the f o l l o w i n g ) phrases best describes the medical p r o f e s s i o n ? " The sample responses are shown i n Table X I I I . TABLE X I I I : PERCENTAGE DISTRIBUTION OF STUDENT CHOICES OF THE BEST DESCRIPTION OF THE MEDICAL PROFESSION D e s c r i p t i o n F a l l Spring A p r o f e s s i o n which has high standing i n the community 10.0 ( 5) 10.0 ( 5) A p r o f e s s i o n of s e r v i c e to the community 54.0 (27) 50.0 (25) A p r o f e s s i o n which Is secure and l u c r a t i v e — — A p r o f e s s i o n which helps i n d i v i d u a l s d i r e c t l y 30.0 (15) 30.0 (15) A p r o f e s s i o n i n which r e a l a b i l i t y i s recognized by one's colleagues — 2.0 ( 1) A p r o f e s s i o n r e q u i r i n g harder work than others 4.0 ( 2) 8.0 ( 4) No answer 2.0 ( 1) — 100.0 (50) 100.0 (50) S i g n i f i c a n t l y , by s p r i n g , of those ten students who t h i n k medicine i s best described n e i t h e r by "A p r o f e s s i o n of s e r v i c e to the community" nor "A p r o f e s s i o n which helps i n d i -v i d u a l s d i r e c t l y " , s i x are u n c o n d i t i o n a l l y committed. They r e f e r medicine back to what i t can do f o r them r a t h e r than g i v i n g the normative response of the sample which i s s t a t e d i n terms of what medicine can do f o r others. In any event, e i g h t y per cent of the sample see medicine as a " s e r v i c e " and "helping p r o f e s s i o n . No student t h i n k s the p r o f e s s i o n can best be described as "secure and l u c r a t i v e " . Seen as a group, there i s l i t t l e change i n o p i n i o n as to what best describes the medical p r o f e s s i o n , between f a l l and s p r i n g . I t i s , of course, s i g n i f i c a n t and i n t e r e s t i n g to note the order i n which students endorse these statements. More p e r t i n e n t to t h i s study, however, i s the f a c t t h a t , although these f i g u r e s f o r f a l l and. s p r i n g are almost i d e n t i c a l , f i f t y -s i x per cent (twenty-eight students) give a d i f f e r e n t response i n the s p r i n g to what they d i d i n the f a l l . This i n d i c a t e s t h a t , although the general areas of consensus do not change, the students do. The t o t a l s of the responses are noteworthy f o r t h e i r s t a b i l i t y ; the students' i n d i v i d u a l responses are noteworthy f o r t h e i r i n s t a b i l i t y . F u r t h er, the p r o p o r t i o n of change v a r i e s w i t h i n a commitment group. I f the commitment groups are arranged according to students' expressed change w i t h i n t h e i r commitment group, the l e a s t change f i r s t , one f i n d s the f o l l o w i n g : Per cent of students who change Commitment group 25.0 U n c o n d i t i o n a l changers (one of s e v e r a l careers) 37.5 Q u a l i f i e d committed 62.5 Q u a l i f i e d changers (only career) 62.9 U n c o n d i t i o n a l l y committed 66.6 "Not most s a t i s f y i n g career" i n the f a l l - two changed i n s p r i n g . The low percentage of change i n the top two groups i n d i c a t e s l e s s s t r e s s than i n the other three groups i n at l e a s t the area p e r t a i n i n g t o these questions. With regard to these same statements, the students were asked i f they considered them to be a "very good des-c r i p t i o n " , a ' Tair d e s c r i p t i o n " , or a "poor d e s c r i p t i o n " of the medical p r o f e s s i o n . Many students d i d not mark any of the statements as "poor d e s c r i p t i o n s " . Out of a p o s s i b l e three hundred responses, "poor d e s c r i p t i o n " was marked only s i x t y - t h r e e times i n the f a l l and f i f t y times i n the s p r i n g . However, the responses to t h i s question c l u s t e r e d around three statements: 1. A p r o f e s s i o n which i s secure and l u c r a t i v e . 2. A p r o f e s s i o n i n which r e a l a b i l i t y i s recognized by one's colleagues. 3. A p r o f e s s i o n r e q u i r i n g harder work than others. Most students' answers c l u s t e r around the middle range - a " f a i r d e s c r i p t i o n " - i n t h i s q uestion. Students were al s o asked: "What things do you th i n k you w i l l l i k e best about being a doctor?" Table XIV i n d i c a t e s the sample's responses. Table XV i n d i c a t e s the d i f f e r e n t i a l emphasis placed by the commit-ment groups. 31 Students were asked to check as many of the above statements as a p p l i e d to them. No one statement was checked by a l l the students. However, percentages are worked out on the ba s i s of the e n t i r e c l a s s because they had equal opportunity to check each statement. TABLE XIV: PERCENTAGE DISTRIBUTION, FALL AND SPRING, of STUDENTS' CHOICES OF WHAT THEY WILL LIKE BEST ABOUT BEING A DOCTOR. Statement No. F a l l Spring 1. Being able to help other people 8 0 . 0 78.0 2. The c h a l l e n g i n g and s t i m u l a t i n g nature of the work 6 8 . 0 8 2 . 0 3 . Being able to deal d i r e c t l y w i t h people 6 8 . 0 76 .0 4 . Being my own boss 3 4 . 0 4 6 . 0 5 . Having i n t e r e s t i n g and i n t e l l i g e n t people f o r colleagues 32.0 4 8 . 0 6. The f a c t t h a t medicine i s a h i g h l y respected p r o f e s s i o n 3 2 . 0 3 8 . 0 7. Being sure of ear n i n g a good income 28.0 2 8 . 0 a . Doing work i n v o l v i n g s c i e n t i f i c method and research 26.0 36.0 TABLE XV: ORDER OF PREFERENCE OF WHAT STUDENTS THINK THEY WILL LIKE BEST ABOUT BEING A DOCTOR,-BY COMMITMENT GROUP Commitment Group Order of importance by table-statement numbers F a l l S p ring 1s t 2nd 3rd 4 t h 1s t ' 2nd 3rd 4 t h U n c o n d i t i o n a l l y Com'd. 1 2 3 6 1 2 3 5 Q u a l i f i e d Changers -(only career) 1 2 3 4 3 4 1 6 Q u a l i f i e d Committed 3 1 2 4 2 1 3 4 U n c o n d i t i o n a l Changers (one of sev e r a l ) 3 1 4 2 1 2 3 7 Grouping those students who, i n the f a l l , say medi-cine i s the "only career" f o r them, they place the same emphasis on what they w i l l l i k e best about being a doctor, regardless of t h e i r subsequent change or non-change of commitment group. The same i s true f o r the students who, i n the f a l l , say medicine i s "one of s e v e r a l careers" to them. I n the s p r i n g , the uncondi-t i o n a l l y committed remain constant i n .ranking the importance of what they w i l l l i k e best about being a doctor. The q u a l i f i e d committed have kept t h e i r top three choices but have changed the emphasis. The u n c o n d i t i o n a l changers (one of s e v e r a l careers) have now the i d e n t i c a l choice and order f o r t h e i r f i r s t three p o s i t i o n s as do the unconditionally.committed. They have taken on some of the a t t i t u d e s of the peers w i t h whom they now share a s i m i l a r s t a t e d degree of commitment. The q u a l i f i e d changers (only career) have now taken on some of the l e s s e r choices of t h e i r peers, but they have not giv e n the same order of preference. This group i s the most divergent from the patterns of the other groups. This question, then, says something about the d i s o r g a n i z a t i o n t h a t accompanies change. This " d i s o r g a n i z a t i o n " i s meaningful only when i t i s considered i n comparison w i t h the responses of the r e s t of t h i s sample. I n comparison w i t h some other group these q u a l i f i e d changers might not be out of step. However, compared to t h e i r classmates and compared to t h e i r o r g i n a l thoughts on what they would l i k e best about being a doctor, t h i s group of students i s deviant - they are the most u n s e t t l e d of the commitment groups. Comparing the emphases placed on what they w i l l l i k e best about being a doctor between the two non-change groups, i t i s found that the u n c o n d i t i o n a l l y committed put the emphasis on "being able to help other people". The q u a l i f i e d committed put the emphasis on the " c h a l l e n g i n g and s t i m u l a t i n g nature of the work". Taking the l i s t of statements, i n i t s e n t i r e t y , the un-c o n d i t i o n a l l y committed tend to be more a l t r u i s t i c and more i n t e r e s t e d i n 'others' - both people they w i l l "help" i n the f u t u r e and t h e i r f u t u r e colleagues. I n a manner they are more i d e a l i s t i c . The q u a l i f i e d committed emphasize i n t e r e s t i n t h e i r work, i n t e r e s t i n medicine r a t h e r than i n people. They appear to be more concerned w i t h i n s t r u m e n t a l i t i e s and are l e s s i d e a l i s t i c toward t h e i r f u t u r e p r o f e s s i o n a l l i v e s than the u n c o n d i t i o n a l l y committed. Continuing w i t h questions to d i s c o v e r the students' conceptions of the medical p r o f e s s i o n and of standards w i t h i n medicine, the students were asked which of a number of charac-t e r i s t i c s they considered most important i n making a good p h y s i c i a n . The f i g u r e s i n Table XVI are f a i r l y constant f a l l and s p r i n g , except f o r the decrease i n those who think " d e d i c a t i o n to medicine" i s an important c h a r a c t e r i s t i c i n a p h y s i c i a n and and increase i n those who consider the " a b i l i t y to t h i n k i n an organized way" an important c h a r a c t e r i s t i c . People tend to evaluate c h a r a c t e r i s t i c s i n terms of themselves: whether they have a c e r t a i n one, or would l i k e t o have i t . The aforementioned trend i n responses then, again, denotes a l o s s of i d e a l i s m and the s u b s t i t u t i o n of a ma t t e r - o f - f a c t approach - " l e t ' s get doing what we have to do" - on the p a r t of the sample t a k e n as a whole. TABLE III: FIRST YEAR MEDICAL STUDENTS' CHOICES OF THE TWO CHARACTERISTICS MOST IMPORTANT IN MAKING A GOOD PHYSICIAN. C h a r a c t e r i s t i c F a l l Spring Good appearance — — Warm and p l e a s i n g p e r s o n a l i t y 7 10 Ded i c a t i o n to medicine 21 10 High i n t e l l i g e n c e 7 5 S k i l l f u l management of time 2 — . S c i e n t i f i c c u r i o s i t y 1 1 I n t e g r i t y 14 14 A b i l i t y to t h i n k i n an organized way 12 19 Research a b i l i t y — — A b i l i t y t o get along w i t h people 11 15 Recognition of own l i m i t a t i o n s 5 8 Ge t t i n g r e a l enjoyment out of medicine 10 14 No answers 10 4 100 100 However, once again, i f the changes are examined by commitment group, the changes w i t h i n the sample are not uniform. The r e l a t i v e p o s i t i o n i n g of "important c h a r a c t e r i s t i c s " f o r a p h y s i c i a n , by commitment group, f o l l o w : U n c o n d i t i o n a l l y Committed  F a l l Spring Q u a l i f i e d Committed F a l l 1. D e d i c a t i o n Organized t h i n k i n g 1. I n t e g r i t y 2. Organized t h i n k i n g A b i l i t y to get along w i t h others 3. Enjoyment of Enjoyment of medicine medicine 4. Get along D e d i c a t i o n w i t h others 5. I n t e g r i t y I n t e g r i t y 2. Organized t h i n k i n g 3. Research a b i l i t y Spring I n t e g r i t y Organized t h i n k i n g R e c o g n i t i o n of l i m i t s 4-. Dedication Enjoyment of medi-cine For the u n c o n d i t i o n a l l y committed between f a l l and s p r i n g there i s a change i n emphasis about what they consider to be more important and l e s s important c h a r a c t e r i s t i c s f o r a p h y s i c i a n to embody. This change seems to be, f i r s t l y , a l e s -sening i d e a l i s m , or of " d e d i c a t i o n " toward medicine; and, secondly, a g r e a t e r emphasis on what to do about g e t t i n g through t h i s course. The u n c o n d i t i o n a l l y committed seem to be saying: "Dedication i s not going to get us through t h i s . What i s the best way?" The q u a l i f i e d committed begin, i n the f a l l , w i t h a " p r o f e s s i o n a l " approach to what c h a r a c t e r i s t i c s a p h y s i c i a n should have. Further, t h e i r f i r s t two choices remain constant. The t h i r d and f o u r t h choices, i n the s p r i n g , are, l i k e the choices of the u n c o n d i t i o n a l l y committed, i n terms of the pre-sent r a t h e r than the f u t u r e . I t seems r e a l i t y takes over. Once again, the q u a l i f i e d committed appear t o be more co n s i s t e n t than the u n c o n d i t i o n a l l y committed. Q u a l i f i e d Changers (only career) U n c o n d i t i o n a l Changers (one of s e v e r a l careers) F a l l 1. D e d i c a t i o n 2. I n t e g r i t y 3. A b i l i t y to get along with others 4. Warm,pleasing p e r s o n a l i t y Spring I n t e g r i t y A b i l i t y to get along w i t h others Warm,pleasing p e r s o n a l i t y F a l l Spring 1. Warm,pleasing Warm,pleas-p e r s o n a l i t y ing person-a l i t y 2. D e d i c a t i o n The u n c o n d i t i o n a l changers (one of s e v e r a l careers) apparently see good personal r e l a t i o n s as the most important c h a r a c t e r i s t i c i n the make-up of a good p h y s i c i a n . By s p r i n g , they s t i l l hold t h e i r c o n v i c t i o n but have added another compo-nent: d e d i c a t i o n . This group i s the only one t h a t becomes more " i d e a l i s t i c " r a t h e r than l e s s . Those who change to become "more" committed to medicine as a career have a tendency to express s a t i s f a c t i o n with a l l f a c e t s of a medical career. They are l e s s d i s c r i m i n a t i n g i n t h i s regard than t h e i r peers. The q u a l i f i e d changers (only career) l o s e a component i n the make-up of a good p h y s i c i a n i n the process. The importance of " d e d i c a t i o n to medicine" i s completely absent i n the s p r i n g , whereas i t was the most important c h a r a c t e r i s t i c i n the f a l l . This group has l o s t i n i d e a l i s m , while the other change group has gained. In the foregoing, the c o n d i t i o n a l student a l i g n s himself w i t h the q u a l i f i e d committed. The u n c o n d i t i o n a l change 91 student (not the most s a t i s f y i n g career I can t h i n k of) a l i g n s w i t h the other u n c o n d i t i o n a l change group. The q u a l i f i e d change student (not the most s a t i s f y i n g career I can t h i n k of) a l i g n s w i t h the other q u a l i f i e d change group. The students xvere a l s o asked which of the above mentioned c h a r a c t e r i s t i c s they considered to be more important to medical men than t o other p r o f e s s i o n a l s . Fewer students answered t h i s question i n the s p r i n g than i n the f a l l . The four character-i s t i c s most o f t e n i n d i c a t e d were: F a l l Spring D e d i c a t i o n t o medicine 4 4 . 