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UBC Theses and Dissertations

A stage in the making of a physician Chang, Yunshik 1961

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A "STAGE II THE HAKI3JG 01 A PHYSICIAN  Yunsiiik Ghang B.A., University of Seoul, (Seoul, Korea) 1958  A THESIS SUBMITTED II PARTIAL FULFILMENT OF ,: THE EEQUIEEMENTS ! FOE THE DE GHEE OF ' v  " ; s.\  MASTER OF AETS in the Department 'of  Anthropology and Sociology _<  We accept this thesis as conforming to the required standard  THE UNIVESSITT OF BRITISH COLUMBIA April,.1961  T 0  L Y N N  P A L M E R  (  ACKKTQWEED GEMENT Tills study is, to a large degree, a collaborative effort, and "belongs not to me but to others.  To these I  owe much. To Professor Kaspar D. Maegele I am grateful for his interest and his many kindnesses.  I am most indebted  to Professor R.A.H. Robson who contributed significantly to solving many of my methodological problems.  For the cor-  rection of my English I wish especially to thank Professor Stanford Lyman, Lynn Palmer, Lawrence Douglas, Bachee ParkerJervis, Marjory Duxbury, Kent Autor, and I. Paulus, and for the typing of this, study, Mrs. Catherine Toynbee.  My  greatest indebtedness and deepest appreciation go to Professor Bernard Blishen, without whose direction this study could hardly have been done.  ABSTRACT  The process of the socialization of first year medical students is analyzed according to a paradigm of adult socialization.^ Shis paradigm consists of three sets of variables, that is, independent variable (I), personal background characteristics, independent variable (II), elements of interpersonal relation in which students are involved,, and dependent variable, the cultural content of socialization. The study shows (a) that during the first year the medical students tend to think: of"the first year as the least important period for their later career.  Besides  being least important, the first year appears to be the most difficult.  'They also feel hard pressed for time  —  there seems to be too much to learn for the time allowed* However, they expect that as they go through medical school, their training will be less difficult. ^ A majority of them find themselves very much involved in the Competition among themselves. neutral.  Their attitudes towards this are rather  They express satisfaction with their faculty  members in the given direction in their studies..  (b)  In  the assessment of their performance during their training,  a majority of the students classify themselves as average, the reference point of which is largely found in themselves rather than in their fellow students, or in the' opinion of the. faculty members. ; (c) With regard to their attitudes and values; students tend to hold the initial values which they had on entering medical school, namely, "peopleorientation."  No student thinks of himself as a doctor in  thefirst .year, in fact, from thebeginning he. did not expect to establish his professional self-image in the first year.  On the other hand, the- outline of the image of  physician whichemerged on entry into medical school remains almost the same at the end of the year with only a slight modification.  The image is chara.cterized/primarily by  personality traits.,, and a task-oriented emphasis.  As the  year comes to an end, a substantial proportion of students tend to specify themselves as preferring general practice as their later career.  This was not chosen by anyone at  the beginning of the year.  Their expected income differs  little from the actual current income of physicians.  They  tend to express more satisfaction with their chosen career as they progress through the first yeai;>  In presenting this thesis in partial fulfilment of the requirements for an advanced''degree at the University of British Columbia^ I agree that the Library shall make it freely available for reference and study.  I further agree that permission  for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission.  Department The Univers Vancouver Canada. Date  -An • ,  Ic . IS-f  f Ql i LlLi  TABEE 01/CONTENTS Chapter I.  Page Introduction  .  1  X« olem («••••«•••••»•»»««« II:. Method and the Background of the Eesearch III. Methodological Eeconsideration .......... IV. Descriptive Aspects of Independent Variables (I) V. Curriculum II.  The Social Structure:  The Change of Variables  I. Social Eelations Among Students: Cooperation and Competition ..........i . / II. Reciprocal Relations of Medical Students and Faculty Members ................... III. Students and Patients ..... «;.-. .. III*  s  .  39 . 39/ 50 56  77  Sell-Evaluation ..•••.•.•................ Motivation .............................. Identification: Professional Self-Image The Image of the Physician .............. Specialization Eemuneration ................. *..........  77 .9© 104 110 126 137  B. Relationship Between Selected .Variables ....  154  I. II. III. IV. V. VI. IV.  20 24  77  A.. The Change of the Variables .....>.......... I. II. III. IV. V. TI.  1? 19  Self-Evaluation ...................... * . Motivation .............................. Identification . . . . . . . . . . . 1 The Image of the Physician .............. Specialization Eemuheration ..............  Summary  i..........  Appendix A.. Note on Test of Significance .............. Appendix B» The Questionnaire Bibliography  155 157 7 1 ,175 182 190 204  209 210 227  LIST 0F TABLES Table  Page  I.- Percentage Distribution of the Sample by Age, Sex, and Marital Status" II.  Financial Pressure  22 .....................  23  1.1  Comparison of Difficulty of ..................... Medical Training with Other Careers. Spring  27  1.2  Student Feeling about Time Requested for Certain Activities  29  1.3  Students' Yiews on Studies in Successive Medical School Tears. Spring ...................  31  1.4-  Extent of Students' .Worry Concerning the Medical Career They Want. Spring ...............  31  1.5  Students' Feeling about Medical School. Spring  34  1.6  Students' on for the their Importance Four Tears of MedicalYiew School Later of Careers* Spring  35  2.1  Students' Opinion on the Extent of Cooperation among Themselves  44  2.2  Students' Report of Level of Competitiveness among the First Tear Glass  46  2.3  Students' Feeling about the Competitive . Situation  48  2.4  Students According to Degree of Concern about Progress .......................................  49  2.5  Students' Expectations Regarding Amount of Expected-Contacts with Faculty. Fall  53  .2.6  Students' opinion on Amount of Direction Given by the Medical Faculty  54  Table-... 2.7  *  Page  Students' Opinion on Amount of Direction Given "by tlie Medical Faculty at U.B.C. and in U. S. Medical School  .  56  2.8  Kinds of Patients to Whom Students Feel Especially Drawn or Particularly Sympathetic .... 2.9 , Kinds of Patients Toward Whom Students Find Themselves Reacting Negatively  64-  2;10  Extent of Student Preference for Patients ......  66  2.11  Kinds of Patients Toward Whom Students are Sympathetic and Toward Whom They React . Negatively  68  2.12  Student Opinion about Sympathetic Attitude Toward a Patient  7©  2.13  Students. According to Their Attitudes Toward the Sympathetic Feeling Related to Number of Patients Toward Whom Preference was Expressed ..  71  3.1  Degree of Self-Evaluation ...... *  80  3.2  Degree of Certainty About Self-Evaluation ......  81  3.3  Correlation Between the Degree of SelfEvaluation and the Degree of Certainty .........  82  3.4-  Degree of Self-Evaluation According to Class  ..  65  Standing. Spring .................  83  3.5  Students' Dependence on Various Evaluations ....  86  3.6  Students' Dependence on "Various Evaluations .... in U.B.C. and U.S. Medical School Correlation Between Evaluation and the Standard of Evaluation* Spring .......................... Rank Order, Self-Evaluation, and the Standard  87  3.7 3.8  88  of Evaluation. Spring ......... ...*.............  89.  3.9  Elements in Motivation *........................  94  3.10  Students' Motives for Entering and Remaining In Medicine ...i................................  99  3.11  Inconsistency of Value-Orientation During Fall and Spring  101  Sable  Page  .3>12 Students According to tlie Numbers of Categories of Value Selected ...............................  103  3 -13 /When Students Expect to Think of Themselves as Doctors  106  3.14  Self-Image as a Doctor According to U.B.C. . Sample in Medical School and Others ............  10?  Important Factors in Making a Good Physician ...  115  3.16 : Important FrequencyFactors Distribution and Rank Order of in Making a Good Physician ...  119  3.15  3.17  3.18  Frequency Distribution and Rank Order of Characteristics More Important to Medicine. Than to Other Professions .... . . .................... Student Conception of Relative Importance of Various Types of Social. Behaviour to the Success of a Physician ............................... . .  122  124  3.19  Student Consideration of Specialty Choice ......  129  3.20  The Rank Order of the Choice of Specialty ......  131  3.21  Students' Plans for Later Career  132  3.22  Career Plans of First Year Medical Students at U.B.G., Cornell University and Others ..........  133  3.23  Most (Least) Important Consideration for Selection of a Specialty or of General Practice  136  3.24  Specific Consideration in the Choice of Specialty According to Various Specialties .....  138  Specific Consideration in the Choice of Specialty According to Specialty Practice, .. General Practice, Research, and Public Health ..  139  3.26  Student Expectation of Average Yearly Income of the Specialist and of the General Practitioner  141  3.27  Realistic Expectation of Yearly Income Ten Years After Medical School and at the Peak of Career  143  3.28  Expected Income of First Year Medical Students at the Peak of Their Career, and Ten Years After Graduation  144.  3.25  Table 3.29  3.30  3•31  ,  '  Correlation Between Student Expected Income at the Peak of Their Career and in Ten Tears after Medical School .......... *  145  Relation Between the Expected Income Ten Tears After Medical School and Expected Satisfaction With It  14?  Relation Between the Student Expected Income at " the. Peak of Career and Expected Satisfaction With It ..... ....  148  3.3.2. • Description of Students' Feeling About a Career in Medicine ........................ ............ 3*33  Page  Students' Preference for the Work Situation in Which They Would Like to Carry Out Their Professional Activity ....................... . . .  , 3»34- Self-Evaluation and Opinion on Competition Among Students ................................. 3.35  Degree of Self-Evaluation in Relation to Involvement in Competition ......................  3.36  Degree of Self-Evaluation and Opinion on  150  153 156 I56:  Amount of Direction Given by the Medical Faculty  158  Value and Degree of Economic Pressure. Fall ....  160  3.38  Values and Community Background. Pall  1^1  3.39  Values and Medical Family. Fall ................  162  :  •3«37  3*4-0 Values and the Degree Pressure. Spring .  ......  164  3.41  Values and Community Background. Spring ........  165  3.42 3.43  Values and Medical Family. Spring ............. . Students According to Values and Degree of Self-Evaluation. Spring i..........  166 166  3.44  Values,. Self-Evaluation,. and Economic Pressure. Spring ....v-.  170  3.45  Students' Expectation of Having Self-image as Doctors and Medical Family  172  Table  Page  3.4-6 Student Expectation of Having Self-image as Doctors and the' Degree of SeIf-Evaluation. Spring  173  3.47 Student Expectation of Having Self-image as • Doctors and the Degree of Self-Evaluation. Spring  174  3.4-8 'Gommunity Background and the Characteristics of Doctor ..  177  3.4-9 .Medical Family and the Characteristics of Doctor ....-  179  3.5D  Degree of Self-Evaluation and the Characteristics of Physician. Spring ...........................  181  3.51  Specialty Choice and Economic Pressure. Spring  183  3.52  Specialty Choice and Marital Status. Spring ....  183  3.53  Specialty Choice and Age. Spring  184-  .3.54- Specialty Choice and Community Backgrotmd. \  Spring .........................  186  3.55  Specialty Choice and Medical Family. Spring ....  186  3.36 3.57  Specialty Choice and the Degree of Self- , Evaluation. Spring 188 Expected Income at the Peak of Career and Community Background ^ . .. .. 191  3.58  Expected Income in Ten Years After Medical. School and the Degree of Self-Evaluation. Spring;  194  Expected. Income at the Peak of Career and the-. Degree of Self-Evaluation. Spring ..............  195  3.59  CHAPTER I  INTRODUCTION This is a study of one type of adult socialization,1 the socialization of medical students.  By adult  socialization we mean the acquisition of attitudes, values, interests, skills and "behaviour patterns defined as appropriate for the status of physician which medical students will eventually occupy.  Thus defined, the concept is dis-  tinct from that of "education."  Adult socialization refers  not only to the acquiring of knowledge, and the learning of skills, attitudes, and behaviour formally provided by the institutionalized arrangements of the medical school, but also to such learning that is implicit, unwitting and p xnformal, as a by-product of patterned experience. Since there are many similarities between socialization in early childhood and in adulthood, the concept usually refers to a process continuing throughout the life cycle.  However, adult socialization can be distinguished  from the concept of child socialization in the sense that the former refers to the learning of attitudes, values and behaviour patterns which prepare students for the future status and role of physician, while the latter indicates the learning which simply equips the child to meet current demands.  The following are important characteristics evident in the socialization of the adult hut not in that of the child. In the following the medical student will he used as an example of adult socialization. (1)  The adult is not a tabula rasa.^ He has already learned a number of roles and values  which give him a perspective for evaluating his world.  It is  from this perspective that he chooses an occupation and fixes his expectations of his work role. 4 ceptions  That is, he has lay con-  of the medical profession based on generalized  societal values. (2)  The adult is required to have a certain type of background. The first task of adult socialization is the trans-  formation of the lay conceptions of the outsider into the technical orientations of the insider.  The professional school  accomplishes this transformation by selecting applicants who could meet its established standard.  Applicants may come to  medical school with educational.backgrounds ranging from Junior Metriculation to a Bachelor's degree.^  Besides a  certain degree of scholarship, the professional school requires a diversity of talents.  The admission committees of medical  schools urge that only those students be admitted who have demonstrated a high level of intellectual ability, integrity, perseverance, responsibility and intellectual curiosity.^  (3)  Tlie adult has no alternative choice. Once the adult has committed himself to "becoming a  member of the profession, his activities are definitely directed toward the goal formally defined by the professional school,  lor the medical student, medicine is more likely to  be a terminal occupation. (4)  Technical competence is necessary. The adult must have a command of technical competence.  Almost all the literature on the professions emphasizes that one of the defining characteristics of a profession is its possession of a body of specialized skills as a prerequisite for professional licensing.  Professional schools tend to deny  novices access to clients until they have been certified as proficient, or to allow only partial access, which gradually increases as the novice acquires more skills.'7  Clients or  the society will, in general, concede autonomy to the profession only if its members are able and willing to police themselves; will grant higher fees or prestige only when both its competence and its area of competence seem to merit them; or will grant an effective monopoly to the profession through licensure boards only when it has shown that it is the sole master of its specific craft, and that its decisions are not 8  to be reviewed by other professions. (5) Multiplicity of authority and influence. The socializer in adult socialization is a collective  entity.  Each socializer in this collectivity is a source  of authority and influence upon the socializee. Problem Socialization of the medical student takes place primarily in the medical school through social interaction with people who are significant for the individual, namely faculty members, fellow-students, the complement of associated personnel (nurses, technicians, case workers, etc.), and patients. These personnel with whom the student interacts are conceived as interdependent components of a social system. The medical student is therefore affected, to a significant extent, by his social relationships with others in the school, and by the values these others hold.  Such factors are an  important part of the soeial environment of learning of medical students. Generally speaking, this environment can be thought of as social, comprising the relationships that obtain between the people in the school, and as cultural, comprising the values held by these people. values are held to be related:  Social relations and cultural each affects the other.^  In the light of the above considerations we intend to introduce a scheme, — one —  albeit a partial and a temporary  of adult socialization.  However, it will, at least,  serve as ail initial step in the establishment of a more comprehensive analytical scheme of the.adult socialization process.  _  . ... ,V-  It is hot our major concern to evaluate the technical  performance of medical students, although we do not neglect such data as grades and ratings.  But for the purpose of this  study, ./this technical professionalization is considered' : secondary to the complementary development of various attitudes and values. Our analytical framework of adult socialization consists of three types of variables, the distinction of which is apparent in the ahove discussion. ;Ehey are independent, variable (I), independent variable (II), and dependent variable."^® Firstly, the independent variable (I) refers to the inherent personal characteristics namely, age, marital status, economic pressure, family and home community background. Secondly, independent variable (II) includes the components of interactions in medical school, which might be instrumental in bringing about changes in the dependent variables as will be discussed later.  As noted before, the  medical student is seen as involved in a network of interpersonal relations in which three significant groups are, found:  peers, medical school faculty members, and patients.  Ih addition to these three factors we also included the  students' self-evaluation of their ability in their chosen field as a part of the interpersonal network in the sense that the students' self-evaluation, as suggested "by Kendall,11 mediates the interaction "between them and the above three •groups. • Thirdly, the dependent variable consists of those components of the content of socialization in the medical school namely: , .•••'.. (1) motivation:  occupational value,  (2)  identification:  professional self-image,  (3)  the image of the physician,  (4)  specialization,  (5)  remuneration.  This formulation will be illustrated with the available data in the following chapters.  Since we are  dealing with secondary dsita provided, our effort to apply this formulation to the data is inevitably very limited.: We will try to fit our data into the framework as far as possible. Prior to - further exploration we will briefly discuss each variable, v.I.  Independent Variables  (1) Age The performance of students with different background characteristics responds differently to their motivations and experiences in medical school.  Age, then, is the first characteristic to he considered as a variable in the socialization of medical students.  Since the period of this socialization  generally  (not necessarily) is confined to certain age groups, the pressure which the process of socialization will exert upon students will turn out to he different according to their age * Differences in students' ages during the  sociali-  zation process may be significant as an antecedent variable in two ways which m a y be distinguished.  First, the older  students seem to be in a position to hasten to finish their course more than younger students.  Second, it is often  argued that a person's creativity is somehow related to his  12 age.  Age, in this sense, m a y serve as a clue to explain  the different pattern of students' attitudes or values in medical (2)  education.  Marital status Another factor which must be considered in relation  to medicine's long educational process is the set of recent changes in the mode of living of students —  changes  ated with the rapid changes in our society.  Increasingly,  medical students are marrying at an earlier age. marriage, however, a number of problems arise.  associ-  With  First and  paramount is the necessity for the support of a family.  In  addition, the entire relationship between the sexes is altered. In most cases, until the arrival of a child, the working wife  contributes the largest share to the support of the couple. The increasing load of guilt the student feels as the result of his wife' s financial support, or the "birth of a child drive him-to work at an increasing pace."^ As a concomitant to this, there is a great increase in work attitudes on the part of the working student.  Under  the stress and strain of supporting a family by doing part time work that.is not rewarding other than financially, the, student is in a hurry to finish his education.  The  influence of student's early marriage on the educational process in this sense deserves' our attention as another variable at socialization. (3)  Economic pressure  It is often claimed that the high cost of a medical education usually prevents many able students from entering the medical profession.  Such comments may also.further imply  that financial anxieties seriously hinder optimum learning after the student is admitted to medical school.  In this  regard we are trying to ascertain the effects of financial pressure on the process of learning. (4) Family background It is generally known that sons of professional families are more apt to become professional themselves, than are sons of families in other occupations, especially  the lesser white-collar and manual occupations. therefore, that difference in social origin might  It may he, account  for the observed difference in students' performance medical (5)  in  school.  Home community A slight majority of medical students come from  urban centers.  Difference between residents of large and  small communities with regard to environmental setting have raised many questions such as the following:  How do residents  of large and small communities compare in their performance in medical school?  Do city-dwellers have special competitive  advantage because of any superiority in their  educational  preparation because their environment has taught them h o w to be successful  strivers?  II.  Independent  Variables  (1)  Social relations among Students:  co-operation and  competition Co-operation and competition are universal elements in the interaction among group members.  These are  not separate items, but are phases of one process which always involves something of both. 1 ^" As soon as students enter medical school, and begin to interact with each other, they recognize that they have a  common interest which leads them to co-operate in the ment of it.  Friendship is one outcome of this  and plays a fairly important role in their  achieve-  interaction,  socialization.  However, even in the most intimate  associations,  there is some point at which interests and attitudes diverge. Students seek to attain "a desirable place in the prestige hierarchy" which is, by definition, limited to a few.  It has  been observed that the student in training in medical school, competes for grades, prizes, honours, and fellowships.  The  selection of candidates for these rewards is based upon criteria that assume competition for these "scarce  resources."  Competition, in this sense, is directly related to the productivity of individuals. This study will attempt to determine: (a)  The genesis of co-operation and competition among medical  (b)  students.  The consequences of changing peer-relations in terms of professional interests and values.  (2)  Reciprocal relations of students and faculty Unlike the relation with their peers, the  students'  interaction with faculty members of medical schools is usually assymetrical.  That is, the teacher is more likely to influence  his students than to be influenced b y them.  But all faculty  members are not equally influential in student  socialization.  Instead, students choose a few faculty members whom they try to emulate. It can be further assumed that value  climates  constituted by the faculty differ to an unknown degree  among  15 different medical schools. regard are to ascertain:  The basic problems in this (1) how the values held by the  medical faculty are transmitted to students?  (2) the extent  to which specific faculty members serve as role models for students; who chooses whom; how is this selection made;  and,  how do changes over time occur in this selection process? (3)  Students and patients The care and cure of the patient is, after all, the  main goal of the student in training, and the principal justification for the medical p r o f e s s i o n . 1 ^  But  social  students  have contacts with patients throughout their training in medical school and this undoubtedly affects the patterns of behaviour which they finally develop. In this regard an attempt will be made to determine: (1)  the norms governing professional behaviour and attitudes toward patients,  (2)  the orientations of students toward patients,  (3)  the consequences of conformity or  non-conformity to professional norms for effective learning of the role of the phys i c ian. (4)  Self-evaluation A student's efforts to reach his goal are  subjected  to evaluation by objective criteria, as well as by his own subjective assessment.  This self-evaluation of his own  ability is not always in accord with the objective  evaluation.  Students of the same degree of ability in selected respects rate themselves differently depending upon their choice of reference groups; that is, whether they compare  themselves  with classmates, faculty members, practising physicians, or interns and residents.  When self-evaluation deviates from  objective assessment, it may be functional as well as dysfunctional for an individual in the sense that it results in the "self-fulfilling prophecy. In the light of these considerations, we attempt to ascertain: (1)  the selection of reference or groups, for  (2)  individuals,  self-evaluation,  the deviation of self-evaluation of ability from the measurement of ability by objective criteria,  (3)  the effects of self-evaluation in socialization.  III. (1)  Dependent Variable Motivation - occupational value Participation in medicine as a profession is on a  voluntary basis.  When an individual chooses the medical  profession, he thinks there is something "good" about it, and this conception of "good" is part of an internalized mental picture regarding what he wants out of life.  To ask what an  individual wants out of his work is, to a large extent, to ask what he wants out of life.  It is, therefore,  indispensable  to understand the value an individual attaches to the medical profession when he chooses it.  This value m a y not be the same  as the one which predisposes him to remain in medicine. Our major concerns, therefore, are: (1)  A comparison of the values held on entry into the profession with those  affecting  the decision to remain in medicine. (2)  The differentiation of these values according to independent variables (I)..  (2)  Identification (i)  Professional  self-image  One of the most significant developments which occurs when participating in a professional role is the growth of a professional self-image.  An individual ta&es  over the image of himself as the holder of a particular specialty in the division of labour.  Although a medical  student will think of himself as a student during the earlystages of his medical training, as he progresses through medical school acquiring knowledge about medicine and having contact with patients, he comes to regard himself as a doctor The length of time required for this professional to develop differs among individuals.  self-image  This development  varies markedly according to the type of relationship  also  in  which the student finds himself. The student who consistently feels and thinks like a doctor is presumably more able to carry out his training effectively.  With this image, students learn who they are,  how they ought to behave, and they acquire a set of perspectives in terms of which their conduct is shaped. 1 ® In the light of these considerations the following problems emerge: (1)  Individual differences in the development of a professional  (2)  self-image.  The variation of the professional  self-image  in different types of interaction. (3)  Consequences of a professional for the socialization of the  (4)  self-image  student.  Mechanisms which facilitate the development of a professional  self-image.  (ii)  Elements of identification Identification with, a professional role is not  confined only to the title of the profession.  The elements  of identification with a profession can be further broken down; for instance, into occupational title, commitment to task, commitment to a particular organization or institutional position, and the significance of this position in the larger 19 society. '  Each of these has a part to p l a y in professional  identification. This leads to the following (1)  questions:  Is there a sequence to these elements of identification?  (2)  What are the conditions for, and consequences of, the selection of different elements in identification?  (3)  The image of the doctor A medical student who identifies himself with a  20 role model  will seek to approximate the behaviour and values  of that model.  A role model may be a specific individual, or  person in whom the desirable characteristics of a physician are  crystallized. With regard to the role model of the student, the  following problems will be discussed:  (1)  Who do students choose as a role model among faculty or outside the  (2)  school?  If they do not choose a specific person, what do they consider to he the desirable and undesirable  (4)  characteristics?  Specialization Within medicine there is a wide choice of specialties  which offer alternative career lines, some of them mutually exclusive from an early stage.  These career lines are  variously ranked within the profession itself as well as outside.  In the course of socialization students are exposed  to a variety of specialties, and are expected to choose one of them.  Thus, medicine entails not only desirable  positions,  but also relatively undesirable ones which are necessary for society. The problem of the student's choice of a specialty is, from the society's point of view, one of recruitment the social positions.  Specific interest for one  for  specialty  brings about a serious shortage for the recruitment of others. In this regard we are mainly concerned with the following problems: (1)  Who chooses what  (2)  What conditions make a student choose that  specialty?  specialty?  (5)  Remuneration Every individual has certain creative  potentialities  which find greater or lesser expression in work.  Part of the  richness of h u m a n experience lies in our ability to spend ourselves in an activity which challenges and draws out our highest potentialities.  Consequently, the chances of living  a life characterized by productiveness and  self-fulfillment  will depend to some extent on the degree to which our work  Pi allows us to exercise our creative potentialities.  Then  there is also the question of rewards, especially money and prestige.  The enjoyment of material goods and services, and  the opportunity to follow a characteristic style of life hinges on the remuneration one receives from his work.  Therefore, the  individual choosing an occupation, does so with reference to a host of wants which the extrinsic rewards of work may  satisfy.  With regard to remuneration, the following issues will be discussed: (1)  The amount of income students expect to earn?  (2)  A comparison of expected incomes and the actual income of physicians.  (3)  Are students satisfied with their expected income?  Method and the Background of Research In September 1957, the Faculty of Medicine at the  University of British Columbia introduced a new course  called  "Preclinical Session" to be taken by first year medical students.  Sociologists from the Department of Anthropology  and Sociology were invited to assist in an evaluation of this new course.  At the end of the first year of assessment, those  involved in both departments agreed that further assessment would be valuable.  systematic  Up to M a y I960, data have been  collected on the first year medical students during the university terms of 1957-58, 1958-59, 1959-60.  Every student  in the first year of medicine at the University of British Columbia during the September of 1957, 1958, and 1959 was asked to complete a questionnaire based on one used in the  op studies of The Student Physician circumstances.  but altered to suit local  At the end of each academic year students were  again asked to complete the same  questionnaire.  Our study is based on the data obtained in the 1959/60 academic year, and attempts to analyze the differences in response to the September 1959 and April I960 questionnaire.  In Ghap~.II we shall try to -understand collective  changes in variables which constitute the social structure of medical school namely, relations of students among themselves, with the faculty members and patients.  Chap.HI will also  deal with the collective changes in the rest of variables which are centering around individual personality.  This  collective change often does not account for individual within the group.  changes  Therefore, in this chapter an attempt will  "be made to ascertain what relationships exist between two selected variables, for instance, is the amount of expected income influenced by self-evaluation or rather b y the home community?  By having two different patterns of relationship  between dependent variables and Independent variables on one hand and dependent variables and independent  (II)  variables  (I) on the other, we are able to estimate the effect of experience in medical school and Qf personal background upon the dependent variable.  Methodological  Reconsideration  Research in this fashion presents a basic problem which has long been debated —  whether the behaviour that is  being measured is purely verbal behaviour or whether it is behaviour the student is going to manifest in action. Research conducted over a period of years indicates that wellconstructed instruments using questions which require verbal agreement or disagreement are related to nonverbal  behaviour.24  Moreover, most of the attitude or value studies indicate that verbal behaviour is like other kinds of behaviour and is important because we are always dealing with words. One way to study the actual behaviour is to have preliminary verbal behaviour.  Since individuals can verbally express  their conception of the more favourable alternatives from a set of alternatives, it is possible to infer, from the pattern of verbal choices over a series of situations, the latent  value structure influencing the direction of these Descriptive Aspects of Independent Variables In April I960 there were fifty-nine  choices. (I)  registered  first year medical students at the University of British Columbia.  Hot all of these students completed both  questionnaires at both sessions.  Therefore, when the  questionnaires were "paired" for fall and spring there were only fifty sets which could be matched. (1)  Age In September of 1959 respondents ranged in age. -  from under twenty-one to over thirty years of age. Table I shows, the majority of students —  As  sixty-one per cent  belong to the age group twenty-one to twenty-five and only six per cent were over thirty years old.  The average  class  age was 23.9 years. (2)  Sex Table I indicates that the sex composition of the  sample consisted of eighty-four per cent men and sixteen per cent women. (3)  Marital status Only one student was engaged when the term began,  but was disengaged by the time the term ended.  As far as the  marital status of the sample was concerned, no change during the year.  In the spring of I960, twenty-two per cent  of the class was married. 3.1 years.  They had been married an average of  The range i n years married was from one year to  eight years.  Five of the eleven married students had one  child each in the (4)  occurred  spring.  Social status In an effort to determine from what kinds of hack-  grounds these medical students come, the occupations of their fathers are rated according to a Canadian occupational  class  26 scale.  Occupations are ranked in Classes from I, the  highest to VIII, the lowest, according to combined standard scores from income and years of schooling b y sex.  The first  three classes represent professional and upper income The "managerial" category has the largest  families.  representation.  Eleven of the students' fathers are in this vocational  group.  The fathers of six boys and of two girls are medical doctors. Other occupational groups represented in the classes I to III are school teachers - 4, accountants - 3, engineers - 2, real estate agents - 2, armed service officers - 2, a social welfare worker, a draughtsman, a chemist, and an unlisted professional. The classes IV to VII are comprised of three farmers, a transportation foreman, a plumber, a furnaceman,  22  TABLE  2.8  PEECEBTAGE DISTKIBUTIOif OP THE SAMPLE BX AGE, SEX, AND, MARITAL STATUS  Age  Male  Female  Total  16 - 20 years  14  21 - 25  54  8  62  26 - 30  12  -  12".  31 - 35  4  .2  6  84  16  100  20  Marital Status  Male  Single  : 64  12  76  Married  20  2  22  Engaged  : -  2  2  84  Female  16  Total  .  100  two office clerks, a metal fitter, a policeman, a guard, a cook, and a longshoreman. One strikingfeature of - -eur sample is that more than half of" the students, seventy per cent, belong to classes I and: II.  This concentration in the upper elasses does not allow  us to make a comparison according to social status.  Ve, there-  fore, tried to ascertain the present economic situation of the students hy asking the following question both in the fall and in the spring.  23 "How difficult is it for you to finance your medical  education?" TABLE II FINANCIAL PRESSURE  Fall  Spring  Percentage of students Very difficult  10  12  Fairly difficult  32  34-  Not very difficult  36  36  Not at all difficult  20  18  No  answer  Total  2  students  50  .  _  50  As can "be seen from the above table the economic situation of the students remained relatively unchanged between fall and spring. (5)  Community background The communities where students spent most of their  life were dichotomized into urban and rural areas.  By urban  area we mean all incorporated cities with a population of over 30,000 at the 1956 census in Canada.  All the cities, tovrcis and  villages having populations of 30,000 or less in that year are defined as rural areas.  Those students who lived in other  countries are properly distributed either into rural or into urban areas according to the above standard.  The majority of  students, seventy-two per cent, are from urban areas whereas only twenty-eight per cent are from rural areas. Curriculum In medical school an enormous amount of material is presented to the student which he has difficulty in digesting. As Becker and Geer pointed o u t : 2 ?  "Though the student and  faculty agree that the criteria for choosing what to learn should be relevant for medical practice, there is enough disagreement and uncertainty among the faculty as to what is relevant that the student is never presented with a clear directive to guide him in his own studies." further illustrated by Renee F o x . 2 8  This point is  From the first the  student  is told that he will be "given" the major responsibility for learning, that information is not presented in readily usable form, and that no precise boundaries are set on the amount of work expected of him.  Under these conditions, a beginning  student faces the uncertainty of not knowing h o w much he  should  know, exactly what he should learn, and how he should go about his studies.  This, according to Renee Fox, Is the first kind  of uncertainty encountered by a beginning medical student. Moreover, she also analyzes a second type.  The  student's  experience in medical school concerning the magnitude of knowledge and the lack of strategy for study, lead him to realize the fact that even as a mature physician he will not  always  experience the certainty that comes with knowing all there is to know about the medical problems with which he is faced.  25 He begins to realize that no matter h o w skilled and well-informed he may become, his mastery of all that is known in medicine will never be complete. Renee Pox further pointed out a third type of uncertainty derived from the first two.  This consists of the  difficulty in distinguishing between personal ignorance  or  ineptitude and the limitations of present medical knowledge. Since we are only dealing with the first year medical student, the second and third type of uncertainty do not deserve as much attention as the first one.  Before he begins to worry  about the uncertainty of medical knowledge he. must tackle the medical knowledge given by the instructor.  He is too profes-  sionally immature to share the inherent uncertainty  about  medical knowledge which is usually shown by a practising physician.  We will, therefore, discuss the first kind of  uncertainty in some detail. The Calendar of the Faculty of Medicine at the University of British Columbia lists the required courses for the first year student as follows:  General Biochemistry,  Outlines of Biochemistry, General and Advanced General and Advanced Biochemistry Laboratory,  Biochemistry, General  Pathology, Human Physiology, Advanced Mammalian Physiology, Advanced Mammalian Physiology Laboratory, Human Behaviour, Introduction to Medical Statistics, and Parasites of Man. Besides these courses, each student is assigned to a family in which there are young children, in order to permit  obser-  vation of the growth and development of the children and the  26 interpersonal relations of a growing family.  This is called  Preclinical Session as mentioned previously.  As stated "by  Eenee JFOX,-^  throughout the first year the student is  impressed with the magnitude and intricacy of medical knowledge, the scarcity of time in the medical world, and the difficulty in the distribution of time and difficulties in realizing the highest standards of medicine. The first year student was asked his impression of this situation. All things considered, how do you think medical training compares with each of the following kinds of training: studying to be a lawyer, studying to be an engineer, studying to be a dentist, training, to be an army officer, studying for a Ph.D. in physics, and studying for a Ph.D. in psychology? Are medical studies more difficult, less difficult, or about the same? As Table 1.1 shows, there is general agreement  that  medical training is the most difficult other than obtaining a Ph.D. in physics.  One thing to be noted here is that more  than ten per cent of the students indicated their difficulty in comparing medicine with other career training, such as training to be an army officer, and studying for a Ph.D. in psychology. This assessment of the difficulty of medical training, of course, is not based on the practical comparison with other types of training since few students have  TABLE 1.1 COMPARISON OP DIFFICULTY OF MEDICAL TRAINING WITH OTHER CAREERS. SPRING  Percentage of Students Medical Training  Other careers  Much more difficult than  Somewhat more difficult than  About the same as  Less difficult than  Don't know  Total students  _  _  50  Studying to "be a Lawyer  70  24  6  Studying to be an Engineer  16  46  30  -  6  50  Studying to be a Dentist  12  52  32  2  2  50  Training to be an Army Officer  62  14  2  4  18  50  6  16  38  32  8  50  20  36  24  8  12  50  Studying for a Ph.D. in Physics Studying for a Ph.D. in Psychology  ro S3  28 experienced tliem.  But the student has a perception of  medicine as a difficult field to master.  The  difficulty  which he faces with medicine is reflected clearly in his feelings about the time at his disposal.  He seems to feel  the scarcity of time for learning all that he is expected to learn.  Table 1.2 indicates only thirty-six per cent of the  students (in the Spring) feel that they have "ample" or "just about enough time" whereas the remaining sixty-four per cent feel that they do not have enough time. As far as activities other than lectures are concerned, most of the students felt that they would not have enough time for following the latest medical advances in books and journals or following their own interests in the field of medicine.  E v e n for the time spent w i t h their family  and friends, only a minority —  twenty-eight per cent  —  expected to have enough time. With respect to the students' opinion on the distribution of their time, they showed significant shifts of opinion between Fall and Spring in two activities,  "following  up your own interests in the field of medicine" and  "reading  the newspaper and keeping up with current affairs."  For the  former activity, students tend to feel more the scarcity of time.  The latter activity shows a reversal, in that the p r o -  portion of students who feel enough time for this activity increased from thirty per cent to fifty per cent.  29 TABLE 2.8 STUDENT KEELING- ABOUT TIME REQUESTED FOR CERTAIN ACTIVITIES  Percentage of Students Time  Activity  Enough timei  Not enough time2  No answer  Learning all that you are expected to know in F? 3 6 medical school S 36  62 64  2  Following the latest medical advantages in books and journals  F S  4 2  94 98  2  Spending time with your family and friends  F S  34 28  64 72  2  Following up your own interests in the field of medicine  F S  20 8  76 92  4  Reading the newspaper and keeping up with current affairs  F S  30 50  68 50  2  Total students  50  50 50  50*  505  1.  Two categories, "ample time" and "just about enough time" are combined.  2.  Two categories, "not quite enough time" and "not reallyenough time" are combined.  3-  F - Fall S - Spring  4.  Percentage difference statistically significant at 0.05 level. (0T = 4 df = 1 ) Percentage difference statistically significant at 0.05 level. ( 4.16 df = 1 )  As Table 1.2 indicates, tlie recognition of the scarcity of time is what students already anticipated at the beginning of the school. Fox further states^  that the scarcity of time is  one of the problems which are inherent in the professional role and in the situation of the mature physician.  