0 (22) 4 2 . 0 (21) Recognition of own l i m i t a t i o n s 3^.0 (19) 3 6 . 0 (18") A b i l i t y t o get along w i t h people 3 4 . 0 (17) 28.0 ( 1 4 ) Warm and pl e a s i n g p e r s o n a l i t y 1 4 . 0 ( 7) 12.0 ( 6) The n e c e s s i t y of s p e c i a l c h a r a c t e r i s t i c s f o r the medical p r o f e s s i o n decreases s l i g h t l y i n a l l categories during the f i r s t year i n medical s c h o o l . The students see medicine as more l i k e other p r o f e s s i o n s . This was r e f e r r e d to e a r l i e r . This type of r e a c t i o n i n l e a r n i n g , i n t h i s case, i s l i k e l y to come from a combination of two sources: 1. dev a l u a t i o n of something (medical t r a i n i n g ) one i s disappointed i n - i t does not meet preconceptions - and 2. r e a l i t y t h a t medicine, l i k e a l l p r o f e s s i o n s , e n t a i l s hard, r o u t i n e slugging as w e l l as e x c i t i n g , s t i m u l a t i n g m a t e r i a l . A t a b u l a t i o n of the twelve c h a r a c t e r i s t i c s most im-portant i n making a good p h y s i c i a n ( l i s t e d on page BB) was made a l s o t o determine which of these c h a r a c t e r i s t i c s were considered to be of " l i t t l e importance" by the students i n the making of a good p h y s i c i a n . Throughout the questionnaires, no student takes a c o n s i s t e n t l y negative approach by marking the most negative s e l e c t i o n i n every question. I n f a c t , i t seems more l i k e l y from the questionnaires t h a t , i f t h i s sample was "not sure'' of how they wanted to answer a question, they took the middle ground. This sample i s much more p o s i t i v e than negative i n approach. Therefore, negative expressions of any s i z e are noteworthy. The f i v e c h a r a c t e r i s t i c s considered to be of " l i t t l e importance" to t h i s sample were: F a l l Spring Research a b i l i t y 4 8 . 0 (24) 68.0 (34) S c i e n t i f i c c u r i o s i t y 26.0 (13) 12.0 ( 6) S k i l l f u l management of time 8.0 ( 4) 18.0 ( 9) Good appearance 10.0 ( 5) 12.0 ( 6) G e t t i n g r e a l enjoyment out of medicine 8.0 ( 4) 6 .0 ( 3) In the s p r i n g more than f i f t y per cent of every commit-ment group consider research a b i l i t y to be of l i t t l e importance i n the make-up of a good medical p r a c t i t i o n e r . Perhaps t h i s i s because the m a j o r i t y of students a s s o c i a t e "research" w i t h a l a b o r a t o r y and f u l l - t i m e employment. This i s c e r t a i n l y a question t h a t should be asked again during the t r a i n i n g years. I t would be i n t e r e s t i n g t o know i f , and when, the students f e e l ''research'' i s p a r t of the medical doctor's r e g u l a r r o u t i n e . I t would a l s o be i n t e r e s t i n g to know i f , and when, as p r a c t i t i o n e r s they drop t h i s " f r i l l " . The l a c k of s c i e n t i f i c c u r i o s i t y can l i k e l y be regarded i n the same l i g h t as the c o n s i d e r a t i o n of "research a b i l i t y " . I t i s the u n c o n d i t i o n a l l y committed who consider n e i t h e r the " s k i l l f u l management of time" nor "good appearance" to be important. For " g e t t i n g r e a l enjoyment out of medicine" there i s no concentration by commitment group; each response being from a d i f f e r e n t commitment group. G e n e r a l l y , the nega-t i v e responses are i n t e r e s t i n g f o r the c l a s s * a t t i t u d e , but they are not s i g n i f i c a n t by commitment group. Summarizing the sample's conceptions of medicine as a career, i n gener a l , they consider medicine to be best described as f i r s t , a p r o f e s s i o n of s e r v i c e to the community, and second, a p r o f e s s i o n which helps i n d i v i d u a l s d i r e c t l y . I"he percentage d i s t r i b u t i o n of students' responses to t h i s question i s constant f o r f a l l and s p r i n g . However, h a l f the students make a d i f f e r e n t response i n the s p r i n g than they do i n the f a l l . P r o p o r t i o n a t e l y , the commitment changers give d i f f e r e n t answers i n the s p r i n g than i n the f a l l twice as o f t e n as the non-changers. The sample considers the l e a s t appropriate d e s c r i p t i o n of the medical p r o f e s s i o n to be:"A p r o f e s s i o n which i s secure and l u c r a t i v e . " The aspects of a medical career the sample th i n k s they w i l l l i k e best are: being able to help other people, the c h a l l e n g i n g and s t i m u l a t i n g nature of the work, and being able to d e a l d i r e c t l y w i t h people. The importance placed on these three aspects d i f f e r s by commitment group; the u n c o n d i t i o n a l l y committed emphasizing a l t r u i s m , w h i l e the q u a l i f i e d committed emphasize the work of a doctor. The c h a r a c t e r i s t i c s considered to be most important i n the make-up of a good p h y s i c i a n vary w i t h the f a l l and the s p r i n g . I n the f a l l " d e d i c a t i o n " and " s c i e n t i f i c c u r i o s i t y " are rated as the most important. I n the s p r i n g , " a b i l i t y to t h i n k i n an organized way" and " a b i l i t y to get along w i t h people" are considered to be most important. Again, the emphasis v a r i e s by commitment group. "Research a b i l i t y " i s considered to be the l e a s t important c h a r a c t e r i s t i c of those l i s t e d . CHAPTER VII FACTORS IN SOCIALIZATION From the foregoing chapters i t i s apparent that the f i r s t year medical students' conceptions and d i r e c t i o n of change d i f f e r according to t h e i r expressed degree of commitment. What happened within the process of medical s o c i a l i z a t i o n to f i r s t year medical students to effect t h i s change? According to the theory of s o c i a l i z a t i o n previously outlined there are at least three major factors which influence the process of s o c i a l -i z a t i o n : the teachers or representatives of the superordinate system into which the neophytes are to be so c i a l i z e d - i n t h i s case the medical f a c u l t y ; the members of the subordinate system who are to be s o c i a l i z e d - the f i r s t year medical students and the i n d i v i d u a l selves who make up the subordinate system. The t h i r d factor i s important i n r e l a t i o n to the f i r s t two i n s o c i a l i z a t i o n . That i s , i t i s important how each s e l f sees himself i n r e l a t i o n to his superiors - the fa c u l t y - and i n r e l a t i o n to his peers - the other members of the f i r s t year medical class of 1959-1960. Faculty Unfortunately, the f i r s t year medical students were asked very few questions with regard to t h e i r teachers; and how they were reacting to the actual learning process. Of course, these kinds of questions are d i f f i c u l t to ask i n a manner which w i l l e l i c i t meaningful answers, because students are very much aware that the persons they are asked to assess 96 are the very same people who give them t h e i r grades. Students see l i n e s of communication between authorities everywhere. They are not anxious to "cut t h e i r own throats" by t e l l i n g one set of authorities f a c t s , which another set of authorities could "use against them", i f they had the information. The question-naire given to the sample did not overcome t h i s d i f f i c u l t y . In the area of teacher-student relations there i s l i t t l e i n f o r -mation. There was one question, however, where the students were asked whether or not the facult y gave them s u f f i c i e n t d i r e c t i o n f o r t h e i r studying. TABLE XVII: PERCENTAGE DISTRIBUTION OF FIRST YEAR MEDICAL STU-DENTS' OPINIONS AS TO WHETHER THE FACULTY GIVES MEDICAL STUDENTS ENOUGH DIRECTION IN WHAT TO EMPHASIZE IN THEIR STUDYING. Commitment Group Too l i t t l e d i r e c t i o n Right amount More than enough No answer F a l l spring r a n spring r a n spring F a l l Spring Unconditional 11.1 ( 3) 37 .0 (10) 88.8 (24) 59.2 (16) — 3.7 (1) — --Qualified — 25.0 ( 2) 75.0 ( 6) 75.0 ( 6) — — — 25.0 ( 2) Conditional 100.0 ( 1) 100.0 ( 1) Qualified Change;' (only career! 50.0 ( 4) 25.0 ( 2) 50.0 ( 4) 75.0 ( 6) Unconditional Change (not most s a t i s f y -ing career) 100.0 ( 1) 100.0 (1) (One of several) Qualified Change (not most s a t i s -fying career) 25.0 ( 1) 100. C ( 1) 50.0 ( 2) - r 50.0 ( 2) 25.0 ( 1) 100.0 ( 1) — — 25.0 (1) 25.0 ( 1) Twenty students - f o r t y per cent of the sample -express d i s s a t i s f a c t i o n with the amount of facul t y d i r e c t i o n they receive. Nineteen students - t h i r t y - e i g h t per cent -think they should receive more d i r e c t i o n . Of these nineteen students, seventeen - t h i r t y - f o u r per cent - make t h i s statement i n the spring (seven students - fourteen per cent - of these seventeen students make the same statement f a l l and spring). The one student who states, i n the spring, that the f a c u l t y gives "too much d i r e c t i o n " i s a woman. Although over one t h i r d of the sample - with repres-entatives from each commitment group - f e e l they receive too l i t t l e d i r e c t i o n from the f a c u l t y , t h i s question does not give any answers to the question: Can any patterns of change be traced to the faculty? This question does, however, again indicate that the unconditionally committed are the most consistent of a l l groups i n responses. The seventy-five per cent of that group who states that the f a c u l t y gives the "right amount" of d i r e c t i o n to students i n the f a l l , i s the same seventy-five per cent who places i t s e l f i n that group i n the spring, except for one student. The movement i n the other commitment groups i s diverse. Peers There i s a wide s o c i o l o g i c a l l i t e r a t u r e on the com-position and functioning of small groups.33 i t i s assumed i n 33 Hare, Paul; Edgar Borgatta and Robert F. Bales, Small t h i s thesis that the phenomena of group sanction, control, norms, selection, r e j e c t i o n , support, and s a t i s f a c t i o n e x i s t and operate within the "small" group being studied here - -the f i r s t year students of medicine. They are considered to be a small group because over the school term they have had sustained face-t'o-rface contact with one another. They have worked together - isolated from students of other d i s c i p l i n e s who conceivably could divert the l o y a l t i e s of members of the medical class. They play f o o t b a l l together during t h e i r lunch hours, and together they plan the major yearly s o c i a l outing of a l l medical students - the Med B a l l . This regular, sus-tained, and exclusive grouping c l a s s i f i e s the medical class as a small group. In actual number, also, they are r e l a t i v e l y small. The students, presumably, are given i d e n t i c a l s t i m u l i to learn - they have the same teachers, the same classrooms, the same subject material. An e f f o r t was made to discover why some students change t h e i r mind about how they f e e l about a career i n medicine and some do not. I f the students are exposed to the same situations a f t e r entering medical•school, but react d i f f e r e n t l y , they must experience the situations d i f f e r e n t l y i n some - or many - respects. Studies of small groups have shown that members of the group exert considerable ef f e c t on t h e i r peers. In some instances they can "make or break" a member of t h e i r group by Groups, New York, Knopf, 1955, i s a good source book containin both th e o r e t i c a l and experimental work. t h e i r attitude or by th e i r overt or covert actions toward him. In a learning s i t u a t i o n , p a r t i c u l a r l y i n our society where performance of a high ca l i b e r - winning - i s rewarded and given much approval, candidates often regard each other, not as peers struggling toward the same goal, but as adversaries. Students were asked questions to determine to what extent the sample found "competitiveness" among t h e i r classmates and whether or not t h i s varied by commitment group. TABLE XVIII: PERCENTAGE DISTRIBUTION OF HOW MUCH COMPETITIVE-NESS FIRST YEAR MEDICAL STUDENTS FOUND AMONG THEIR CLASSMATES IN MEDICAL-SCHOOL. -Commitment Group Great deal or f a i r amount L i t t l e or none F a l l Spring F a l l Spring Unconditional AS.2 (13) 73.1 (20) 51.9 (14) 26.9 (7) Qualified 62.5 (5) 8 7.5 (9) 37.5 (3) 12.5 (1) Conditional — 100.0 (1) 100.0 (1) — Qualified Change (only career) 37.5 (3) 100.0 (8) 62.5 (5) — Unconditional Change (one of several careers) 50.0 (2) 100.0 (4) 50.0 (2) — (not most s a t i s -fying career) — 100.0 (1) 100.0 (1) — Qualified Change (not most s a t i s -fying career) — — 100.0 (1) 100.0 (1) There i s a general increase i n the amount of competition experienced i n the spring as contrasted to the f a l l , f o r a l l commitment groups. However, proportinnat l y , the changers experienced more competition i n the spring although they had experienced less competition i n the f a l l , than the non-changers. The range of the changers' movement i s greater than the movement of the non-changers. Further, i n the spring, there i s only one changer who states he has experienced " l i t t l e competition" from his classmates. This i s the student who placed f i r s t i n the f i r s t year medicine class. Change or non-change of commitment makes a difference i n the amount of competition experienced by students. Although the students state that they experience a f a i r amount of competition among t h e i r classmates, they also state that they have found that the students help one another. TABLE XIX: PERCENTAGE DISTRIBUTION CF THE HELPFULNESS THE FIRST YEAR MEDICAL STUDENTS EXPERIENCED FROM ONE ANOTHER. Commitment Group F a i r Amount Not Much No Answer F a l l Spring F a l l Spring F a l l Spring Unconditional 88.8 (24) 88.8 (24) 3.7 (1) 11.1 (3) 7 .4 (2) — Qualified 100.0 (8) 62.5 (5) — 25.0 (2) — 12.5 (1) Conditional — 100.0 (1) 100.0 (1) Q u a l i f i e d Change (only career) 87.5 (7) 75.0 (6) 12.5 (1) 25.0 (2) -- — Unconditional Change (one of several) 75.0 (3) 50.0 (2) . 