Students  are thus introduced to the problem of the scarcity of time through the medical curriculum, and learn to cope with it in patterned ways which become progressively more like those of the physician. Although students stress that medicine is most difficult to master, their views on their future training are not so pessimistic.  Students were asked their views on their  future training: Do you think that, as you move from the first to the fourth year of medical school, your studies will become more difficult for you, less difficult, or do you think they will remain relatively unchanged in this respect? As Table 1.3 indicates, a minority — t e n cent ~  per  think of the coming years as more difficult while  forty per cent state that they "will become less difficult," and another forty per cent claim they "will remain about the same." Some interesting tendencies are indicated when students were asked how much they worried about being able  TABLE 2.11 STUDENTS' VIEWS ON STUDIES IN SUCCESSIVE MEDICAL SCHOOL IEASS. SEEING  Percentage of Students Will "become more difficult  10  Will become less difficult  40  Will remain about the same  40  Don't know  10  Total Students  50  to have the kind of medical career they want.  As shown in  Table 1.4 one-half of the students worried only a little, while sixteen per cent expressed a fair amount or a great  TABLE 1.4 EXTENT O F STUDENTS' WORRY CONCERNING THE MEDICAL v CABEER THEY WANT. SPRING  Percentage of Students A great deal  4  A fair amount  12  Only a little  52  Not at all  32  Total Students  50  deal of anxiety concerning their future career.  Thirty-two  per cent indicated no anxiety. Furthermore, a majority of students — cent —  eighty per  feel that "•'basically, medical school is going to he  an enjoyable experience, even though it will mean very hard work at times." Despite the fact that students feel that medicine is more difficult to study than other subjects, they express optimistic views on their future training.  Two reasons can  be suggested: (1)  Students tend to think of the first year as the least important to their later career.  (2)  Besides being least important, the first year seems to appear as the most difficult time in the medical training.  With regard to the first point students were asked: Which phase of your medical training do you think will be most important for your later career? A high proportion of students, thirty-two per cent, are not prepared to give a definite answer to this question at the end of the first year in medical school.  But it is evident  that the first year is hardly considered by them to be of  33 critical importance in the course of medical training. As Table 1.5 shows, forty-eight per cent of the students tend to regard the last two years of medical school as most important for their future careers while only twelve per cent think of the first year as most important. We cannot help, here, quoting Becker's illustration of the disillusionment that medical students face on entering  zp  medical school:^  In several ways the first year of medical school does not live up to their expectation that medicine is made up of a great body of well established facts that they will be taught from the first day on and that these facts will be of immediate practical use to them as physicians. They are disillusioned when they find they will not be near patients at all, that the first year will be just like another year of college. It is conceivable that students are rather disappointed with the amount of medical knowledge provided in the first year. The first year medical student thinks that what he has learned in his first year is relatively -unimportant. Students were also asked: Which phase of your medical training do you expect to find most difficult? Answers to this question as summarized in Table 1.6 indicate that one—half of the students expect to find the first two  TABLE 2.11 STUDENTS' VIEW ON THE IMPORTANCE OF EACH YEAR OF HEDICAL TRAINING- FOR THEIR LATER CAREERS.. SPRING  Most Important Years  Percentage of Students  First two years of medical school  12  Last two years of medical school  48  Internship  6  Residency  2 2  Don't know  3  Total Students  50  years in medical school most difficult; twenty per cent indicated that the last two years could be most difficult. As in the previous question summarized in Table 1.6 a substantial minority, twenty-eight per cent, stated that they "don't know."  But fifty per cent think that the first  two years in medical school are going to be the most difficult and thus give a clue to the circumstances in which the first year medical students find themselves. They find themselves poorly equipped to meet a sudden flood of knowledge which is not considered to be of prime importance for the subsequent treatment of patients.  35 TABLE 2.8 STUDENTS' KEELING ABOUT THE DIFFICULTY OF EACH YEAR OF MEDICAL TRAINING. SPRING.  Most Difficult Year  Percentage of Students  First two years of medical school  50  Last two years of medical school  20  Internship Residency  2  Don't know  28  Total Students  50  In short, the medical curriculum of the first year is characterized as most difficult and unimportant.  Students,  however, expect that, as they go through medical school, their training will be more enjoyable and easier.  36  FOOTNOTES 1  The concept of adult socialization is set forth "by Merton. See Merton, R. K., Social Theory and Social Structure, Glencoe, Free Press, 1957, PP« 263-268.  2  Fox, R., A Sociological Calendar of.the First Year of Medical School, Columbia University, Bureau of Applied Social Eesearch, 1958, p. 6.  3  Simpson, I. H., "Patterns of Socialization into Professions," Draft of a paper presented at the annual meeting of the American Sociological Association, I960.  4  Hughes, E. C., "The Making of a Physician," Human Organization. XIV, No. 4 (Winter 1955), pp. 21-25. Reprinted in his Men and Their Work, Glencoe, Free Press, 1958, pp. 116-130.  5  Deitrick, J. F., "Objectives of Medical Education," Journal of Medical Education. XXXIV, No. 3 (March 1950), pp. 205-208. ' ' So many medical educators who worry about the decline of the standard of medical culture are willing to add more factors for the consideration of selecting applicants.  6  Ibid.  7  Simpson, op. cit., p. 10.  8  Goode, W., "Encroachment, Charlatanism, and the Emerging Profession," American Sociological Review. XXV, No. 6 (December I960), pp. 902-914. "  9  Merton, R. K., Bloom, S., and Rogoff, N., "Studies in the Sociology of Medical Education," Journal of Medical Education, XXXI, No. 8 (August 1956), pp. 552-565.  10  In fact, these variables should be considered as intervening variables. In our study we are not yet able to ascertain the relationship between the dependent variable and the independent variables (group I) with  37 these variables (due to the lack of data) we will treat them as another kind of independent variables. Henceforth both groups of independent variables will be denoted as Independent variable (I) and Independent variable (II) respectively. 11  Kendall, P. L., "Medical Education as Social Process," Draft of a paper presented at the Annual Meeting of the American Sociological Association, I960.  12  Gee, H. G., and Glaser, R. J., ed., The Ecology of the Medical Student, Evanston, Association of American Medical Colleges, 1958, p . 49.  13  Ibid.  14  Cooley, C. H., Social Process, New York, 1918, p. 39.  15  Christie, R., . and Merton, ,R. K., "Procedure for the Sociological Study of the Values Climate of Medical School," in Gee and Glaser, op. cit., pp. 125-153.  16  Platou, R. V., Reissman, L., Sledge, S. H., and Maione, D. H., "Medical Students' Attitudes toward Teachers and Patients," Journal of Medical Education, XXXV, No. 9 (September I960), pp. 857-864.  17  Merton, Social Theory and Social Structure, pp. 421-436.  18  Becker, H. S., and Carper, J., "The Elements of Identification with an Occupation," American Sociological Review, XXI, No. 3 (June 1956), pp. 341-348.  19  Ibid.  20  Role model is different from the reference individual or group in the sense that the latter refers to the person(s) with whom students compare their capacity whereas the former is a person(s) students try to model after.  21  Rosenberg, M., Values and Occupations, Glencoe, Free Press, 1957), p. 2.  22  Merton, R. K., Kendall, P., and Reader, G., The Student Physician, Cambridge, Harvard University Press, 1957.  23  Gee and Glaser, op. cit., pp. 157-163.  24  Ibid., p. 162.  25  Ibid.  38 26  Blishen, B. E., "The Construction and Use of an Occupational Class Scale," The Canadian Journal of Economics and Political Science, XXIV, No. 4 (November 1958;, pp. ' 51-9-531.  27  Becker, H. S., and Geer, B., "Student Culture in Medical School," Harvard Educational Review, XXVIII, No. 1 (Winter 1958), pp. 70-80.  28  Fox, E., "Training for Uncertainty," in Merton, Kendall, and Eeader, op. cit., pp. 207-241.  29  Ibid., p. 208.  30  Fox, A Sociological Calendar of the First Year of Medical School, pp. 1-16.  31  Ibid., p. 10.  32  Becker, H. S., and Geer, B., "The Fate of Idealism in Medical School," American Sociological Beview, XXIII, No. 1 (February 1958), pp. 50-56.  CHAPTER II THE SOCIAL STRUCTURE: I.  THE CHANGE OP VARIABLES  Social Relations Among Students: Cooperation and Competition  Deutsch designated two aspects of groups, cooperation and competition.  He defined these two situ-  ations as follows: In a cooperative social situation the goals for the individuals in the situations under consideration have the following characteristics: the goal regions for each of the individuals in the situation are defined so that a goal region can he entered (to some degree) by any given individual if all the individuals under consideration can also enter their respective goal regions to some degree. In a competitive social situation the goals for the individuals in the situation under consideration have the following characteristics. The goal regions for each of the individuals, in the situation are defined so that if a goal region is entered by any individual the other individuals will, to some degree, he unable to reach their respective goals in social situations under consideration.! He uses the phrase "promotively interdependent goals" to identify any situation in which the individuals composing it have their goals interrelated by the characteristic defined in the former sense.  The term "contriently inter-  40 dependent goals" will "be used to identify any situation in the latter sense. Except for a very few situations which, are purely cooperative or competitive, most situations of everyday life involve both cooperative anc competitive elements.  Con-  sequently it is possible for individuals to be promotively independent with respect to another goal.  Thus defined, two  aspects of a group, the first year medical class, will be observed in the same framework.  The first year medical class  as a peer group, involves two situations:  firstly, they are  cooperatively interrelated with respect to a common intention (or goal), i.e. becoming physicians, and secondly, they are competitively interrelated with respect to another goal which is established in the class after it becomes a group, that of being highly ranked. We will discuss these points in some detail. Unlike most of the regular classes in other undergraduate courses, medical students tend to form a group in which all, or nearly all, members have opportunities for interaction with each other.  They arrive in medical school with the  common intention of becoming physicians, and as soon as they are accepted as medical students they carry a number of "pressing and chronic problems, the most important stemming from the fact that they are continuously presented with an p enormous, unlimited amount of material to learn." Medical  41 school also provides extremely convenient conditions  —  intensive interaction and relative isolation from outside contacts —  for the common solution to the problems which  they must face.  These two conditions apparently make for  rapid establishment of a cooperative group.  They usually  spend more than eight hours in school every week day, working and studying together in the class.  In addition, they pro-  mote group solidarity on special occasions such as the Medical Ball, or during activities celebrating the successful completion of various stages of their medical training. The students are insulated from contact with others, both by reason of their heavy schedules and because they find difficulty in talking to people who are not in the same group sharing the same difficulties.  This intensive inter-  action in an isolated group produces the mutual understandings and agreements which Becker and Geer called "student culture" i.e. a set of provisional solutions and guidance for activity.^ Becker and Geer noted three basic characteristics of these common understandings.4 One set of understandings specifies goals and values telling the students that they are in school to acquire the knowledge and clinical experience one must have before he can assume the physician's responsibility for the lives of his patients, a responsibility he intends and expects to have once he has finished school.  He bases his inter-  pretations of the worth of various school activities on the  criterion of liow well this function is served in each. Another set of understandings suggests modes of cooperation designed to meet examinations and other crises, and such recurrent problems as sharing loads of clinical work assigned to groups. The student's interpretation of specific events and issues tends to be made in categories which are part of the student culture, because these events and issues are new and unfamiliar, and do not fit easily into categories provided by his earlier experiences.  These cultural under-  standings influence his behaviour in implicit ways. It is not that the student must abide by these informal, hardly conscious, agreements, but rather that they constrain his thinking and perspective almost without his being aware of it.  He may have been torn between what  he might like to do and what the group norms specify as correct. Within the radius of this common understanding, the students are involved in the rather rigid competition for academic achievement.  This degree of competitiveness  is one of the important aspects of student culture which affects the ease with which medical students acquire the technical information they are expected to learn and the speed with which they develop professionally appropriate attitudes.  Returning to our data, we will discuss these two aspects of student relationships, namely cooperation and competition, with regard to the students' perceptions of and attitudes toward them. A.  Cooperation In order to ascertain the extent of students'  cooperation we asked: To what extent do you think the first year medical students help each other? As Table 2.1 indicates, four out of five students state they help each other a fair amount both in the fall and in the spring while only two per cent respond negatively. then, do they help each other?  How,  With regard to cooperative  activity among the class we will refer to two concrete types of laboratory work, Anatomy, and Physiology and Biochemistry. In the Anatomy course, the class is divided into a number of groups each of which consists of six students. Each student freely chooses the group he wishes to join. Members of each group act as a unit in the Anatomy class for the dissection of the body, the use of T.V., and other duties.  In these groups which are established arbitrarily  on the second day of lectures before any ties can be formed between the students, friendships develop. 5  44 .. TABLE 2.4 STUDENTS' OPINION ON THE EXTENT OP COOPERATION AMONG THEMSELVES  Extent of Cooperation  Percentage of Students Pall  Spring  24  12  a fair amount  62  68  only a little  10  16  not at all  0  2  no answer  4  2  Total Students  50  50  Help a great deal  Anyone violating the group ties will find himself in isolation.  