25.0 (1) 50.0 (2) — — Unconditional Change (not most s a t i s -f ying career) 100.0 (1) 100.0 (1) Q u a l i f i e d Change (not most s a t i s -fying career) 100.0 (1) 100.0 (1) The great majority of students consider t h e i r classmates to help one another a f a i r amount - eighty-eight per cent of the sample i n the f a l l (eight per cent replied i n the negative, four per cent did not answer) and eighty per cent i n the spring (eighteen per cent replied i n the negative, two per cent did not answer). The majority of each commitment group think students help one another a f a i r amount. However, each commitment group has two or three students who reply i n the negative i n the spring except for those three students whose i n i t i a l commitment was that medicine was "not the most s a t i s f y i n g career" they could think of. Except f or t h i s group of three students, the remaining four commitment groups each indicate an increase i n the percentage of those students who, by spring, state that they do not think the f i r s t year medical students help each other much. The i n d i v i d u a l change i n position i s for the most part, i n one d i r e c t i o n : from stating students help each other a " f a i r amount" to stating "not much" help i s given by students to one another. That i s , within the commitment groups the answers remain constant or move i n the one d i r e c t i o n . There i s not a great deal of switching from one category to the other. Although t h i s pattern of less endorsement toward one's peers i s evident i n the spring, the majority of students s t i l l indicate that they think students are hel p f u l one toward another. This i s an i n d i c a t i o n that the sample's esprit-de-corps i s generally high. I t i s also evident that i t i s proportionately highest i n the unconditionally committed group. The less enthusiastic spring response might be correlated with the pervasive theme that runs through the majority of the spring responses: the students are less enthused i n almost a l l areas they were questionned about. I t seems as though they are somewhat "disenchanted" with "the whole world". What seems to be a contradiction appears upon examination of the responses to the l a s t two questions: 103 "How much competitiveness have you found among your classmates?" and "To what extent do you think f i r s t year students help each other?" The students express feelings that they have experienced both a great deal of competition and a f a i r amount of help from t h e i r classmates. These two conditions are usually regarded as mutually exclusive i n American society. I t i s not expected that adversaries - competitors - "help" one another. A competi-tor i s not expected to give away his price-copping secrets and thereby aid his adversary to "beat" him. I t i s suggested that i n the case.'of the f i r s t year medical students, although they f i n d one another competitive, they do not regard one another i n the f i r s t instance as compe-t i t o r s . The two above-mentioned questions need to be examined along with a former question, where students ranked the import-ance of 1. fellow students' comments, 2 . information from the facu l t y , and 3 . personal self-evaluation i n determining how wel l they were doing. This question indicates that the majority of students consider themselves as the most s i g n i f i c a n t estima-tors of how they are performing as medical students. They r e l y upon t h e i r own judgment; they assess themselves. They are most interested i n - and regard i t as most s i g n i f i c a n t - how well they are doing i n t h e i r own estimation. This would seem to indicate that medical students do not d i r e c t t h e i r competi-t i o n against one another but turn i t back upon themselves. That i s , the f i r s t year medical student i s not so concerned how he does i n r e l a t i o n to other medical students as he i s concerned how well he does i n comparison to how well he thinks he should do. Competition becomes more personal. A smaller proportion of one's competitive drive i s directed toward keep-ing up or getting ahead of others. A larger proportion i s concentrated on achieving the standard one has set f o r oneself, whether i t be to "make" s i x t y - f i v e per cent or get over eighty per cent i n one's f i n a l examination mark. In t h i s way students experience a competitive atmosphere i n the medical school - students are t r y i n g hard to beat ( or obtain) a certain standard. They can also regard one another as " h e l p f u l " when they do not have to "hoard" special knowledge but can share i t . In fac t , the students have a common adver-sary - a s e l f - s e t target. This, along with the knowledge that there i s "room" i n t h e i r class for them a l l - no one has to be dropped i n order to keep within a quota - (that was done the previous year) t h e i r close association, and common occupational goal produces a high esprit-de-corps among the students during t h e i r medical school years. Competition American society i s assumed to regard "competitive-33 ness'' and "success" as major values. These are often con-sidered to be "levers" i n the s o c i a l i z a t i o n process employed to spur socializees to t r y harder. There are greater '^rewards" given f o r being " f i r s t " or "best" than there are for being l a s t " . As the sample indicated that they had experienced a competitive learning atmosphere i n t h e i r f i r s t year of medical school, and to test the explanation drawn above, t h e i r attitude toward t h i s point was pursued. 33 Robin Williams, American Society, New York, Knopf, 1957, pp. 388-442. TABLE XX: PERCENTAGE DISTRIBUTION OF FIRST YEAR MEDICAL STU-DENTS' FEELINGS ABOUT COMPETING WITH OTHER PEOPLE FOR HIGH STAKES, BY COMMITMENT GROUP. Commitment Group Dislike., i t Neutral Enjoy i t F a l l Spring F a l l Spring F a l l Spring Unconditional 29.6 18.5 11.1 29.6 59.2 51.8 Qualified 62.5 12.5 — 25.0 37.5 62.5 Conditional 100.0 . — — 100.0 — Qualified Change (only career; 50.0 25.0 37.5 50.0 12.5 25.0 Unconditional Change (one of several) 25.0 25.0 50.0 25.0 25.0 50.0 (not most s a t i s -fying career) . . . — — -- 100.0 100.0 Qualified Change (not most s a t i s -fying career) — — 100.0 100.0 — TABLE XXI: PERCENTAGE DISTRIBUTION OF CHANGE IN SAMPLE'S FEELINGS ABOUT COMPETITION. Description F a l l Spring D i s l i k e competition Neutral Enjoy Competition 38.0 (19) 18.0 ( 9) 44.0 (22) 18.0 ( 9) 34.0 (17) 48.0 (24) 100.0 (50) 100.0 (50) 106 There i s a trend f o r the students to f e e l less negative toward competition i n the spring than they did i n the f a l l . S t i l l , proportionately, the non-changers "enjoy" competition more than the changers, both i n the f a l l and i n the spring. There i s a s i g n i f i c a n t amount of change on the part of individuals on the above question between f a l l and spring. The pattern of change i s not s i g n i f i c a n t by commitment group. One pattern of constancy does emerge however. Those persons who enjoyed competitive situations i n the f a l l - except f o r four students - also enjoyed them i n the spring. Regardless of commitment, i f a student f e l t at home i n a competitive s i t u a t i o n i n the f a l l , he was l i k e l y to f e e l similarly i n the spring. Those students who f e l t d i s l i k e or n e u t r a l i t y with regard to competitive situations i n the f a l l were l i k e l y to. give a d i f f e r e n t response i n the spring, although there i s no apparent pattern to which of the other categories these students would switch to. Although commitment group can t e l l us l i t t l e about competition, for t h i s sample, those persons who remain con-stant i n t h e i r commitment, l i k e competition better than those who do not remain constant i n t h e i r stated degree of commit-ment to a medical career. In a further attempt to determine the effect, i f any, of a'bompetitive" atmosphere on the sample, the students were grouped according to t h e i r f a l l and spring statements per-taining to competition. TABLE XXII: PERCENTAGE DISTRIBUTION OF FIRST YEAR MEDICAL STUDENTS ACCORDING TO THEIR FEELINGS ABOUT COMPETING WITH OTHER PEOPLE FOR HIGH STAKES, FALL AND SPRING. F a l l Statement Spring Statement Per Cent of Sample Like i t Like i t 36.0 (18) Don't l i k e i t Don't l i k e i t 13.0 ( 9) Neutral Neutral 10.0 ( 5) Don't l i k e i t Neutral 14 .0 ( 7) Don't l i k e i t Like i t 6 .0 ( 3) Like i t Neutral 3 .0 ( 4) Neutral Like i t 6.0 ( 3) Neutral Don't l i k e i t 2.0 ( 1) 100.0 (50) A l i t t l e over one t h i r d of the class state they " l i k e " competition i n the f a l l , and, again, i n the spring. Of t h i s t h i r t y - s i x per cent, fourteen per cent come from the lower class socio-economic group. This i s f i f t y - f o u r per cent (seven) of the entire representation (thirteen) i n the sample from the lower classes. The twenty-two per cent of the students who " l i k e " competition and come from the upper classes, represent 29.7 per cent of t h e i r entire group (thirty-seven students). Pro-p o r t i o n a l l y , t h i s i s half as many as the lower socio-economic group. Where t h i s "competitive" s p i r i t came from and how i t has aided the students i n t h e i r career ambitions i s f o r speculation. The only other expression of attitudes toward competition of any magnitude was from those students who stated, f a l l and spring, that they "don't l i k e " competitive s i t u a t i o n s . Eighteen per cent of the students made t h i s statement. Only one student i n t h i s group was from the lower class socio-econo-mic group. The remaining students represent 21.6 per cent (eight) of the upper class socio-economic group of t h i r t y -seven students. As can be seen from the table, the other stu-dents are d i v e r s i f i e d i n t h e i r combinations of f a l l and spring feelings. Taking the age of the sample i n the f a l l of 1959, those students who have "neutral" feelings with regard to com-p e t i t i o n are the oldest group. Their average age i s twenty-s i x years. The other groups are a l l under twenty-four years, ranging up from eighteen years. The four students who begin i n the f a l l with "neutral" feelings about competition and change to another group by the spring are the youngest. They average about nineteen and one h a l f years, while a l l other groups, excluding the oldest group, average twenty-three years of age. I t would seem that age of the s o c i a l i z e e and his socio-economic background could be factors i n the attitudes held about competition. However, to return to the effect of these feelings upon learning, i n the case of the sample, these f a c t s , although i n t e r e s t i n g , a r r i v e nowhere as f a r as contributing to the solution of questions surrounding the s o c i a l i z a t i o n process. L i t t l e could be discovered from the available data regarding the part played by the recognized agents of s o c i a l i z a -t i o n ; i n t h i s case, the medical f a c u l t y . Seventy-two per cent i n the f a l l and sixty-two per cent of the sample i n the spring took the middle road and stated that they received the " r i g h t " amount of d i r e c t i o n from t h e i r teachers. The students indicated that they had experienced a competitive atmosphere i n f i r s t year medical school, but they regard t h e i r peers as helpmates. Together with data presented i n a former section, t h i s would indicate that students do not primarily regard one another as competitors. Usually, a student competes with himself. This r e s u l t s i n a "competitive* atmosphe as students are trying to r tbeat ! l a s e l f - s e t goal, while, at the same time, a high esprit-de-corps i s developed through sus-tained contact and support from one another. The combined f a l l and spring statements pertaining to attitudes toward competition are d i v e r s i f i e d . I f the above conclusions are accurate, i t would appear, at t h i s time, that students are not too concerned about competition i n the usual sense of p i t t i n g oneself against others. CHAPTER VIII DEGREE OF COMMITMENT AND PATTERNS OF CHANGE Regardless of expressed commitment, for t h i s sample there i s a notable change i n f e e l i n g i n some areas between the f a l l and spring questionnaire. In p a r t i c u l a r , there i s a decrease i n the expressions of how d i f f e r e n t and unique medicine i s , compared to other professions. By the spring of I960, the profession i s considered to be more " l i k e 1 ' other professions and less "special". There i s an increase i n the number of negative responses to questions i n the questionnaire, in d i c a t i n g increased c r i t i c i s m on the part of the students. They f i n d more f a u l t with t h e i r environment. At the same time, there i s a change of emphasis of what i s important to the medical student. The emphasis switches from a focus on "dedication" to the profession to a focus on the work at hand - getting through medical school. At t h i s point i t seems that many of the students suspend the ' I d e a l i s t i c " attitudes they have held regarding medicine and turn to the more pres-sing, p r a c t i c a l matters which have to be dealt with irnme-d i a t e l y . Whether or not the " i d e a l i s t i c " focus i s ever picked up again, or i f i t i s permanently put to one side, or l o s t e n t i r e l y , i s beyond the scope of t h i s thesis. 34 S i g n i f i c a n t l y , as stated previously, the q u a l i f i e d change group does lose the component of dedication i n i t s state ment of the important characteristics of a medical man. 35 The M.A. thesis of Y. Chang, now i n preparation for the Department of Anthropology and Sociology, University of Although there i s a general "change" on the part of the sample, there i s a d i f f e r e n t i a l change by commitment groups. Looking f i r s t at the students with respect to whether or not they changed t h e i r expressed degree of commitment between the f a l l of 1959 and the spring of I960, i t i s apparent from the foregoing chapters that those students who change i n t h e i r ex-pression of commitment also tend to change more often i n t h e i r responses to other questions than do the non-changers. The changers are more inconsistent i n t h e i r answers than the non-changers. They are less c e r t a i n . They indicate that they are i n a greater state of disequilibrium than the non-changers. Seventy-two per cent ( t h i r y - s i x students) of the sample do not change t h e i r expression of commitment to a career i n medicine between f a l l and spring. This represents 67*5 per cent of the upper class group and 84.7 per cent of the lower class group. Twenty-eight per cent (fourteen students) do change t h e i r expression of commitment to a career i n medi-cine between the f a l l and spring. They represent 32 .5 per cent of the upper class group and 15 .3 per cent of the lower class group. In t h i s sample the changers were more apt to be from the upper class group than from the lower class, and younger i n years at the time of entry into the medical school than those i n the commitment group they aligned themselves with i n the f a l l who did not change. B r i t i s h Columbia, focuses on t h i s loss of idealism, which he c a l l s " r e a l i s t i c disillusionment". Howard S. Becker and Blanche Geer, "The Fate of Idealism i n Medical School", American Socio-l o g i c a l Review, Vol. 23, No.l, Feb. 1958, pp. 50-56, write that medical students change t h e i r mind about which matters they define as appropriate to receive t h e i r idealism. The devaluation or decline of idealism surrounding the medical career has been referred to above. However, the changers are more pessimistic and more negative toward medicine i n the spring than the non-changers. The majority of the changers expect to have more trouble "learning what i s expected" of them than the non-changers. They also experience more anxiety regarding t h e i r future career, learning to think f o r themselves and t r y i n g not to become overly tense. They are less "decided" about the future: the specialty they would l i k e to enter, the kind of work environment they would prefer. Interestingly, they expect to earn a higher income than do the non-changers. With regard to competition, i n the f a l l , the changers experienced less than the non-changers. However, by spring the changers experienced more than the non-changers, who also had experienced more than they did i n the f a l l . This means that the changers' movement was comparatively greater. In addition, the changers indicated that they enjoyed competition to a lesser extent than the non-changers. In actual achieve-ment, the changers did not perform as well as the non-changers. However, i t i s noteworthy that the change group that became more committed did not have a f a i l u r e , while the change group that became less committed proportionately had the greatest number of f a i l u r e s . Although both groups were changing more r a p i d l y than the non-change groups, and presumably experiencing greater disorganization and stress, t h e i r results were quite d i f f e r e n t . Proportionately, the non-change groups shared the "better than average" honours. I t i s evident t h a t , i n t h i s sample,those students who change i n t h e i r degree of commitment to a career i n medicine, are also more anxious and less secure i n t h e i r convictions and ideas about a medical career. A l l learners experience stress but r e l a t i v e l y the changers experience more stress within t h i s s o c i a l i z a t i o n experience than the non-changers. Non-change: Degree of Commitment: "Only career that could s a t i s f y me" - The Unconditionally Committed. This group of students, f i f t y - f o u r per cent of the sample, (twenty-seven students) which i s numerically the largest commitment group, i s characterized by a wholehearted and posi-t i v e approach to the future when compared to the other commit-ment groups. The unconditionally committed made t h e i r " f i n a l decision" to study medicine at an e a r l i e r age than the other groups. They see medicine as being more d i f f e r e n t and set apart from other careers than do t h e i r peers. Their future career choices are the most stable; as are the s p e c i a l t i e s they l i k e l e a s t . This group would seem to have the strongest i d e n t i f i c a t i o n with the profession of medicine. They also seem to be the most self-confident: the majority of t h i s group do not expect to have trouble keeping themselves from becoming overly tense and they can picture themselves as doctors e a r l i e r than can t h e i r classmates. Proportionally more of the unconditionally committed expect to do "better than average" i n t h e i r studies than th e i r peer groups. In actual performance they shared t h i s honour with the q u a l i f i e d group. However, 48.1 per cent of t h i s group placed below average. This they did not foresee and just how t h i s affected t h e i r stated degree of commitment and what t h e i r commitment response would be at the beginning of t h e i r second year of medical school i s open f o r speculation. In estimating how wel l they are doing, these students turn f i r s t inward for self-examination, and then to other students. They continue to be independent and are the one group that c l e a r l y indicates that when they graduate they wish to have t h e i r own o f f i c e with a hospital a f f i l i a t i o n . However, they state that they would l i k e more di r e c t i o n from the f a c u l t y with regard to t h e i r studies. The unconditionally committed also experienced an increase i n student competition from f a l l to spring. This may be an ex-pression of the increased pressure a l l students f e l t . How-ever, i n t h i s group the majority enjoy competition r i g h t from the beginning. Also, eighty-eight per cent of this group, both f a l l and spring, thought that students were hel p f u l to one another. This response i s outstanding both for i t s constancy and i t s degree of i n t e n s i t y . Two th i r d s of the unconditionally committed change t h e i r ideas about what phrase could best describe the medical profession. However, they referred medicine back to the pr a c t i t i o n e r rather than on to :his c l i e n t s or the community proportionately more often than members of the other groups. There i s a change between the f a l l and spring statements of th i s group as to what they consider to be the most important ch a r a c t e r i s t i c i n the making of a good physician. In the f a l l "dedication to medicine" i s considered to be most important. By spring the " a b i l i t y to think i n an organized way" rates f i r s t . These seem to be a f a i r l y p r a c t i c a l group of students and i f they found that t h e i r f i r s t assumption was not getting them where they had to be, they would change. And they d i d . In the f a l l t h i s group estimated t h e i r future i n -come at a lower l e v e l than a l l other groups but one. In the spring, however, they made the second highest estimate. In stating what they think they w i l l l i k e best about being a . doctor, the unconditionally committed are consistent over the year. They state they w i l l l i k e "being able to help other people" when they are M.D.'s. Their statements centre around the people they w i l l help and work with, rather than the actual work of the doctor. The unconditionally committed have made up t h e i r mind with regard to the various aspects of the profession of medicine. As t h e i r answers are the most consistent and the most constant, compared to the other commitment groups, they appear to be the most dedicated to a career i n medicine. Along with t h i s consistency they have fewer fears regarding t h e i r future and seem to be experiencing fewer strains i n the learning process i t s e l f . I t seems as though t h e i r definitude, t h e i r sureness, and assuredness, give them the support they require to see them through the stresses of learning. Non-change: Degree of Commitment: "One of several careers I could f i n d equally s a t i s f y i n g " - The Qualified Committed This group of students was the oldest at entry into medical school, and the oldest when they made t h e i r f i n a l decision to study medicine. This i s the only group that has a majority of lower class students rather than upper class. From the beginning they see medicine as being "more l i k e " other professions rather than "different from" other professions, as t h e i r peers do. As a group, they worry more than the unconditionally committed about not becoming overly tense i n their work, but less than the changers. In assessing how well they are doing, these students also rate t h e i r own estimate f i r s t but the faculty's second. In fact, during the year these students f i n d t h e i r contemporaries of less help than they did at the beginning. The q u a l i f i e d committed experience more competi-t i o n i n the spring but they also l i k e i t more. In stating which descriptions best suited the medical profession, the q u a l i f i e d committed followed the same pattern as the other commitment groups. However, whereas two thirds of the other groups changed t h e i r answers, the q u a l i f i e d group were constant f a l l and spring. This would indicate that t h e i r pre-medical assessment of themselves and of medi-cine has not been seriously found wanting, i n t h i s regard, at l e a s t . When t h i s group rated what they thought they would l i k e best about being a doctor, i n the f a l l they emphasized being able to deal d i r e c t l y with people, and i n the spring they emphasized the challenging and stimulating nature of the work. They emphasize the work a doctor does rather than the results of that work. They seem to be more interested i n doctoring than i n being a doctor. This same emphasis recurs when th i s group l i s t s what they consider to be important cha r a c t e r i s t i c s i n the make-up of a good physician. F a l l and spring, the q u a l i f i e d committed l i s t i n t e g r i t y as the most important c h a r a c t e r i s t i c , and organized thinking as the second most important. They present the most "professional " approach of a l l groups. That i s , t h e i r terms of reference are more objective and r a t i o n a l rather than subjective. This group was the most accurate i n estimating actual performance. In estimating what they expected to earn at the peak of t h e i r careers, they gave the lowest estimate of the f i v e groups i n the f a l l and the second lowest i n the spring. Of a l l the commitment groups, the q u a l i f i e d commit-ted seem to be more deliberate and mature i n t h e i r answers. They seem to be the most selective and, as said before, "professional" i n t h e i r approach to a career i n medicine. Change: Degree of Commitment: From "Only career that could s a t i s f y me" to "One of several careers I could f i n d equally s a t i s f y i n g " - Qualified Changers This group of students decided on a medical career at a l a t e r age than other students, who i n the f a l l said medicine was the "only career" for them, the unconditionally committed. However, the q u a l i f i e d changers are the youngest of a l l groups at the time of entry into medical school. The time factor of decision i s lowest f o r t h i s group. Neither did the q u a l i f i e d changers see medicine as being so d i f f e r e n t from other profes-sions as did the unconditionally committed. In a sense, medi-cine was not so " s p e c i a l " to the q u a l i f i e d changers r i g h t from the beginning of t r a i n i n g . At the same time, t h i s group expected more trouble i n t h e i r learning process than did any other group. They are the only group that expected to experience d i f f i c u l t y i n a l l four of the following areas: keeping up with other students; learning to think f o r yourself; learning what i s expected of you; and t r y i n g not to become overly tense. The q u a l i f i e d changers are the most pessimistic group. By spring none of them expected to do better than average i n his studies -and none of them did. Also, proportionately, t h i s group had the highest number of f a i l u r e s . In evaluating how well they were doing, they r e l i e d f i r s t , upon self-evaluation and second, upon the f a c u l t y . Other students were not considered as important factors i n evaluation. In stating what best describes the medical profes-sion, and what they think they w i l l l i k e best about being doctors, the q u a l i f i e d changers change often and indicate more disorganization i n t h e i r thoughts i n at least these matters than do the other commitment groups. In the actual statements of what they w i l l l i k e best about being a doctor, t h i s group switches from statements concerning what they w i l l be able to give to others, to statements i n the spring which indicate having control of the s i t u a t i o n , for example, being my own boss. When asked what characteristics they considered to be most impor-tant i n the make-up of a good physician, i n the f a l l the q u a l i -f i e d changers stated f i r s t , dedication and second, i n t e g r i t y . In the spring they l i s t e d i n t e g r i t y f i r s t and a b i l i t y to get along with others, second. They are the only group that completely l o s t a c h a r a c t e r i s t i c between f a l l and spring. Looking to t h e i r future, the Qualified changers expect to think of themselves as doctors at a l a t e r time than a l l other groups. They are also the only group that says they received the "right amount" of f a c u l t y d i r e c t i o n , and state a decrease i n need f o r f a c u l t y d i r e c t i o n . They also change from experiencing l i t t l e competition i n the f a l l to one hundred per cent agreement that there was a great deal of competitive-ness i n the f i r s t year medical class. Along with this,, they experienced a decrease i n students' helpfulness and, as a group, enjoy competition the l e a s t . The q u a l i f i e d changers indicate the greatest change and the greatest inconsistency i n responses between f a l l and spring. They seem to be d i s i l l u s i o n e d and disorganized. 