This isolation is a form of punishment in  that the other members are not willing to help him in any way. In Physiology as well as in Biochemistry the students are divided into a number of groups, each of which consists of two students alphabetically assigned.  However  when an experiment requires more than two students, there will be a coalition of two sets of partners.  As an example  of a specific type of cooperation we noticed that after the experiment is written UP by a student of the group it will he rotated among the group, but it never goes out of the group.  B.  Competition With regard to competition students were asked to  estimate how much competition they anticipated in their first year in medical school.  Table 2.2 shows that "a great  deal" and "a fair amount" of competition were expected by eight per cent and thirty per cent of the students respectively.  At the end of their first year the proportion of  students who found "a great deal" of competition increased to sixteen per cent and sixty-four per cent stated that they found "a fair amount".  No one reported that there had been  no competition at all.  This tendency is quite contrary to  Thielens1 finding that as medical students go through school, they find themselves involved in reduced competition Reader also found a considerable variation from one school to another in response to the perception of 7 competitiveness among classmates.' His study suggests that one source of this variation is the difference in class size that is, with the increasing size there is an increasingly high level of competition.  Table 2.2 shows a distribution  of expectation of competitiveness similar to that of small schools in Reader's table.® One may assume that in a large class the probability of achieving distinction, such as being top man in the class, winning a sought after prize, being elected to an honour society, and the like is lower for any one  46 ..  TABLE 2.4  STUDENTS' REPORT OF LEVEL OF COMPETITIVENESS AMONG THE FIRST TEAR GLASS  Level of Competitiveness  Percentage of Students Fall  Spring  A great deal A fair amount Only a little No competition No answer  8 38 32 16 6  16 64 16  Total Students  50  50  —  4  Percentage difference statistically significant df = 3, p<.001).  31.02  READER'S TABLE  Level of Competitiveness  Percentage of students in three types of school citing competitiveness^ Small school  Medium school  Large school  A great deal A fair amount Only a little No competition  18 50 28 4  30 45 24 1  36 45 18 1  Total Students  158  604  557  1 Reader, George G., "Development and Capacities," in Gee, H. H., and The Ecology of the Medical Student, American Medical Colleges, 1958, p.  of Professional Attitudes Glaser, R. J., ed., Evanston, Association of 167.  2 Three schools in the small group (less than 70 students), eight medium (70 - 90), and four large (more than 90).  student than is the case in smaller classes.  Achieving  these distinctions, therefore, involves greater competition.^ Students were also asked how they feel about competing with other people, especially when the stakes are so high.  Table 2.3 summarizes students' feelings about com-  petitive situations.  At the beginning of school almost  equal proportions, forty per cent, appeared in each of the two opposed categories, "dislike somewhat" and "enjoy them somewhat."  It is difficult to make a generalization on the  basis of this bimodal type distribution. In the spring, however, most of the beginning students are not likely to avoid competition.  It is sug-  gested that they tend more often to perceive competition as being an unavoidable characteristic of medical school which they must face in order to get through.  This tendency is  considered to be an outcome of the socializing process in the course of which medical students gradually show less concern with competition and by the end of the year manifest neutral attitudes toward it, a fact which may indicate acceptance of the prevailing atmosphere.  As Table 2.3 shows  the proportion of the students who reported that they somewhat disliked competition is reduced to eighteen per cent from thirty-six per cent whereas the proportion of students with neutral feelings toward competition increased considerably —  from eighteen per cent to thirty-two»  48 TABLE 2.8 STUDENTS' KEELING ABOUT COMPETITIVE SITUATIONS  Percentage of Students Fall Dislike and avoid  Spring  2  2  Dislike somewhat  36  18  Neutral  18  32  Enjoy them somewhat  40  40  4  8  Get a kick out of them and seek them out  Total Students 50 50 Percentage difference statistically significant ( X*= 24.38 df = 4, p <.001).  The tendency indicated in Table 2.4 shows that during the year, apparently, they are likely to become involved in competition rather than trying to avoid it. To what extent are you concerned about how well you are doing in comparison with the other students in your class, deeply concerned, quite a bit concerned, little concerned or not at all concerned? This question was an attempt to determine if students regarded a competitive situation as important in assessing their class standing.  This table shows, at the beginning of their career,  49 .. TABLE 2.4 STUDENTS, ACCORDING TO DEGREE OF CONCERN ABOUT THEIR PROGRESS  Percentage of Students Fall  Spring  Deeply concerned  12  8  Quite a "bit concerned  56  46  Little concerned  32  42  -  4  5©  50  Not at all concerned Total Students  Percentage difference statistically significant ( Ka'= df = 3, P <.05).  tlie proportion of students who were deeply and quite a bit concerned is more than twice as much as the proportion of less concerned students.  At the end of the first year the  two proportions tend to become almost the same. indicated,  As Thielens  compared with students in other fields, medical  applicants tend to perceive the competitive situation as being unavoidable and more competitive.  This tendency is  largely based on their greater experience of competitiveness on admission to medical school. But once accepted as a medical student, competition for selection is replaced by competition for a higher  academic ranking.  The latter competition is much milder  than the former in the sense that it is not only confined to only medical students themselves hut is also not so serious as the one they experienced for entrance. Thus far we have discussed some aspects of first year medical students as a peer group, namely cooperation and competition among the group, the perception of the competitive situation, their attitude —  like or dislike  —  toward it, and their estimation of its importance in their task performance. II.  Eeciprocal Relations of Medical Students and Faculty Members  It is assumed that a medical school constitutes an environment in which students are expected to acquire not only the relevant knowledge and skills, but also a set of characteristic attitudes and values.11 Since the faculty members in professional schools are largely drawn from the profession toward which the student aspires, it may be expected that faculty members in such schools will play an important role in moulding the values and career decisions of their students.  As found by Platou  and associates, when the junior and senior students were asked to indicate which persons they felt had contributed most importantly to their training for nine items that had  been developed from their earlier interview materials, the faculty —  among other persons in the school —  was most  valued by the juniors for the teaching of general medical principles, as contrasted with teaching more "practical information."  For the seniors the faculty was evaluated  similarly, but slightly higher than by the juniors.I P The influence of the faculty is not all pervasive. While the student may seek advice on important decisions that he has to make, and a model after whom to pattern his behaviour, there are some situations in which it is not so clear what role the faculty will play.  Coker Jr. and  associates found that the values of medical students appear to be very little influenced by the very faculty members whom they named as having influenced them, and that there are no differences between these students and those vjho did not name an influential faculty member. . . On the other hand, there are varying degrees of relationship between the departmental affiliations of influential faculty members and the specialties chosen by those students who name them. This slight discontinuity of value orientation between faculty and students is further confirmed by 14Caplovitz.  He indicated that only a minority of students  about to graduate from medical school accept the same values as those held by the faculty members. The disparity between the previous assumption and  the above finding needs clarification.  In what respects  are faculty members influential or not influential with respect to students? The effects upon students of the social environment constituted by the faculty can be understood clearly if there are systematic data about the values held by the faculty members and their relations with students® Unfortunately we did not distribute our questionnaires to the faculty.  It is difficult to make any genera-  lizations on the relationship between the faculties and students with data obtained from students only. Our concern, therefore, is confined to asking students if they are satisfied with the direction given by the faculty members.  This is considered to be an index  showing to what degree the faculty influences the students. When they began their medical training the students were asked:  "How much contact do you expect to have with  faculty members during your first year of medical school?" Table 2.5 shows that almost three out of five expected to have a fair amount of contact with the faculty, fewer than one out of five expected only a little, while an equal proportion did not know. In addition to the above question we also asked them the kind of contact with the faculty they expected to have  On the whole, do you expect that your contacts with the medical school faculty during your first year will be more formal, less formal, or about the same as your contacts with your undergraduate professors?  TABLE 2.5 STUDENTS' EXPECTATION REGARDING AMOUNT OP EXPECTED CONTACT WITH FACULTY, FALL  Amount of Expected Contact  Percentage of Students  A great deal  2  A fair amount  58  Only a little  18  Don't know  18  No answer Total Students  450  Approximately half of the students anticipated having less formal contact, thirty-six per cent anticipated the same relationship they held with their professors in undergraduate study, whereas only twelve per cent indicated a more formal relationship. The majority of the students who start their training in medical school expect to have more informal contact with the faculty than they had previously.  Since  they already anticipate a large amount of medical knowledge  54 through a variety of sources such as contact with seniors, students, and so on, it seems that they will inevitably have more frequent contacts with faculty members other than in the classroom setting in order to digest effectively what they learn. Students also think that the faculty will give them enough direction on what to emphasize in their studying. As Table 2.6 shows, seventy-two per cent think that they will be provided with the right amount of direction, and twenty per cent expect too little direction.  TABLE 2.6  :  STUDENTS' OPINION ON TIE AMOUNT GE DIRECTION GIVEN BY THE MEDICAL FACULTY  Opinions on Given Direction  Percentage of Students Fall  Spring  Too little direction  20  34  About the right amount  72  62  More than enough  -  4  No answer  8  -  Total Students  50  50  Percentage difference statistically significant ( df = 3, P <.05).  = 8.37»  In the spring, after they have lived a year in the medical school, a slight shift portions of each category.  . occurred in the pro-  The percentage of the students  who tend to think that the faculty gives too little direction is increased to thirty-four per cent from ten per cent, while the majority of them, sixty-two per cent, are still likely to say, "Faculty gives about the right amount of direction."  However, only a negligible number of students,  four per cent, regard the direction given by the faculty as more than enough. Similar data contained in Table 2.7 for all four years are found in the study carried out by the 15 American Medical Association  which showed no considerable  difference between two samples with respect to students' opinion of the amount of direction given by the medical faculty. In short, the majority of the year year medical students expect to have a fair amount of contact which is less formal than the contact they had previously. With regard to the direction given by the faculty, they tend to think that the faculty gives about the right amount, even though a number of students gradually express the lack of direction.  56 TABLE 2.8 STUDENTS' OPINION ON THE AMOUNT OP DIBECTION GIVEN BY THE MEDICAL FACULTY AT U.B.C. AND IN U.S. MEDICAL SCHOOL  Opinions on Direction Given  Percentage of students U.B.C.1  U. S. 2  Too little  34  39  About the right amount  62  57  More than enough  4  4  No answer  -  1  Total Students  50  1322  1 Data obtained at the end of the first year. 2 Gee, H. M., and Glaser, E. J., ed., The Ecology of the Medical Student, Evanston, Association of American Colleges, 1957, P. 65.  III.  Students and Patients  "The role of the physician" as stated "by Parsons "centers on his responsibility for the welfare of the patient in the sense of facilitating his recovery fa?om illness to the best of the physician's a b i l i t y . H e is responsible for every patient without any discrimination according to social class, age, sex, and the degree and kinds of sickness. 17 This ideal has been traditionally maintained. ' This was clearly stated in Sir Thomas Watson's The Principles of  Medical Ethics:18 Medicine dispenses its peculiar benefits, without stint or scruple, to men of every country, and party and rank, and religion, and to men of no religion at all. The relationship between the doctors and patients is always under the control of this norm.  Deviation from it is sub-  ject to disapproval. However the socially prescribed attitude towards patients still permits some deviation, since the individual is not forced to give a consistent response as the only approved attitude..19 As also indicated by Martin "a physician, like anyone else, can be expected to form likes PO and dislikes for those with whom he interacts."  A  physician would be more likely to appreciate those with whom he can most easily work, and to avoid patients who malce his role performance more difficult. Thus Platou and associates point out that the physician perhaps should hold favourable attitudes towards all patients, but, within these bounds, he can prefer one type of patient over another without violating a social or 21  professional conduct.  The medical students are exposed to  the value-environment of the school within which they learn the correct types of attitudes and behaviour in relation to the patient.  Prom instructors they may learn that some  patient-oriented attitudes are considered more appropriate  than others, and the students' experience may show how their attitude affects their ability to work effectively with patients. Owing to individual differences in disposition and ability, the attitudes centering around the patients permit individual variations among students at the same time that they provide insight into this aspect of their professional role.  But likes and dislikes for certain types of  patients might limit the choice of specialty.  This might  also lead a student to suspect he has an aptitude for a certain field. The components of the student-patient relationship to be discussed are: (1)  Image of the patient —  perception  of the patient, (2)  Anxiety aroused by contact with the patient,  (3) Preference for a particular type of patient. A.  