120 Change: Degree of Commitment: From "One of several careers I could f i n d equally s a t i s f y i n g " to "Only career that could s a t i s f y me" - Unconditional Changers The unconditional changers are younger and decided at an e a r l i e r age to study medicine than the group with which they were aligned i n the f a l l , the q u a l i f i e d committed. With respect to t h e i r outlook on medical school, there was a change from h a l f of the group expecting medical school to be b a s i c a l l y tough and the other h a l f expecting i t to be b a s i c a l l y enjoyable i n the f a l l , to one hundred per cent agreement i n the spring that medical school was going to be b a s i c a l l y enjoyable. Similar to the balance of the sample, the uncondi-t i o n a l changers expected trouble not becoming overly tense. This was i n l i n e with the sample norm. In no other area did t h i s group experience undue stress. The outstanding ch a r a c t e r i s t i c of t h i s group i s t h e i r constancy between f a l l and spring. They have i d e n t i c a l expectations of performance, f a l l and spring. Although two expected todo better than average, no member of t h i s group did do better than average, but the unconditional changers were the only group where no one had to write a supplemental examination, repeat the year, or withdraw. In t h e i r estimate of how w e l l they were doing compared to other students, the fa c u l t y was t h e i r primary source and self-estimation was t h e i r secondary source. Like a l l the other groups, except the unconditionally committed, they did not consider t h e i r c l a s s -mates' estimates of primary importance. The unconditional changers' statements of what best describes the medical profession have the least change between f a l l and spring of any group. In stating what they consider to be important characteristics of a good physician, i n the f a l l they think that a pleasing personality i s most important. In the spring, they have added a c h a r a c t e r i s t i c - they state both a pleasing personality and dedication to medicine as being important. They are the only group that becomes more i d e a l i s t i c . One question area where t h i s group does change, i s i n t h e i r statements of what they think they w i l l l i k e best about being a doctor. They change from statements l i k e the q u a l i -f i e d committed's to statements l i k e the unconditionally com-mitted' s. They turn more to the sati s f a c t i o n s of being a doctor. In terms of income expected at the peak of t h e i r careers, the unconditional changers have the highest hopes of any group. In the f a l l they give the second highest estimate but i n the spring they give the highest estimate of a l l groups. They expect to think of themselves as doctors sooner than they had estimated they would i n the f a l l . They found more competi-t i o n among t h e i r classmates i n the spring than they had i n the f a l l , but they enjoyed competition more than they did formerly. The unconditional changers are d i f f e r e n t from the other groups between f a l l and spring i n that they are either constant i n t h e i r expectations and conceptions of medicine, or they become more positive i n t h e i r expressions. This i s especially i n t e r e s t i n g because the other groups move the other 122 way. In many respects they take on the attitudes of the unconditionally committed. I t seems as though the expecta-tions of t h i s group have been met to some s i g n i f i c a n t degree and t h i s has reinforced t h e i r s t a b i l i t y and t h e i r o r i g i n a l plans to become a doctor. The three students who i n the f a l l of 1959 stated medicine was "not the most s a t i s f y i n g career I can think of" are presented here as possible indicators of patterns within the change groups rather than i n d i v i d u a l commitment cases. I t seems l i k e l y that the labels attached to these three can as l o g i c a l l y be hung on other students within a respective change group. This i s not to assume that these three comprise a comprehensive l i s t of kinds of students. I t does point out, however, that the same career pattern i s l i k e l y followed by quite d i f f e r e n t "kinds" of students. Change: Degree of Commitment: From "Not most s a t i s f y i n g career I can think of" to "The only career that could r e a l l y s a t i s f y ; ! ^ Unconditional Changer Male, 21 years old, father c l a s s i f i e d i n socio-economic class V. None of his immediate r e l a t i v e s i s a professional. This student f i r s t thought of medicine as a career before he was ten years old and d e f i n i t e l y decided to study medicine bet-ween eighteen and twenty years of age. Many professions were considered as occupations, including engineering, law, business, and the ministry. He i s a mobile student: s o c i a l l y and economic-a l l y . In the f a l l he expressed " s l i g h t doubts" about his occupational decision, and worry about the financing of his career. His choice of specialty within medicine was f i r s t , psychiatry, and second, pathology. He enjoyed competitive si t u a t i o n s . By spring of I960 t h i s student had a more optimistic outlook. In the f a l l he stated he "didn't know" how well he was doing i n comparison to his classmates. In the spring he thought he was doing "better than average". In the f a l l he was "not sure" how he was performing. In the spring he was "quite sure". Along with these two statements, i n the spring, t h i s student had experienced l i t t l e d i f f i c u l t y making friends with his classmates, considered medical students to be "help-f u l " toward one another, and when asked which of eight aspects of-a medical career he would l i k e best, checked them a l l . He also changed his "choice" of s p e c i a l t i e s . In the spring he thought he would l i k e to be a p e d i a t r i c i a n or do research. These two choices are higher i n prestige with medical students than his f a l l selections. He stated he would not l i k e to do obstetrics or Ear, Nose and Throat specialty practice. I t would seem that t h i s young man has been "shopping" among the professions, looking for the " r i g h t " one for him. In the f a l l of 1959 he was ready to take on a "coat" but was not sure i f the coat would f i t . By the spring of I960, he was f a i r l y sure he and the coat "were made for each other". Change: Degree of Commitment: From "Not most s a t i s f y i n g career I can think of" to "one of several careers I could f i n d equally s a t i s f y i n g " - Qualified Changer Male, 21 years old, father c l a s s i f i e d i n socio-economic class I. A few r e l a t i v e s are professionals. This student f i r s t thought of medicine as a career when he was fourteen or f i f t e e n years old. He d e f i n i t e l y decided to study medicine between eighteen and twenty years of age. He seriously considered the professions of engineering and architecture. In the f a l l he states that he has had "serious doubts" about his decision to become a doctor. He was worried "a f a i r amount" about the kind of medical career he would have. This i s a questioning student. By spring this student's questionnaire indicates that he has been somewhat reassured i n his choice of careers. In the f a l l he stated he expected to do "average" i n comparison to his classmates. By spring he expected to do "better than average". In the f a l l he was "not sure" how well he was doing; i n the spring he was "sure". I t seems his reassurance came from his professors and peers, whom he considers more important than himself i n appraising how he was doing. This student i s more confident i n the spring than he was i n the f a l l , but s t i l l i s not self-confident. Few students wrote on t h e i r questionnaires to explain t h e i r answers, but t h i s student when asked which medical specialty he would l i k e to enter checked off pathology or research and then wrote: " I f I had the brains." This young man placed f i r s t i n his class. Non-change: Degree of Commitment: "Medicine i s not the most s a t i s f y i n g career I can think of, everything considered" -Conditional Male, 24 years old, father c l a s s i f i e d i n socio-econo-mic class I, r e l a t i v e s are professionals. This student f i r s t thought of medicine as a career af t e r he was eighteen years old. He d e f i n i t e l y decided to study medicine after he was twenty-one years old. His pre-college education i s European. He states the one other occupation seriously considered was a Ph.D. i n mathematics. Since "choosing" a medical career he has had "serious doubts" regarding the wisdom of the choice. His questionnaire responses indicate l i t t l e idealism and com-pared to many students, a good deal of realism. I t would seem, that for some reason, this young man chose to become a doctor a f t e r a very deliberate weighing of the pros and cons of medicine and his other al t e r n a t i v e . For t h i s reason, because of t h i s apparently r a t i o n a l decision, t h i s student i s a r a t i o n a l student. This student i s self-confident. His answers, f a l l and spring, are highly consistent. At both time periods he stated he expected to do "better than average" i n his class. He was "sure" of his expectations. He would l i k e to become a p s y c h i a t r i s t . He expresses no doubts or qualms, i n terms of performance, regarding his a b i l i t y to achieve his occupa-t i o n a l goal. He d i s l i k e s competitive situations, but t h i s also seems to be a " r a t i o n a l " statement which has no obvious connec-t i o n or negative e f f e c t on what he expects to do. Although t h i s student does not expect to have i n t e l l e c t u a l d i f f i c u l t i e s i n becoming a doctor, he expresses anxiety i n two areas: 1. that he made the , fbest" occupational choice (for him), and 2. he expresses worry with regard to financing his t r a i n i n g throughout medical school and his f i r s t years of practice. Although t h i s student i s very r a t i o n a l i n his responses, they also indicate that he i s an i s o l a t e . CHAPTER IX CONCLUSION AND SUGGESTIONS FOR FURTHER STUDY At the beginning, the objective of t h i s paper was stated to be to demonstrate that the s o c i a l mechanism of degree of commitment i s connected with, f i r s t , the experiences of learning during the process of becoming a member of a so c i a l system and, second, the " s o c i a l i z e d " resultant when the learning process has been completed. For t h i s sample, differences i n attitudes and experiences during the f i r s t year i n medical school have been shown to vary with d i f f e r e n t degrees of commitment. The major assumption i n t h i s thesis has been that an i n d i v i d u a l does not change his mind unless he decides that his former decision was "wrong" or "incomplete" and that -changing one's mind i n a negative d i r e c t i o n , especially about a matter of some importance, "losing a bet" i n Becker's terms, i s injurious to his self-imagei Each miscalculation has some effect on t h i s self-image but a concentrated series of mis-calculations i s d i s e q u i l i b r a t i n g . In t h i s sense, then, the unconditionally committed have been shown to be the most stable of a l l commitment groups. There i s continuity to t h e i r answers; they have the strongest i d e n t i f i c a t i o n with the profession i n the early stages of tr a i n i n g , at le a s t . The "degree" of t h e i r commitment seems to have two major bases, and one sustaining point. F i r s t , they started to think of medicine as a career at an early age, they have had a long time to think about, read about and t a l k about medicine. Relat i v e l y , they have considered few other occupations seriously, so the digressions i n t h e i r contemplation of medicine have been minor. They have a substantial 'investment' to carry out t h e i r decision to become a doctor. Secondly, although, l i k e t h e i r classmates, the unconditionally committed lose some of t h e i r "idealism" with regard to a medical career, they do not lose i t a l l . They have the strongest i d e n t i f i c a t i o n with the profession so that not only do they have more to lose, but they see medicine as a "good" thing and the t r a i n i n g i s a means to the end. This group some times seems to be immature, but they are usually enthusiastic. When dedication to medicine i s "a non-functional emphasis i n t h e i r learning, they change to a more p r a c t i c a l one. This group of students want to become d'octors, they i d e n t i f y with being a member of the medical pro-fession. They i d e n t i f y with the end and perhaps t h i s helps them to be able to "take" the means. I t should be remembered, too, that although these students undergo " r e a l i t y shock" they have the facul t y and t h e i r peers for support. That brings up a v i s i b l e sustaining point of t h i s group's commitment. They are the group that states they r e l y upon peers for support. A competitive s i t u -ation i s not usually considered as a supportive s i t u a t i o n . Yet, although the majority of the sample stated they found a f a i r amount of competition among t h e i r classmates, they also stated that they found t h e i r classmates to be " h e l p f u l " toward one 129 another. This would seem to be a contradiction. I t i s sug-gested, therefore, that t h i s i s a special case. This i s a s i t u a t i o n where there i s room for a l l the socializees as long as they reach a minimum standard of excellence. There i s no cut-off l i n e i n terms of numbers of students who can pass. Although there i s honour attached to coming " f i r s t " , there i s no particular"dishonour" to just reaching the minimum standard. Also, the s o c i a l i z e r s , especially i n the beginning, are impartial toward students regardless of t h e i r achieved performance - as long as they reach the set minimum. The socializees then may d i r e c t t h e i r competitive e f f o r t s toward th i s standard, or toward the point where they think they should be above i t , rather than against t h e i r contemporaries. The socializees have a common goal, which i s accessible to a l l . They can afford to help one another and, i n f a c t , can use one another both f o r s p e c i f i c help and less s p e c i f i c support i n the s t r e s s f u l learning s i t u a t i o n . The small group setting, the face-to-face contact over time, and t h i s common objective to become a doctor, promote "helpfulness" and esprit-de-corps. Once the socializees graduate they can resume competition against colleagues, e.g., getting patients, because there are then other rewards, s a t i s f a c t i o n s , and supports for t h e i r work. The same i s true for children ( i d e a l l y ) . They do not have to "compete" with one another to become adults. There i s no quota as to how many w i l l reach twenty-one. Novices i n the church are another example. Once they are taken into the tra i n i n g , they are expected to do t h e i r "best". They are not expected to compete w i t h one another. The e n t i r e sample experienced competition and help -f u l n e s s from t h e i r classmates. I f the above i s accepted, then i t seems th a t the students experienced the competitiveness of t h e i r classmates against t h e i r personal o b j e c t i v e and, at the same time, h e l p f u l n e s s toward one another. While t h i s arrange-ment seems to have withheld some pressure from the other com-mitment groups, the u n c o n d i t i o n a l l y committed seem to have been able to use i t to advantage. They evidenced the highest es p r i t - d e - c o r p s and the l e a s t change. The u n c o n d i t i o n a l l y committed are more u n i t e d and, consequently, l e s s alone than the members of the other groups. They had a more uniform approach to medicine than the members of the other groups, and seem to have been able to both support and r e i n f o r c e one another. Their "degree" and " k i n d " of commitment seems to have enabled them to use the e x t e r n a l resources at hand to the best advantage. The q u a l i f i e d committed are more independent and l e s s bound to other students than the u n c o n d i t i o n a l l y commit-ted . I n the sense of t h i n k i n g out choices, t h i s group i s the most mature. They are not so u n d i s c r i m i n a t i n g i n t h e i r enthusiasm about medicine. From the beginning they seem to have the more ' p r o f e s s i o n a l " and r a t i o n a l approach to medicine -they look at i t as a way of work r e q u i r i n g i n t e g r i t y and organized t h i n k i n g . Compared to the other non-change group, they are l e s s i n t e r e s t e d i n being a doctor and more i n t e r e s t e d i n doing the work of a doctor. The changers are outstanding for t h e i r impatience. However, the impatience, change, and subsequent disorganization, has had opposite result s for the change groups. The uncondi-t i o n a l changers were unsure of themselves at the.beginning of the year, but since having a successful year - with many of t h e i r expectations being met - they are anxious to get on with t h e i r t r a i n i n g . They ''changed" t h e i r mind about t h e i r commit-ment to medicine but i n a d i r e c t i o n satisfactory to themselves, proving they were more " r i g h t " i n t h e i r decision to study medicine than they were a f r a i d to admit i n the beginning. They are now prepared to wager more on t h e i r investment of becoming a doctor. The q u a l i f i e d changers seem to have experienced more disillusionment as a resu l t of miscalculated expectations. In a comparison with the unconditionally committed, with whom they began i n the f a l l , the q u a l i f i e d changers appear as is o l a t e s . They did not consider medicine to be as dif f e r e n t from other occupations, they expected more trouble i n stress situations and rather than turning to t h e i r peers for an e s t i -mate of how they were doing, t h i s group turned to the faculty. Of the three students who i n the f a l l stated that medicine was. "not the most s a t i s f y i n g career I could think of", the conditionally committed one seems to be an i s o l a t e among his classmates. The unconditional changer appears to be l i k e the other unconditional changers, while the q u a l i f i e d changer seems to be l i k e the q u a l i f i e d committed i n many respects. 132 Although the differences among the various commitment groups are outstanding by the responses given to the various questions, the differences are more pronounced when the groups are ordered by the amount of change undergone during the year. In order of change, with the Least change f i r s t , the groups rank: the unconditionally committed, the q u a l i f i e d committed, the unconditional changers, and the q u a l i f i e d changers. Compared to non-changers, very generally, the changers can be characterized by t h e i r comparative youth, an upper class back-ground, more pessimistic and negative approach to t h e i r career, undecided future, experience more competition, expect to earn a higher income, and a fe e l i n g of being on the outside of the f i r s t year medical student group. I t i s assumed that less change i s i n d i c a t i v e of less stress (or the more successful handling of s t r e s s f u l situations) and greater s t a b i l i t y . Degree of change i s one indicator of the degree of disequilibrium of a group. I t i s suggested that the change groups are i n a condition of greater disequilibrium than the other commitment groups and, further, that the q u a l i -f i e d changers (only career) are i n the greater state of d i s -organization. To become more committed to a previous decision i s not l i k e l y to be highly disorganizing. But i t i s "change" and therefore concomitant with i t , according to the previous assumptions of t h i s paper, a state of disequilibrium may be expected. I t i s contended here, therefore, that i f the second year of medical school i s not as "successful" for the uncondi-t i o n a l changers as t h e i r f i r s t year, they can be expected to change t h e i r p o sition again. Under the same amount of stress, the non-changers would not be expected to change during the second year. The difference between the two change groups then, i s that, although both are i n a state of disequilibrium, only the q u a l i f i e d changers (only career) are presently i n a state of disorganization. S p e c i f i c a l l y , why did some students change while others did not when they began f i r s t year medicine with the same stated degree of commitment? They received a s i m i l a r exposure to medicine and although a l l students became less enthusiastic about medicine, only a few changed t h e i r commit-ment. Comparing the unconditionally committed with the q u a l i -f i e d changers (only career), the unconditionally committed decided at an e a r l i e r age to become doctors, so they had time to become "more" committed. But perhaps most important, although the unconditionally committed were also under stress, they turned to and received the support of t h e i r peers. The q u a l i f i e d changers (only career) did not. The q u a l i f i e d com-mitted, compared to the q u a l i f i e d changers (only career), are older i n years and more deliberate i n t h e i r choices. They were expecting, and were better prepared to deal with, stress. The unconditional changers (one of several careers), although they experienced stress as w e l l , had many of t h e i r expecta-tions met and they received the support of t h e i r classmates. I t seems, therefore, that the q u a l i f i e d changers (only career) had the poorest equipment to meet stress: the fewest reserves and the fewest compensations from t h e i r learning experience. In attempting to determine which students are the "most" committed to t h e i r decision to have a career i n medi-cine, i t becomes apparent that not only are there "degrees" of commitment, but there are also "kinds". This sample e v i -denced two "kinds". Other samples and/or other learning situations may uncover additional "kinds" of commitment to a learning s i t u a t i o n . In assessing the unconditionally committed and the q u a l i f i e d committed i t i s clear that both groups are determined to become medical doctors. The unconditionally committed have a determination of long standing and the support of "others" to see t h i s learning process through to completion. Each student looks forward to being a member of the medical pro- fession. The q u a l i f i e d committed decided to study medicine aft e r more deliberation and comparison of medicine with other occupations. Their choice i s more deliberate. Their invest-ment l i e s i n t h e i r conscious choice of medicine as a career. They can also be distinguished from the unconditionally com-mitted for t h e i r emphasis not on being a doctor, but on wanting  to do the work of the doctor. Both groups are highly committed to t h e i r chosen profession. Proportionately, t h e i r achievement i n f i r s t year medicine was equal. There i s no basis i n the, available data on which to decide which group i s the "most" committed. Nor i s there any basis for saying which i s the most adequately equipped to handle stress sit u a t i o n s . They seem to manage these situations i n d i f f e r e n t ways - the uncon-d i t i o n a l l y committed seem more ready to absorb situations as being part of becoming a doctor while the q u a l i f i e d committed seem to ponder questions longer. Perhaps the length of time which passed aft e r the unconditionally committed had decided to become doctors, but before they were academically i n a position to enter medical school, was used to resolve many of the questions the q u a l i f i e d committed now have to resolve. S t i l l , the two groups' means of i d e n t i f i c a t i o n with the medical profession also d i f f e r . Looking to the future and the choice of a specialty, one might guess that, as the uncon-d i t i o n a l l y committed seem to i d e n t i f y with the outward symbols of a M.D., e.g., o f f i c e , income, they might be expected to choose a specialty which w i l l give them these symbols for t h e i r own. On the other hand, the q u a l i f i e d committed seem to iden-t i f y more with the work, so that they might be expected to choose the specialty that w i l l allow them to do the kind of work they enjoy. I t i s not intended to suggest that these are mutually exclusive i d e n t i f i c a t i o n s - merely differences i n emphasis. B r i e f l y , d i f f e r e n t degrees of commitment, as s o c i a l mechanisms, effect d i f f e r e n t r e s u l t s . That both groups are "committed" both at the be-ginning and the end of t h e i r f i r s t year of medical school there can be l i t t l e doubt. In terms of stress and change, the q u a l i f i e d committed seem to have - and handle - more. This, of course, says nothing about the r e l a t i v e merits of the finished products. In view of t h i s , the best measure of the force of "commitment" as a s o c i a l mechanism may be the r e l a t i v e measures of change or non-change over time. 136 A degree of commitment, for t h i s sample, was e s t i -mated at two points i n time: the f a l l of 1959 and the spring of i960. At a point i n time a degree of commitment i s com-prised of the components that Kadushin outlined f o r the making of a decision: a perception of what w i l l follow the choice, e.g., what medical school i s l i k e ; a self-image; the s i g n i f i c a n t others i n one's l i f e ; and time. A decision i s a commitment; i n Becker's terms, an investment i n consistency, a "bet" that the decision can be carried out. I t must be clear, however, that a commitment and a decision are not i d e n t i c a l . A commitment -takes up where a decision leaves o f f . U n t i l a decision i s made there i s free-dom to choose a d i r e c t i o n of movement - or non-movement. Commitment, by d e f i n i t i o n , r e s t r i c t s freedom of action. I t r e s t r i c t s and i t governs action. At a point i n time, a degree of commitment may be so low as to allow a subsequent choice or change i n the i n i t i a l decision, but a decision of magnitude, without exception, necessitates a commitment of magnitude, because they are comprised of i d e n t i c a l components. As a s o c i a l mechanism, degree of commitment r e s t r i c t s and governs action. Using the f i r s t year medical students at the University of B r i t i s h Columbia as a sample, degree of commitment has been shown to make a difference i n the learning experience of these students. That i s , degree of commitment makes a difference i n the s o c i a l i z a t i o n process. S o c i a l i z a t i o n i s a process of change. Degree of commitment i s one of the mechanisms i n the process of s o c i a l i z a t i o n . As a mechanism, l i k e socializers,,, degree of commitment makes a difference i n the learning experiences of soc i a l i z e e s . I t i s one of the mechanisms which determines how r e l a t i v e l y complicated or uncomplicated, how more or less p a i n f u l , the process of s o c i a l i z a t i o n w i l l be. The "more" committed a socializee i s to becoming a member of a s o c i a l •system, the "easier" the process should be, a l l other things •being equal. However, i n t h i s regard, i t must be kept i n mind that the measurement of commitment i s , so f a r , imperfect, and what appears to be a greater degree may turn out to be a l e s -ser degree when a l l the facts are known. The generalizations of t h i s thesis arise out of a special case: f i r s t year medical students at the University of B r i t i s h Columbia. Of course, they need to be tested in-other learning s i t u a t i o n s . I t i s submitted f or study that degree of commitment i s an i n t e g r a l part of the s o c i a l i z a t i o n process and, therefore, i t i s one of the mechanisms that must be studied i n any analysis of s o c i a l i z a t i o n as a s o c i o l o g i c a l concept. Problems For Further Study Many times i n the body of t h i s thesis i t becomes apparent that there are many int e r e s t i n g problems i n t h i s f i e l d that require study. A few of them are l i s t e d below: 1. Follow "commitment" through (a) to the end of the four years of medical school: (b) to the end of specialty t r a i n i n g ; and (c) to ten years after practice has commenced. 2. When and how do medical students decide on the specialty of t h e i r choice? 3. What sorts of pressures are of s u f f i c i e n t magnitude to lower a student's commitment and subsequently allow or force him to change his career choice? 4. Compare the ecology of todays' medical students with the medical students • of twenty-five years ago. Do they come from s i m i l a r or d i f f e r e n t backgrounds than formerly? 5. Compare medicine to other professions as a means of s o c i a l and economic mobility. 