The Image of the Patient In his role-relationship with patients, the medical  student develops not only the image of himself as a doctor, but also an image of the patients themselves through either direct or indirect contact with them.  By indirect contact  we mean tlie information about tlie patients through other media such as lectures, talks with senior students, research and so on. Each student envisages the patient, but there appears to be a generalized concept of this image among members of the group.  In their study of the value climate 2?  in medical school Christie and Merton  attempted to ascer-  tain the attributes of the image of the patient.  It was  found that the students largely agreed on their image of the patient as one who is ugly, pitted, narrow, awkward, and an outsider, an image that does not impress one as particularly flattering. But we do not yet know whether this image of the patient is affected by class differences between the student and the patients. B.  Farther research on this is required.  Anxiety Since the interpersonal attitudes involved in the  physician-patient relationship are more crucially implicated in the quality of services rendered than in most other 23 professional-client relationships,  it leads us to explore  the personality and situational factors involved in the student's attempt to learn how to be a "good physician." Our study, regretfully, does not provide sufficient information on this point.  The only possible way  at the moment to explore the development of negative attitudes of the medical students toward patients is to study other investigations, OA  Strecker and his associates  found that forty-six  per cent of senior medical students at the University of Pennsylvania had neurotic handicaps of a major character. Other Q studies confirmed this; that of Kohl^ at Cornell, /on Brosin at Chicago, and Wyler ' at Cincinnati. In a study po of third year medical students at Yale University, Redlich revealed a high incidence of personality maladjustment and, in some instances, severe neurotic behaviour of a type which could hinder their productivity as physicians* It has been observed that medical students, as a group, tend to have certain attitudes, value systems and defenses which do not seem to be consonant with the demands 29  and gratifications of a service-oriented profession.  y  Thus  the subjeet of cynicism and negative attitudes toward patients has made for much discussion.  It was hypothesized  that these attitudes are a manifestation of the neurotic anxiety of the medical student as indicated earlier.  Eron  reports that students with cynical attitudes toward patients rated high on an anxiety scale, that first year medical students tended to have more humanitarian attitudes and less anxiety than seniors, and that there was a greater increase in cynicism and anxiety in medical students than in a  61 0  comparable group of law and nursing students.^  Robert Stollar and his associates regarded negative attitudes toward patients as a defense reaction against the anxiety involved in taking the doctor's r o l e F u r t h e r confirmation was provided by MacCandless and Weinstein.^2 They found a progressive rise in anxiety during a series of conferences on the emotional problems of patients in the "constricted" students i.e. those who showed little concern with the emotional problems of their patients and limited their interest to the treatment of organic factors.  Parker  pointed out that this account resembles his finding.^ Those who scored high on the F-scale^ for the authoritarianism also had diffuse feelings of hostility, tended to idealize (but at the same time harbored covert resentment against) authority figures, were unable to take a psychiatrically oriented view of themselves and others, were moralistic in their judgments, and viewed human relationships in terms of hierarchical status positions. Parker further showed that the personality characteristics and values of medical students had a pronounced relationship with their reaction to patients.^^ It was indicated that the non-authoritarian students were more frequently the recipients of gratification derived through intimate interaction with the patients, and senior staff members. In summary, the medical students, as they move  through medical school, tend to develop an image of themselves as doctors rather than students, "but at the same time display cynical and intolerant attitudes toward patients. This is not because the medical profession attracts and the admission committee selects a higher proportion of individuals with personality maladjustment than other professions, but because the medical curriculum itself tends to unfold these traits.  Some factors in the medical curriculum  which presumably invoke these effects are:  the student's  limitation of medical knowledge for full treatment of the patient, exposure to autopsy, competition among students, lack of clear-cut guidance, and examinations„ It was further indicated that each individual's personality characteristics and values had a profound relationship with the negative attitude towards the patients. 0.  Preference for Particular Types of Patients We have discussed the general image the student  may have of the patient, which usually is expressed in a negative sense, and the anxiety aroused from contact with the patient.  We shall now turn our attention to individual  preferences for the various types of patients.  As shown  below some of the questions pertain to the different kinds of patients and to the situation in which students might be involved positively or negatively with the patient.  Are there some kinds of sick people to whom you felt especially drawn or towards whom you feel particularly sympathetic? Are there some kinds of sick people with whom you find yourself reacting negatively? As Table 2.8 shows there is only a slight change in the frequency distribution between the students' attitudes in the fall and in the spring, except in the case of patients who are suffering from a terminal illness® Table 2.8 indicates that at the beginning of their career,, the medical students feel particularly sympathetic towards young people; people who are optimistic about the illness; and people who are "down and out."  Compared with  other types of patients a larger number of students feel sympathetic towards the above three types, but no one single category exceeds fifty per cent of the students' response. Less than ten per cent of the students are drawn to each of the following types of patients respectively: people who have confidence in the doctor; those who have clear-cut physical illness; and articulate people. We can hardly make any attempt here to say why students prefer one type of patient to another. Similarly, in the case of negative reactions toward the patient, as Table 2.9 indicates, the proportion of students reacting negatively is less than thirty per cent for each type of patient.  Some twenty-five per cent of the  64 TABLE 2.8 KINDS 01 PATIENTS TO WHOM STUDENTS 1EEL ESPECIALLY DRAWN OR PARTICULARLY SYMPATHETIC  Kinds of Patients  Percentage of Students lall  Spring  Young people  50  58  People with terminal illness  20  46  People who are "down and out"  26  32  4  4  People who are optimistic about their illness  28  34  People who have clear-cut physical illness  6  8  People who have confidence in the doctor  8  14  22  10  Articulate people  Other  Difference between two proportions (each, category) is not significant at 0.05 level.  students in both, fall and spring expressed negative reactions towards people who make no real effort to get well; towards those who think they know as much about medicine as the doctor; and people who feel sorry for themselves.  Since they  have had no contacts with patients during the first year in medical school these positive and negative attitudes expressed  toward the patient are quite unstable.  We might assume that  their attitudes toward patients will be changed later when they have actual contact with them.  TABLE 2.9 KINDS 01 PATIENTS TOWARD WHOM STUDENTS FIND THEMSELVES REACTING- NEGATIVELY  Kinds of Patients  Percentage of Students Pall  Spring  6  6  28  24  2  2  People.who have nothing but psychogenetic symptoms  12  4  People who feel sorry for themselves  22  22  Old people People who think they know as much as the doctor Inarticulate people  People who have physiologically improbable symptoms . 12 People who make no real effort to get well Other  4  30  28  8  6  It might be prudent, therefore, to compare students who sympathize with more than one type of patient to those who do not make such a distinction.  On each set of alter-  natives some students expressed a sympathy with either type.  TABLE 2.10 EXTENT OF STUDENT PREFERENCE POR PATIENTS  No. of Preference Expressed  Percentage of Students Pall  Spring  0  30  20  1  18  18  2  20  20  3  20  28  4  10  8  5  2  2  6  -  4  Total Students  50  50  Difference "between two proportions (each category) is not significant  Some students, as Table 2.10 shows, expressed no sympathy whatsoever, while others make a definite choice on all five. Data in this table show a positively skewed curve which suggests the questions differentiate students according to their sympathetic feelings toward patients.  Table 2.11  based on the Table 2.8 and Table 2.9 makes it more apparent that large proportions of the first year medical students either adopt a neutral position with regard to the kinds of  patients about which they were asked or else they have not yet established any attitude.  Thus eighty-eight per cent  of the students claim that it makes no difference whether a patient has a clear cut physical illness or a physiologically improbable one. Sixty-six per cent of the students state that it makes no difference to them if people are "down and out" or have nothing but psychogenetic symptoms.  And fully ninety-  four per cent express neither negative or positive reactions toward articulate or inarticulate people.  "We further find  from Table 2.11 that the student who expresses sympathy toward a certain type of patient does not necessarily show a negative reaction toward the counter type of patient.  For  example, out of twenty-nine students who are particularly sympathetic toward young people only two hold negative attitudes toward old people. With regard to the students' sympathetic attitudes toward patients we asked the following question: What do you think you should do when you find yourself positively drawn to a patient? At the beginning of the first year, as noted in Table 2.12, the proportion of the students who would try to control these feelings, and regain their sense of objectivity is almost twice the number who were opposed to changing their natural feelings—forty-four per cent responded to the  TABLE 2.11 KINDS OF PATIENTS TOWARD WHOM STUDENTS ARE SYMPATHETIC AND TOWARD WHOM THEY REACT NEGATIVELY  Preferred and Unpreferred Patients  Percentage of Students  Fall Young people Old people Per cent Articulate Inarticulate Per cent People who are optimistic about their illness People who feel sorry for themselves Per cent People who have confidence in the doctor People who make no real effort to get well Per cent People who are "down and out" People who have nothing "but psychogenetic symptoms Per cent People who have clear-cut physical illness People who have physiologically improbable symptoms Per cent  + +  4 + +  Spring _1  +  +  —  54  • 2  +  •  —  +  —  -  2  4  +  +  —  +  24  +  +  +  —  6  8  +  +  +  2  +  —  10  —  2  +  +  +  -  8  12  40 _ _  94  —  54 —  +  —  22  +  30 -  +  4  (50)  _  —  •  (50)  64  (50)  (50)  -  66  (50)  -  -  88  (50)  1 Questions asked to the two types of patients read differently. For the first category of patients (e.g. young people) students were asked: "Are there some kinds of sick people to whom you feel especially drawn or toward whom you feel particularly sympathetic?" And for the second category  of patients (e.g. old people): "Are there some kinds of sick people with whom yon find yourself reacting negatively? The combined response to the above two questions should be studied carefully. For example the response, Young people +, Old people indicates the group of students who are sympathetic to young patients and also react positively, i.e. give a negative answer to the latter question, to old patients  former feelings whereas twenty-four per cent to the latter. In the spring, however, the students are nearly equally divided. The number of students in the other categories who hold the opinion that they would take advantage of these feelings to try to draw the patient closer to them remains constant throughout the first year. If students had a chance to establish a patientdoctor relationship during the preclinical sessions, the stereotyped attitudes toward patients might be revised toward the end of the first year.  This stereotyped idea is that a  doctor treats any patient whatsoever with complete neutralism, and if any emotional feelings arise, they must be controlled. As noted before, medical students may have learned from the instructors that some patient-oriented attitudes are considered more appropriate than others, and their experience in preclinical sessions may have shown how their attitudes influence their ability to work effectively with patients.  However, the lack of actual contact with patients  does not allow immediate generalization about this shift.  TABLE 2.11 STUDENT OPINION" ABOUT SYMPATHETIC ATTITUDE TOWARD PATIENT  Opinions about the Sympathetic Attitude toward a Patient  Percentage of Students  Pall  Spring  I'd try to control these feelings, and regain my sense of objectivity  44  36  I'd take advantage of these feelings to try to draw the patient closer to me  18  18  I wouldn't try to change my feelings at all  24  34  Other  6  No answer  8  8  50  50  Total Students  •  4  Difference "between two proportions (each item) is not significant  We shall now endeavor to relate three categories of opinion about sympathetic attitudes toward particular types of patients according to the number of preferences already expressed.  It should be noted that the students who  did not express sympathy toward any particular type of patient felt that if these sympathetic feelings ever did arise, they  TABLE 2.13 STUDENTS ACCORDING- TO THEIR ATTITUDES TOWARD THE SYMPATHETIC FEELINGRELATED TO NUMBER OF. PATIENTS TOWARD WHOM PREFERENCE WAS EXPRESSED  Attitude towards Sympathetic Feelings No. of preference expressed  Try to control these feelings  Take advantage of these feelings  I wouldn1t try to change any feeling  Others  Number of Students 0  1  2  2  1  3  1  5  2  .5  1  5  3  8  2  3  4  1  2  5  1  6  Total Students  1  18  6  1  17  4  (50)  would either tend to take advantage of them in order to draw the patient closer to them, or would not try to change them at all.36 As a student increases the number of categories of patients, up to three, to whom he is particularly sympathetic, the more likely he is to try to control these feelings to maintain objectivity.  Since the number of  students who expressed sympathy with more than three types is so small, no suggestion can be made. In summary: (1)  In the first year of medical school without  contact with actual patients, neither sympathetic nor negative reaction towards patients is fully developed. (2)  The above suggestion is strengthened by the  fact that students failed to express either like or dislike for two types of patients which are opposed in one way or another, for ex:ample, people who have clear-cut physical illness versus people who have physiologically improbable symptoms. (3) As the student progresses through medical school a stereotyped perception of doctor-patient relationship, i.e. all-patlent-oriented, gradually gives way to the preference-oriented attitude.  (4)  It was suggested that the greater the number  of the patients toward whom particular preferences were expressed, the greater the desire to control these biases.  74  FOOTNOTES 1  Deutsch, M. "Effects of Cooperation and Competition upon Group Process," in Cartwright, D., and Zander, A. Group Dr/namics, Evanston, Row, Peterson and Company, 1956, pp. 319-353.  2  Becker, H. S., and Geer, B. "Student Culture in Medical School." Harvard Educational Review, XXVIII, No. 1 (Winter 1958J, pp. 70-80. ~~~  3  Ibid., p. 72.  4  Ibid., pp. 72-73.  5  The significance of friendship for socialization is to be'.; discussed by Nicolls, ¥ . 1 1 , in his research in progress.  6  Thielens, W., Jr. "Some Comparison of Entrants to Medical and Law School," in Merton, op. cit., pp. 131-152.  7  Reader, G. G. "Development of Professional Attitudes and Capacities." Gee and Glaser, op.' cit., pp. 164—185.  8  Ibid., p. 167.  9  Thielens, op. cit., p. 145.  10  Ibid.  11  Coker, R. E., and Associates. "Patterns of Influence: Medical School Faculty Members and the Values and the Specialty Interests of Medical Students," The Journal of Medical Education, XXXV, No. 6 (June I960), pp. 518-527.  12  Platou, R. V., and Associates. "Medical Students' Attitudes toward Teachers and Patients," The Journal of Medical Education, XXXV, No. 9 (September I960), pp. 851-864.  13  Coker and Associates, op. cit., p. 523*  14  Caplovitz, D. "Value-orientation of Medical Students and Faculty Members," Paper delivered at the American Sociological Society, Washington, D. C., August 1957.  75  15  Gee and Glaser, op. cit., p. 65*  16  Parsons, T. The Social System. Glencoe, Free Press, 1958, p. 44?.  17  Ibid., p. 4-38.  18  Watson, T. Tbe.Principles of Medical. Ethics of tbe American Medical Association. Chicago, American Medical Association, 1953, Chapter I, Section 2. This paragraph was quoted by Martin in his "Preferences for Types of Patients," in Merton, op. cit., pp. 189-206.  19  Platou and Associates., op. cit., p. 861.  20. Martin, op. cit., p. 190. 21  Platou and Associates., op. cit., p. 861.  22  Christie, R., and Merton, R., "Procedure for the Sociological Study of the Value Climate of Medical School," in Gee and Glaser, op. cit., pp. 125-153*  23  Parker, S., "The Attitudes of Medical Students toward their Patients: An Exploratory Study," The Journal of Medical Education, XXXV, No. 9 (September I960), pp. 849-856.  24  Strecker, E. A., and Associates, "Psychiatric Studies in Medical Education," American Journal of Psychiatry, LXXXIII, No. 5 (March 1937), PP • 1197-1229.  25  Kohl, E. N., "The Psychiatrist as an Advisor and Therapist for Medical Students," American Journal of Psychiatry, IZLVIII, No. 3 (September 1951), pp. 198-203.  26  Brosin, H. W., "Psychiatry Experiments with Selection," Social Science Review, IV, No. 4 (August 1951), pp. 461-468.  27  Wyler, C. I., "Neurotic Problems in a Student Practice," Journal Lancet, LXV, No. 3 (March 1945), pp. 104-106.  28  Redlich, F. S., and Associates, "Impressions of Third Year Medical Students," (Unpublished study) quoted by Eron in his study, "Effect of Medical Education on Medical Students' Attitudes," Journal of Medical Education, XXX, No. 10 (October 1955), PP- 559-566.  29  See Ashford, M., ed., Trends in Medical. Education, New-York, The Commonwealth Fund, 1949), and Harms, E., "The Professional Neurosis of the Physician," Disease of Nervous System, III, No. 12 (December 1943), pp. 310-314, and Mullin, F. J., "Selection of Medical. Students," Journal of Association of American Medical Colleges, XXIII, No. 3 (May 1948), pp. 163-170.  76  30 Eron, op... cit. 31  Stollar, E. J., and Geertsma, E. H., "Measurement of Medical Students' Acceptance of Emotionally 111 . Patients," Journal of Medical Education, XXXIII, No. 8 ; (August 1958;, pp. 585-590. ~ .  32  MacGandless, P. D. , and Weinst.ein, M,., "The Eelation of Student Anxiety to Concept of Eole in Medical Care," Journal of Medical Education., XXXVIII, No. 2 (February 1958) , pp, 144-151.  33  Ibid.  34  Adorno, T. W., and Associates, The Authoritarian .Personality, New York, Harper and Brothers, 1950.  35  Parker, op. cit., p. 855*  36  Seemingly it is a self-contradiction that the•students who did not express any systematic feelings tend to utilize these feelings for treatment of patients. But; it is possible that to have the positive or negative attitude toward patients is one thing, and the attitudes toward the norm .about the doctor-patient relationship is another. 1  CHAPTER III STUDENTS. : Ai.  THE CHANGE OF THE-VARIABLES I.  Self-Evaluation  Self-evalnation refers to the individual's subjective assessment of his own ability for the task with which he identifies himself.  In this way students attempt  to ascertain whether their abilities are adequate, or inadequate for becoming the kind of physicians they would like to be. Frequently there is no accurate, objective basis for evaluating one's abilities even though regular examinations result in a rank order which may or may not be identical to one's subjective scale.  To the extent that  such an objective basis of evaluation is lacking, the individual may evaluate his ability by comparing himself with the presumed abilities of others in the class of which he is a m e m b e r . 1 A fairly accurate self-evaluation can be made, providing one's capacities are similar to those of the person with whom comparison is being made.  But the  standards used by students in judging their abilities in their future professional roles are not always mutually 2 compatible.  Furthermore, students of the same degree of  ability in certain respects may rate themselves quite differently, depending upon the choice of reference individuals. It would seem to be important to know the consequences of students' self-evaluation.  Some students, for  instance, who have considerable potential ability may nevertheless judge themselves as lacking in needed competence, which could possibly hinder their chances of attaining the desired goal.  Similarly, other students may judge their  abilities to be greater than they actually are, with the same results. But invariably confidence in one's capacity for realistic self-evaluation has functional consequences for performing a task.  Martin indicates that the greater the  students' self-confidence, the greater the tendency to see themselves as physicians rather than as students only.  A  high degree of confidence in one's positive self-evaluation increases the likelihood of making a strong identification with the role.3  Another possibility of this self-confidence,  as suggested by Festinger and associates, is that the greater the confidence the g r e a t e r the attraction of members to^a group and vice versa.  Consequently, it seems important to discover howstudents arrive at their self-evaluation, the standards they use, the amount of confidence they.possess and the implications of this evaluation for their professional development.  •  .(i) Realistic Appraisal of Own Ability Table 5*1 shows how well students with different degrees of realistic appraisal are. doing in their courses. We anticipated that a high proportion of the students in the fall would classify themselves in the "don't know" category, because they would have no basis on which to evaluate themselves at that time.  The table appears to  confirm this, in that thirty-eight per cent so classified themselves.  Oh the other hand, a nearly equal percentage,  thirty-four per cent, classified themselves in the "about average" category.  It appears that these two responses  indicate a certain caution in the student's  self-assessment.  W h e n students were asked about their initial feeling as to how well they were doing, sixty-four per cent were "not sure."  It is not surprising to note that none  of them is "completely sure" about how well he is doing at the beginning of the school course.. Spring answers indicate significant  differences  in the degree of self-confidence and in the degree of certainty in such an assessment.  Two-thirds of the students  who in the fall were not able to make the assessment of their own ability could classify themselves into definite categories.  It is noted in Table 3.1 in the spring answers  that the proportion of students classifying themselves "somewhat better than average" is more than twice as much as the proportion of those classifying themselves "below average" which is twelve per cent.. These proportions are to a large extent based on the greater confidence derived from a year's experience in medical school.  TABLE 3.1; DEGEEE OF SELF-EVALUATION OF STUDENTS  Degree of Evaluation  Percentage of Students Fall  Considerably better than average  —  Spring  2  Somewhat better than average  22  30  About average  34-  56  Below average  2  12  Don't know  38  No answer Total Students  -  -  50.  50  ' '  In response to tlie question regarding certainty about self-evaluation, Table 3.2 shows that nearly three out of four students state that they are quite sure about their self-confidence.  However, eighteen per cent still were not  sure pf their judgment about how well they are doing.  TABLE 3.2 .  DEGREE GE CERTAINTY ABOUT SELF-EVALUATION  Degree of Certainty  Percentage of Students Fall  Completely sure  -  '  Spring , 8  Quite sure  28  74  Not sure  64  18  No answer  8  Total Students  50  -  50  We further observed the relationship between self-confidence and certainty about it.  That is, are those  students with greater self-confidence more sure about their appraisal than those who evaluate themselves as below average?  As Table 3.3 suggests, the reverse relationship  occurs.  The notable aspects of this distribution are that  fifty per cent of the students with lower self-confidence  82 express a high degree of certainty about their judgment of their abilities, whereas none of the students who think themselves doing considerably or somewhat better than average are completely sure about their judgment.-^  TABLE 3.3 RELATION BETWEEN THE DEGREE .03? SELF-CONFIDENCE AND ITS CERTAINTY /  Degree of Certainty  Degree of Confidence Better than average  About average  Below average  (  Percentage of Students •4  50  87  75  33  Not sure  13  21  17  Total Students  16  28  6  Completely sure :Quite  sure  (50)  (ii) Self-Evaluation and Rank Order in the Class Self-evaluation, as was defined above, refers to the way in which an individual judges himself.  Since the  tasks performed., during the first year in medical school are rated by examination and appear in the class standing, the following question is appropriate:  To what extent do the  S3 objective ratings of examinations and the self-evaluation of a student's performance agree?  No positive relationship  was evident between the degree of self-confidence and the class standing.  Table 3.4 indicates that among students with  second class standing, sixty-three per cent give a moderate estimate of their ability, while seventy-five per cent of those students, with third class standing made the same assessment.  On the other hand, the percentage of second class  students who assess themselves below average is over twice that of the third .class students who assess themselves in this manner.  TABLE 3.4 • DEGREE 01 SELP-EVALUATION ACCORDING, TO CLASS STANDING. SPRING  Class Standing Percentage of Students I  II  III  Better than average  61  19  17  About average  39  63  75  -  19  8  18  16  12  Degree of Self-Evaluation  , Below average Total Students  * 2: no examination 2: unidentifiable  (46)*  84One thing to be noted, however, is that the majority of the first class students have greater confidence in their ability than either of the other classes of students, and none of them shows an inverse association between selfevaluation and class standing. As Martin indicates,  self-evaluations rarely  correspond closely to the judgment of the faculty as embodied in the grades.  Two reasons for this disparity are also sug-  gested by him:  (1)  The two measures, self-confidence and  grades, may not be drawing on the same dimension of performance, either because of differences in the skills taken into account or differences in the criteria used in measuring these skills.  (2)  Standards of excellence may differ among  students and these may influence the manner in which they evaluate their performance. Besides the above two possible explanations another possibility can be assumed.  That is, as noted in Table 3«4-,  general agreement on excellence is reached only for a minority who enjoy the top rank in the class when no objective criteria are available with which to compare selfconfidence.  Incidentally, Martin's second point may not be  true since their judgment is being carried out in class.  It  is further assumed that students who have relatively low average grades do not consider that the gap between top ranking students and about average students as very different  from that "between top ranking students and themselves, (iii) Reference Point of Self-Evaluation As we stated above, the students with the same degree of ability with regard,to their course work rate themselves differently, depending upon their choice of reference groups, that is, whether they compare themselves with classmates, faculty members, practising physicians, or interns and residents.  Therefore, we asked the students to  rank three factors according to their importance in decidinghow well they were doing as shown in Table 3«5» elements were:  These  comments of your fellow students, information  given by the faculty, and the student's own personal evaluation.  No change was indicated in average rank order between  the fall and the spring terms.  As this Table indicates, the  student's own personal evaluation was the element most often thought to be of first importance, and only a minority of the students —  two per cent in the fall and eight per cent  in the spring —  did not regard it as the first or second  consideration.?  Information given by the faculty was ranked  second, and comments of fellow students came last.  In the  spring, two elements, holding the same rank, showed considerable change with respect to their importance of ability in the evaluation.  The students ranked information given  by the faculty more highly in the spring than in the fall, while none of the students regarded comments of fellow students as the first consideration.  86 TABLE 3.5 STUDENTS' DEPENDENCE ON VARIOUS EVALUATIONS  Kinds of Standards by Evaluation  1 i.e. most important  Degree of Importance 2 3 No response  Average rank  Number of Students Comments of fellow students  Fall Spring  6 -  16 13  23 37  5  Information given by the faculty  Fall .16 Spring 22  8 19  21 9  5  Own personal selfevaluation  Fall 23 Spring 28  21 18  1 4  5  2.4-6 2.74  2.11  1.74 1.51 1.52  Our data do not show clearly who chooses what reference point for deciding how well one is doing.  But we  can infer that the first year medical students do not depend solely on information given by the faculty.  Nor do they take  the comments of fellow students very much into consideration in this respect. Similar results for medical students of all years in 8 the United States have been reported.  As the Table 3.6  shows, fifty-six per cent of them stated that personal evaluation is the most important factor in determining how well they are doing, whereas thirty-three per cent choose information by the faculty as the most important factor.  Comments  of fellow students are considered as of foremost  importance  "by only five per cent.  TABLE 3.6  STUDENTS' DEPENDENCE ON VARIOUS EVALUATION IN U.B.C. AND U.S. MEDICAL SCHOOLS Kinds of Standards of Evaluation  U . S. Students in First Four Years  U.B.C. First Year Students*  Percentage of Students Comments of fellow  students  5  Information given by faculty  33  Personal self-evaluation  55  No response Total Students  44  56  7 1322  50  * These percentages were taken from Table 3*5 - the row "most important." (Spring)  We then tried to ascertain the relationship the degree of self-confidence and the most important for students' assessment of their own ability. shows, there is no obvious positive relationship these factors.  