6. In professional schools, do students' a t t i -tudes toward competition vary by t h e i r socio-economic backgrounds? APPENDIX A Following i s the questionnaire which was given to f i r s t year medical students at the University of B r i t i s h Columbia i n September 1959, and again i n A p r i l I960. Starred i n red, i n the left-hand margin of the questionnaire, are those questions which were used i n t h i s thesis. INSTRUCTIONS TO MEDICAL STUDENTS This questionnaire is designed to find out what you, as a medical student, think about various aspects of medical training and practice. The information which you provide will be helpful in clarifying certain problems of medical education. We recognize that many of the questions deal with complex issues, and that the check-list alternatives do not always express the subtleties of your' opinions. But the purpose of a questionnaire like this one i s to obtain an overall picture of the attitudes held by medical students. There are a few points which you should bear in mind while f i l l i n g out this questionnaire: (1) The questionnaire is not a "test" —there is no "grade" or other mark. The only "right" answers to the questions are those which best express your feelings, your opinions, and your experiences. ( 2 ) Your individual identity will not be revealed and your personal answers will be kept confidential. The information provided by yocr class wi l l be tabulated and will be made available to the faculty only in the form of statistical summaries. (3) Read every question or statement carefully before answering. Please answer every question in accordance with the directions. Thank you for your cooperation in this study. PART A Medical Students' Expectations and Advance Knowledge 1. (a) At what age did you f i r s t think of becoming a doctor? (Check one) Before the age of 10 Between 10 and 13 years of age At 14 or 15 years of age At 16 or 17 years of age Since the age of 18 * (b) At what age did you definitely decide to study medicine? Before the age of 14 At 14 or 15 years of age At 16 or 17 years of age Between 18 and 20 years of age Since the age of 21 141 - 2 -•M- 2. Before deciding on medicine, did you ever seriously consider any other occupation or profession? Yes No IF YES: Which occupations or professions did you consider? (Check as many as apply) ...... Elementary or high school teaching College or university teaching (What field? ) Scientific research (What field? ) Engineering, architecture Lav Ministry Business Other (Which? ;...) 3. Which one of the following statements best describes the way you feel about a career in medicine? (Check one) It's the only career that could really satisfy me It's one of several careers which I could find almost equally satisfying It's not the most satisfying career I can think of, everything considered ....... A career I decided on without considering whether I would find i t the most satisfying 4. (a) How important was each of the following in your decision to enter the medical profession? (Answer for each) „ . , n ~ . „ , . * ' Fairly Of minor Not at a l l (1) Mother important important importance important (2) Father (3; Other relatives (4) Friends who are not in medicine ( 5 ) Physicians you know personally ...... (6) Physicians you have heard or read about (7) Medical students you know (8) Undergraduate teacher (9) Books, movies or plays (Give titles) (10) Other (What?. (b) Which two of these were of most importance in your decision to become a doctor? (List the appropriate numbers) # and # - 5 - 142 5. Since you made the decision, how much have the following members of your family encouraged you to become a doctor? (Answer for each) Strong Slight Expressed Slight Strong encour* encour- no opposi- opposi- Doesn't egeffiOfit agement opinion tion tion apply Mother Father Wife or Husband Brother or Sister Other relatives 6. Once you made up your mind to become a doctor, did you every have any doubts that this was the right decision for you? (Check one) Yes, serious doubts Yes, slight doubts No, no doubts at a l l 7. How important has each of the following been in helping you to form a picture of what medical school i s like? (Answer for each) Very Fairly Of minor Not at a l l important important importance important Medical school bulletins Medical students at (your) school Medical students at other schools Members of your family who are doctors Your family physician Other physicians who are friends Medical school faculty College faculty Books, movies, plays (Give t i t l e s . . Other (What? 8. Al l things considered, how do you think medical training compares with each of the following kinds of training? Are medical studies more di f f i c u l t , less d i f f i c u l t , or about the same? (Answer for each) Medical Training Is Much Somewhat more more About Less d i f f i - d i f f i c u l t the di f f i c u l t Don't Studying to be a — — same_as than Know lawyer Studying to be an engineer ...... Studying to be a dentist Training to be an Army officer Studying for a Ph.D in physics Studying for a Ph.D i n n n v n V i n l ncnr 143 - 4 -* 9. Which of the following statements comes closest to describing the way you feel about medical school? (Check one) ...... Basically, i t ' s going to be a tough, four year grind, but I ' l l manage to enjoy i t somehow Basically, i t ' s going to be an enjoyable experience, even though i t w i l l mean very hard work at times 10. Do you think that, as you move from the f i r s t to the fourth year of medical school, your studies w i l l become more difficult for you, less difficult, or do you think they w i l l remain relatively unchanged in this respect? (Check one) Will become more difficult Will become less difficult ...... Will remain about the same Don't know 11. In your opinion, how important is each of the following for a student to get the most out of the f i r s t year of medical school? (Answer for each) Haven't Very Fairly Of minor Not at a l l thought important important importance important about i t Manual dexterity (with instruments, +.ools, machines, ett, ) Ability to memorize ..... Ability to cope with theoretical material  Previous knowledge of physical science ..... Ability to put aside almost everything / for your studies  Previous knowledge of social science ..... Getting along with other students  Ability to remain relaxed, rather than overly tense and nervous about your work .... Learning as many medical facts as possible ..... Making up your own mind about what to emphasize in your studying  Getting along with the medical faculty  Ability to carry out research 144 - 5 -12. What i s your r e a l i s t i c appraisal of how well you w i l l do i n your f i r s t year courses compared with the other members of your class? (Check one) ....... I expect to do considerably better than average I expect to do somewhat better than average I expect to be about average I expect to be below average Don't know 13. How d i f f i c u l t do you think each of the following w i l l be for you in your f i r s t year of medical school? (Answer for each) Very Fairly Not very Not at a l l „ „ , . ^ . J . d i f f i c u l t d i f f i c u l t d i f f i c u l t d i f f i c u l t * Making friends in your class * Keeping up with other students * Learning what i s expected of you Adjusting to the sights and smells of the anatomy lab * Learning to think for yourself Getting to know faculty members * Not allowing yourself to become overly tense or nervous about your work 14. (a) How much contact do you expect to have with faculty members during your f i r s t year of medical school? (Check one) A great deal A f a i r amount Only a l i t t l e Don't know (b) On the whole, do you expect that your contacts with the medical school faculty during your f i r s t year w i l l be more formal, less formal, or about the same as your contacts with your undergraduate professors? (Check one) Contacts in medical school w i l l be more formal They w i l l be less formal They w i l l be about the same Don't know * 15. To what extent do you think the f i r s t year medical students help each other? (Check one) They try to help each other a great deal They try to help each other a f a i r amoi.nt They try to help each other only a l i t t l e They do not try to help each other at a l l 16. VJhen would you like to have your f i r s t substantial amount of contact with patients? (Check one") I would like to have my f i r s t substantial contact i n my f i r s t year I would like to have i t in my second year I would like to have i t i n my third year I would like to have i t i n my fourth year I would like to have i t during my interneship Don't know 145 - 6 -17. In which year of training do you expect to have your f i r s t substantial amount of contact with patients? (Check one) I expect to have my f i r s t substantial contact i n my f i r s t year I expect to have i t i n my second year I expect to have i t in my third year I expect to have i t in my fourth year I expect to have i t during my interneship Don't know * 18. When do you expect that you w i l l f i r s t come to think of yourself as a doctor? (Check one) During my f i r s t year in medical school During my second year During my third year During my fourth year During my interneship During my residency Haven't given i t any thought 19. What things do you think you w i l l like best about being a doctor? (Check as many as apply) Being able to deal directly with people Being able to help other people The fact that medicine i s a highly respected profession Having interesting and intelligent people for colleagues Doing work involving sc i e n t i f i c method and research Being my own boss Being sure of earning a good income The challenging and stimulating nature of the work Other (What? ) 20. (a) In your opinion, how well does each of the following phrases describe the medical profession? (Answer for each) Very good Fair Poor description description description (1) A profession which has high standing i n the community (2) A profession of service to the community (3) A profession which i s secure and lucrative ..... (4) A profession which helps individuals directly ..... (5) A profession i n wh' -h real a b i l i t y i s recognized by one's colleagues (6) A profession requiring harder work than others y (b) In your opinion, which one of the above phrases best describes the medical profession? (List the appropriate number) 7777 - 7 -PART B Medical Students' Experiences and Opinions I. This Section of the questionnaire deals with your experiences i n medical school and with your feelings about the kind of training a medical student ought to receive. 1. Many medical students seem to fee l that they do not always have enough time to do a l l the things they want to. How do you feel in this respect - do you fee l that you have enough time for each of the following activities? (Answer for each) Just about Not quite Not nearly Ample enough enough enough time time time time Learning a l l that you are expected to know in medical school Following the latest medical advances i n books and journals Spending time with your family and friends Following up your own interests i n the f i e l d of medicine Reading the newspaper, and keeping up with current affairs * 2. Compared to the other students in your class, how hard would you say that you have worked in your studies during the current semester? (Check one) Considerably harder than average Somewhat harder than average About average Somewhat less than average Considerably less than average 3. (a) Which phase of your medical training do you think w i l l be most important for your later career i n medicine? (Check one) Fi r s t two years of medical school Last two years of medical school ' Interneship Residency Don't know 3 (b) Which phase of your medical training do you expect to find most d i f f i c u l t ? (Check one) Fi r s t two years of medical school Last two years of medical school ...... Interneship Residency Don't know 147 - 8 -r 4. Everyone knows that medical students are given much more factual information than they can possibly assimilate. In general, do you think that the faculty gives medical students enough direction in what to emphasize i n their studying? (Check one) Faculty gives too l i t t l e direction Faculty gives about the right amount of direction Faculty gives more than enough direction * 5. (a) What is your r e a l i s t i c appraisal of how well you are doing i n your courses compared with the other members of your class? (Check one) Considerably better than average Somewhat better than average About average Below average Don't know * (b) How sure are you about how well you are doing? (Check one) Completely sure Quite sure Not sure t (c) Rank the following according to their importance to you in deciding how well you are doing at the present time. (Rank a l l three, placing a 1 before the most important, and so on) Comments of your fellow students Information given you by the faculty Your own personal self-evaluation * 6. To what extent are you concerned about how well you are doing in comparison with the other students i n your class? (Check one) Deeply concerned Quite a b i t concerned L i t t l e concerned Not at a l l concerned *• 7. How do you f e e l about competing with other people, especially when the stakes are so high? My feeling about competitive situations i s that (Check one) I dislike them and prefer to avoid them completely I dislike them somewhat I have neutral feelings about them I enjoy them somewhat I get a kick out of them and sometimes seek them out * 8. How much competitiveness have you found among your classmates i n medical school? (Check one) A great deal of competitiveness A f a i r amount of competitiveness Only a l i t t l e competitiveness No competitiveness at a l l 148 - 9 -9 . Are there some kinds of sick people to whom you fee l especially drawn or toward whom you feel particularly sympathetic? Yes No IF YES: (a) Toward which of the following types of patients are you most sympathetic? (Check as many as apply) Young people ...... People with terminal illnesses People who are "down and out" Articulate people People who are optimistic about their illness People who have clear-cut physical illnesses People who have confidence in the doctor .. Other (Which? ) (b) What do you think you should do when you find yourself positively drawn to a patient? (Check one) I'd try to control these feelings, and regain my sense of objectivity I'd take advantage of these feelings to try to draw the patient closer to me I wouldn't try to change my feelings at a l l Other (What? ) 10. Are there some kinds of sick people toward whom you find yourself reacting negatively? Yes No IF YES: Toward which of the following types of patients do you react negatively? (Check as many as apply) Old people People who think they know as much about medicine as the doctor Inarticulate people People who have nothing but psychogenic symptoms People who fee l sorry for themselves People who have physiologically improbably symptoms People who make no real effort to get well Other (Which? ) 149 - l o -l l . This section deals with the medical profession in general and with standards of medical care. * 11. (a) In your opinion, how important i s each of the following characteristics in making a good physician? (Answer for each) Very Fairly Of minor Not at a l l important important importance important (1) Good appearance (2) Warm and pleasing personality (3) Dedication to medicine (4) High intelligence (5) S k i l l f u l management of time (6) Scientific curiosity (7) Integrity (8) A b i l i t y to thinkin an organized way ..... (9) Research a b i l i t y (10) A b i l i t y to get along with people (11) Recognition of own limitations (12) Getting real enjoyment out of medicine * (b) In your opinion, which two of these characteristics are most important i n making a good physician? (List the appropriate numbers) # and # (c) In your opinion, which of these are more important to medicine than to other professions? # and # 12. How important is each of the following types of social behavior to the success of a physician? (Answer for each) Very Fa i r l y Not at a l l important important important To maintain a restrained and dignified manner To wear conservative clothing To participate i n community activities To be a good conversationalist To have a degree from a top medical school To maintain an air of confidence (even when he i s not feeling confident) ..... 150 - 11 -13. The various specialties within the medical profession present different opportunities, and correspond to different sorts of interests and talents among doctors. What i s your judgment about the following specialties in the respects l i s t e d below? Please indicate to what extent each of the following i s a good  description of the specialties l i s t e d . (If you think the statement i s very  appropriate to the specialty, please put a 1 on the corresponding line"! If you think i t i s f a i r l y appropriate, please put a 2. If you think i t i s not very  appropriate, please put a 3. If you think i t i s inappropriate, please put a 4.) (Please put a number for each specialty on every statement.) Sur- Ifedi- Psy- Paedi- Ob.- General gery cine chiatry atrics Gyn. Practice A f i e l d where one can establish his own hours of work ..... A f i e l d in which patients are highly appreciative of what i s done for them ..... A f i e l d where diag-nostic problems are especially challenging A f i e l d where rel a -tionships with col -leagues i n the same specialty are par-t i c u l a r l y enjoyable A f i e l d which i s very l i k e l y to yie l d a good income A f i e l d which presents opportunities for knowing patients well ..... A f i e l d which has high prestige within the medical profession * 14. In which one of the following categories would you say that the average yearly income of the specialist and of the general practitioner f a l l ? (Check one in each group) Specialist General Practitioner Under $5,000 Under $5,000 $ 5,000 up to $10,000 % 5,000 up to $10,000 $10,000 up to $15,000 $10,000 up to $15,000 $15,000 up to $20,000 $15,000 up to $20,000 $20,000 up to $25,000 $20,000 up to $25,000 $25,000 up to $35,000 $25,000 up to $35,000 151 - 12 -III. This section deals with your professional plans and ambitions for the future. Even though you may not be certain of your plans, please answer the questions on the basis of your present hopes or preferences. 15. How much have you thought about the kind of medical career you would like to have? (Check one) A great deal A f a i r amount Only a l i t t l e Not at a l l 16. Which of the following fi e l d s of medicine would you least like to enter? 1st choice... ......... 2nd choice Which of the following f i e l d s of medicine would'you like to enter? 1st choice 2nd choice Medicine Surgery Obstetrics and Gynaecology Paediatrics Pathology Psychiatry Orthopaedics Dermatology Ear, nose and throat Public Health General Practice Research Other (What? ) 17. If you could arrange i t , i n vh ich one of the following situations would you plan to carry out the professional activity you said you prefer most? (Check one) Own professional office with hospital a f f i l i a t i o n Own professional office without hospital a f f i l i a t i o n Large private c l i n i c or hospital Small group c l i n i c Medical school Other (What? ) (a) For the student who does exceptionally well i n medical school, how would you rank the following five career plans i n order of their desirability? (Rank a l l five, placing a 1 before the most desirable, and so on) Residency, followed by general practice Advanced training, followed by a research career Residency, followed by specialty practice No residency, followed by general practice Advanced training, followed by full-time teaching i n medical school 152 - 13 -17. (Cont'd) (b) How do you think the faculty as a whole would rate these career plans for the student who does exceptionally well? (Rank a l l five) Residency, followed by general practice Advanced training, followed by a research career Residency, followed by specialty practice No residency, followed by general practice Advanced training, followed by full-time teaching in a medical school 18. What yearly income do you think you might r e a l i s t i c a l l y expect (a) Ten years after medical school? (Check one) Under $5,000 $ 5,000 up to |10,000 $10,000 up to $15,000 $15,000 up to $20,000 $20,000 up to $25,000 $25,000 or over *• (b) At the peak of your career? (Check one) Under $5,000 $ 5,000 up to $10,000 $10,000 up to $15,000 $15,000 up to $20,000 $20,000 up to $25,000 $25,000 or over How satisfied w i l l you be with the yearly income you think you might r e a l i s t i c a l l y expect (c) Ten years after medical school? (Check one) Very satisfied F a i r l y satisfied Dissatisfied (d) At the peak of your career? (Check one) Very satisfied F a i r l y satisfied Dissatisfied * 19. what extent have you worried that you may not be able to have the kind of medical career you want? (Check one) A great deal A f a i r amount Only a l i t t l e Not at a l l - 14 - 153 20. Once you have received a licence to practice medicine, to what extent do you expect to continue your medical education by each of the following routes? (Answer for each) Occa-Regularly sionally Never Unsure Reading medical journals Reading medical textbooks Attending local medical society meetings Supplementing your practice with research ac t i v i t i e s Teaching full-time i n a medical school Teaching part-time in a medical school ..... Serving i n an out-patient c l i n i c Taking post-graduate and summer specialty courses Examination of publications of pharmaceutical houses By contacts with consultants on your cases 21. Below are some considerations that might enter into your selection of a specialty or of general practice in medicine. Which two are most important to you as you think about your career? Which two are least important? (Check two i n each column) Most Least important important Having the opportunity to know your patients well Being able to establish your own hours of work Meeting diagnostic problems that are particularly challenging Having enjoyable relationships with colleagues Making a good income Having patients who w i l l appreciate your efforts Having prestige within the medical profession IV This f i n a l section deals with your background and your interests. The information you provide here w i l l permit a comparison of the opinions, plans, and experiences of students with different kinds of backgrounds. * 22. Exact Date of Birth: Month Day Year * 23. Sex: Male, Female * 24. Marital status: Single Married Engaged Divorced, separated, widowed If engaged: When do you plan to marry? 2 5 . If married: (a) How long have you been married? Years (b) How many children do you have? 26. How much have you worried that you might not be happy i n a medical career?' (Check one) A great deal Somewhat Only a l i t t l e Not at a l l 2 7 . How d i f f i c u l t i s i t for you to finance your medical education? (Check one) Very d i f f i c u l t F airly d i f f i c u l t Not very d i f f i c u l t Not at a l l d i f f i c u l t 28. (For students who depend on parents for some or a l l of their support) How do your parents f e e l about having you depend on them for financial aid while you are i n medical school? (Check one) They are not happy about i t They are willing, although i t i s d i f f i c u l t for them They are willing to do i t They are very glad to do i t Other (What? ) 29. How much have you worried about the problems of supporting yourself (and your family): (Check one) (a) While you are i n medical school? A great deal Quite a bit Not very much Not at a l l (b) During your interneship? (Check one) A great deal Quite a b i t Not very much Not at a l l (c) During your residency? (Check one) A great deal Quite a b i t Not very much Not at a l l Do not plan to take residency (d) During your early years i n practice? (Check one) A great deal Quite a b i t Not very much Not at a l l 155 - 16 -30. Have you had a job for pay during the current semester? Yes.... No. IF YES: On the average, how many hours a week have you worked? (Check one) 10 or less 11-20 21-30 31 or more 31. During the coming summer, do you plan to work (Check one) full-time part-time not at a l l If "FULL-TIME" or "PART-TIME": Is this work related to medicine? Yes No. W i l l you get paid for this work? Yes No 32. What are your favorite leisure time activities? (Check 2 or 3 favorites) Going to the movies Reading serious books and magazines Listening to music Attending sports events as a spectator Participating in sports events Going out on dates Talking with friends Working at special hobbies (What?. ) Other (What? ) * 33. What i s your father's occupation? (If retired or deceased, l i s t previous occupation) * 34. Name the city, province or state and country in which you lived longest before going to college. * 35. What undergraduate college did you attend? 36. (a) In what f i e l d did you major as an undergraduate? (b) If jyou had i t to do over again i n what would you major i n undergraduate college? 156 - 17 -#37. Do you have any relatives who are i n any of the following professions? Other Mo Parents Siblings relatives M.D.'s? Lawyers? Dentists? Clergymen? !!!!!! !!!!!! Teachers? !!!!!! Nurses? Engineers? Other professionals? .... (What? ) \[ ...... Name; Fi r s t Surname 3-57 BIBLIOGRAPHY Association of American Medical Colleges, The Ecology of the  Medical Student, Report of the F i f t h Teaching I n s t i t u t e , Evanston, I l l i n o i s , 1958. Becker, Howard S., "Notes on the Concept of Commitment", American Journal of Sociology, Vol. LXVI, No. 1, July I960, pp. 32-40. Becker, Howard S., and Carper, James V/., "The Development of I d e n t i f i c a t i o n with an Occupation", American Journal  of Sociology. Vol. 61, No. 4, January 1956, pp. 289-298. Becker, Howard S. and Carper, James W., "The Elements of I d e n t i f i c a t i o n with an Occupation", American Socio-l o g i c a l Review, Vol. 21, No. 3, June 1956, pp. 341-348. Becker, Howard S. and Geer, Blanche, "The Fate of Idealism i n Medical School", American So c i o l o g i c a l Review, Vol. 23, No. 1, February 1958, pp. 50-56. Becker, Howard S. and Geer, Blanche, "Student Culture i n Medical School", Harvard Educational Review, Vol. 28, No. 1, Winter 1958, pp. 70-80. Blishen, Bernard R., "The Construction and Use of an Occupational Class Scale", Canadian Journal of Economics and  P o l i t i c a l Science. Vol. XXIV, No. 4, November 1958, PP. 519-531. Bloom, Samuel W., "The Role of the Sociologist i n Medical Educa-t i o n " , Journal of Medical Education, Vol. 34, No. 7, July 1959, PP. 667-673. Cahalan, D., C o l l e t t e , P., and Hilmar, N.A., "Career Interests and Expectations of U.S. Medical Students", Journal  of Medical Education, Vol. 32, No. 8, August 1957, PP. 557-563. Cartwright, Ann, "The Career Ambitions and Expectations of Medical Students", Journal of Medical Education, Vol. 35, No. 3, March I960, pp. 251-257. Fox, Renee C, A Soc i o l o g i c a l Calendar of the F i r s t Year of  Medical School, Columbia University, Bureau of Applied S o c i a l Research, 1958. Freeman, Howard E., and Reeder, Leo G., "Medical Sociology: A Review of the Lit e r a t u r e " , American So c i o l o g i c a l  Review, Vol. 22, No. 1, February 1957, pp. 73-81. Gee, Helen Hofer and Cowles, John T., Eds., The Appraisal of  Applicants to Medical Schools, Journal of Medical Education, Vol. 32, No. 10, Part 2, October 1957. H a l l , Oswald, "The Stages of a Medical Career", American Journal of Sociology, Vol. 53, No. 5, March 1948, PP. 327-337. -Hare, Paul, Borgatta, Edgar F., and Bales Robert F., Small  Groups, New York, Knopf, 1955. Jaco, E. Gartly, Ed., Patients, Physicians and I l l n e s s , Glencoe, I l l i n o i s , Free Press, 1958. Kadushin, Charles, Individual Decisions to Undertake Psycho- therapy, Bureau of Applied S o c i a l Research, Columbia University, Reprint 268, 1958. McCandless, F.D. and Weinstein, Morris, "The Relation of Student Anxiety to Concepts of Role i n Mecial Care", Journal of Medical Education, Vol. 33, No. 2, February 1958. Merton, Robert K., S o c i a l Theory and So c i a l Structure, Revised, Glencoe, I l l i n o i s , Free Press, 1957. Merton, Robert K., Reader, George, and Kendall, P a t r i c i a L., Eds., The Student Physician, Cambridge, Harvard University Press, 1957. Nasatir, E. David, Occupational Inheritance Within the Medical  Profession, Paper read at the Fiftv-second Annual Meeting of the American Sociological Society, Washington, D.C., August 29, 1957. Parsons, Talcott, The So c i a l System, Glencoe, I l l i n o i s , Free Press, 1951. Rosenberg, Morris, Occupations and Values, Glencoe, I l l i n o i s , Fre e'Pre ss, 1957-Taxation D i v i s i o n , Taxation S t a t i s t i c s , 1959. Ottawa, Queen's Pr i n t e r , 1959. Williams, Robin M., J r . , American Society. New York, Knopf, 

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