between factors  As Table 3 » 7 between  However, it appears that those students who  evaluate themselves above average are more likely to think of information by faculty as the most important factor in  88 their judgment, whereas the reverse tendency is shown for the students with moderate confidence in their ability.  TABLE 3.7 CORRELATION BETWEEN EVALUATION AND THE STANDARD OF EVALUATION, SPRING  Kinds of Standards of Evaluation  Degree of Confidence Percentage of Students Better than average  About average  Below average  Information by faculty  57  33  50  Own personal self-evaluation  43  67  50  Total Students  17  27  6 <  For the students with lower confidence, these two factors did not make any difference in making their assess-, ment.  An equal proportion is shown to rely both on informa-  tion by faculty members and their own self-evaluation.  This  relationship between self-evaluation and actual grade in the class is further specified according to the most important factor chosen for the self-evaluation in Table 3»8 If we divide the first year medical students into two groups, those who think the information given by faculty  is most important and those for whom personal evaluation is most important, the former are more likely to evaluate themselves more highly than the latter. The first trichotomized group, Class I, placed a higher premium on the information "by faculty in their selfevaluation while the rest relied on their own personal evaluation.  TABLE 3.8 RANK QEDER, SELF-EVALUATION, AND THE STANDARD OF EVALUATION. SPRING  Degree of Self-Evaluation Percentage of Students Rank order  Standard of evaluation  Better than average  About average  Below average  1. Information by faculty 2. Personal selfevaluation  6?  33  -  12  50  50  -  6  1. Information by faculty 2. Personal selfevaluation  25  50  25  4  16  75  9  12  1. Information by faculty 2. Personal selfevaluation  20  80  -  5  15  70  15  7  Total 1. Information by Stufaculty dents 2. Personal selfevaluation  10  10  1  21  6  17  2  25  I  II  III  Total students  II.  Motivation  Our next variable, motivation, as Dubin defines it, refers to tlie complex of forces starting and keeping a person at work in an organization.^  Q}0 put it more  generally, motivation starts and maintains activity along a prescribed line.  Motivation is something that makes a  person act, and keeps him in the course of the action already initiated. at work.  Furthermore, motivation is part of an activity  As Dubin further states, "this motivation in the  organization is continuous."1^  Persons composing the  organization, once they become part of it, fall into a pattern of motivation, initiating and sustaining, their work in the organization.  This motivation insures a line between  the goals of the organization and the goals of its individual membei's and work groups® The concern, in our study, is not only with the reasons for a vocation being chosen, but also with the reasons for the choice, once made, being maintained.  After all,  vocations are institutions with which people identify themselves, and in which they invest their effort and time. A number of studies have been undertaken in order to ascertain the motivations for entrance into medical school, but very little is known about why students remain in this field.  Both types of motivation are of equal importance  for understanding socialization of the medical student.  Let us first discuss the motives for entering medicine as a future career.  To discover reasons why anyone  chooses a particular profession is quite difficult.  As  More notes,11 a thorough explanation would require an intensive exploration of each individual's life history, to find not only the positive forces behind his choice, but also the reasons why each potential alternative was not selected. In most studies using a large sample of entrants such detailed analyses were not possible.  In fact, this  explanation for individual choice is not the direct concern of sociologists. The factors which students take into consideration when making their choice has been approached in several ways: 12  (1)  Biographical method.  Brody  has done a  content analysis of several known physicians' autobiographies in which they stated the reasons for entering medicine. are:  These  their conception of medicine as a special calling;  their basic interest in general science; the influence of o t h e r s — particularly father, mother, friends, teachers, and so on; medicine as a last resort after a process of eliminating other attractive but "unpromising possibilities; sheer impulse; a crusading desire (especially for women); and the conscious sense of dedication. A cursory examination of these factors indicates  that they do not all belong to the same frame of reference. (2)  The direct approach.  Another line of approach  is to ask students simply to state the reasons for their choice of medicine.  Using this approach Gartwright obtained  the following results.13 ^ The great majority, four-fifths, of our sample, mentioned the interest and satisfaction they expected to derive from their work as the main reason for their choice, and the only other reason given by any appreciable numbers was the opportunities available in their chosen field or the lack of opportunities in other fields. Nearly one third mentioned this. This kind of approach, however, can hardly avoid Farnsworth's attack:14 Why did they want to go into medicine? They have all been asked this question dozens of times. Most of them do not know. Many of them have developed rational answers to satisfy those who ask the question. Those who feel comfortable in what they are doing , usually come up with a combination of traits such as that of wanting to be of help to other people, a desire to understand themselves better and a native interest and talent for science in a broad sense. A very considerable proportion, about a fourth, have physicians in the family, usually the father, and hence have to identify with them. In fact, what Cartwright found appears to be less inclusive than what Farnsworth expected. (3)  The structured method.  A student cannot be  considered to have chosen a career in medicine if he has not been encouraged to some degree to deliberate upon the  respective challenges and. rewards of other pursuits.1-^ Students are not capable at any given time of providing the exact reasons for entering medicine;  The next line of  approach, therefore, is to ask students to choose a number of factors which are considered to be the main determinants in the choice of their career. Many studies have tried to ascertain the reasons for entering medicine by having the students choose a factor(s) from the list supplied by the investigator. Table 3-9 summarizes the heterogeneous elements which were taken into consideration by the authors of books and articles dealing with this matter.  But as we note from  the table, these, factors were used without any distinction between internal factors, such as internal dispositions, and external factors, such as the influence of other people or circumstances.  Kornhauser and Lazarsfeld have emphasized  the importance of this distinction as follows:1^ One can proceed in his analysis of any bit of action by analysing those motives and mechanisms that appear significant, and also by studying the outside conditions which appear most clearly related to those inner dispositions. Explanations are found by working back and forth between individual disposition and external influences. The behavior of the moment is always governed by both.  94  TABLE 3.9 ELEMENTS- IN MOTIVATIONS  h> rQ © H -P d CO O ra  Finance finally available Association with person, other than father, in medicine Own ability in science Father practicing medicine Work experiences related to medicine Parental pressure Early interest Need of making decision Influence of instructors Reading of medical literature Prestige Promise of economic income Particular social demand Personal interest, values, and motives Unusual early restrictions or handicap Autonomy (being my own boss) Humanitarian value (to help others) Relative opportunities in the different branches of medicine Professional satisfaction Desire to make contribution Desire to have opportunity for self expression Desire to acquire self-understanding  T) H CD •H <H 0 rf 0 CQ  d a H 0i A c3 0  x x  x  s m  -p & bO •H fH •s -P cti O  x x x xx x x x x x  x  x  x x  x x x  x x x  x x  x x  x x  x x x  x x  We shall, therefore, try to approach this problem first by separating internal from external factors and then we shall,seek to link the two together. A value i s defined as a desideratum, i.e. anything desired or chosen by someone sometime,1^ or things in which people are interested —  things they want, desire to be or  become, feel as obligatory, worship, enjoy.  TO  When an individual chooses an occupation, he thinks there is something "good" about it, and this conception of "good" is part of an internalized mental structure which establishes priorities regarding what he wants out of life: to ask what an individual wants out of his work is, to a large extent, to ask what he wants out of his life.  It is,  therefore, indispensable to an adequate understanding of the occupational decision process to consider what people want out of life, for this is the essential criterion by which choices are made.19 The considerations affecting the choice of an occupation are not the same as those associated with remaining in it once the choice has been made.  A change in  attitude toward occupational values is likely to occur when an individual begins to internalize the values of occupational incumbents.  96 (i) Motivations fop Entering and Remaining in Medical School In the light of the above considerations we shall outline some values apparently related to a medical career and ascertain to what degree they attract students entering and remaining in it. categories:  Those values are classified into four  "Poeple-oriented", "Extrinsic-reward-oriented,"  "Self-expression-oriented," and "Autonomy-oriented."20 (1)  "Extrinsic-reward-oriented" value  Positive responses to either "The fact that medicine is a highly respected profession" or "Being sure of earning a good income" are indications of an "extrinsic-rewardoriented" value complex.  Respondents selecting these values  tend to view work in instrumental terms.  Doctors as a group  have higher social standing in the community.  Blishen has  shown that the social status of the physicians is the highest only next to judges and dentists in Canada.PI  The physician  generally enjoys a good income as well as high prestige. is the most highly rewarded professional man.22  He  There is no simple linear relationship between the social desirability of an occupation and its income level. It would appear, however, that when individuals are essentially uninformed as to the nature of the work and responsibilities of various jobs, their preferences may be heavily weighted by the supposition about anticipated income.2^  (2)  "People-oriented" value  Positive responses to.either "Being able to help other people" or "Being able to deal directly with people" are indications of a "people-oriented" value.  Respondents  selecting these values tend to view work largely as an opportunity to obtain gratification from interpersonal relations. (3)  "Self-expression-oriented" value  Positive responses to either "The challenging and stimulating nature of the work" or "Doing work involving scientific method and research" are indications of a "self-expressionoriented" value.  Respondents selecting these values tend to  view work chiefly as an end in itself —  as an opportunity  for expressing their talents and creative potentialities. (4)  "Autonomy-oriented" value  A positive response to "Being my own boss" is an indication of an "autonomy-oriented" value.  Respondents selecting this  value tend to view work more likely as an opportunity for obtaining individuality for own action. As a profession, medicine permits great independence. As with most other professions, regulations of the physician's conduct is minimal, subject only to legal licensing and 24  jurisdiction of his professional peers.  .  To a considerable  extent, the physician can establish his own fees and the hours and conditions of his work.  In short, the notable  98 aspect of a medical career among professions is to get rid of the constraint of other persons, to avoid or escape from domination, and to he -unattached and independent.2^ Together, these features of medicine based on the four categories of an occupational value, provide an initial basis for analyzing some attitudes for both entering and remaining in medical school. With regard to the above factors, students were asked: What things do you think you will like best about being a doctor? (Choose as many as you like.) This question was asked when students first entered medical school, and at the end of the term.  By correlating  the first questionnaire with the second questionnaire, we obtain some indication of the relation between factors affecting entrance into medical school, and factors affecting stay in medical school. Table 3»1G summarizes responses to the above question.  As a motive for choosing the medical profession  as a career the idea of "being able to help other people" is most often s t a t e d — by eighty per cent of the students under study.  "The challenging and stimulating nature of the  work" and "being able to deal directly with people" were responded to by equal proportions -- sixty-eight per cent.  99  To a large extent students are more likely to choose a "People-oriented" value as a reason for coming to medical school.  TABLE 3.10 STUDENTS' MOTIVES FOR ENTERING AND REMAINING IN MEDICINE*  Percentage of Students Fall checked  Spring  unchecked  checked  unchecked  Being able to help other people  80  20  80  20  The. challenging and stimulating nature of the work  68  32  76  24  Being able to deal directly with people  68  32  74  26  Being my own boss  34  66  46  54  The fact that medicine is a highly respected proposition  32  68  Having interesting and intelligent people for colleagues  32  68  56  44-  Doing work involving scientific method and research  26  74  36  64  Being sure of my good income  26  74  26  76  * Percentage changes between Fall and Spring are not significant at .05 level.  It is notable that only a third of the students chose autonomy —  thirty-four per cent, prestige —  two per cent, or good income —  thirty-  twenty-six per cent.  The tendency which emerged in the fall remained . relatively unchanged in the spring. Throughout the first year students tend to emphasize "People-oriented" and "Belf-expression-oriented ,, values' more than "Extrinsic-reward-oriented" or "Autonomyoriented" values. •• (ii)  Jalue Consistency It is possible to observe whether, there is a value  inconsistency between the fall and spring.  For example,  Table J.ll shows there were three students who indicated the "people-oriented" value in the fall >ut not in the spring and for one.student the situation was reversed.  In general  these four students were not psychologically consistent in their value orientation, and constituted eight per cent of the panel members.  At most, thirty-two per cent of the students  showed a similar inconsistency in the oriented11 value.  "self-expression-  It is interesting to note that the incon-  sistency of value-orientation in the first years occurs more frequently with "self-expressed-orientation" and "Autonomy" than with the other two categories.  However, the difference  TABLE. 3.11 INCONSISTENCY OF VALUE-ORIENTATION DURING FALL AND SPRING  (1)  "People-oriented." valne Spring  Fall  + 44 - 1  3  2  4-7 3  +  checked unchecked  50  45  Difference between the proportion of panel members -is not significant at .05 level. (2)  "Self-expression-oriented" value '  Fall  Spring  + 31 5  11 3  42 8  36  14  50  Difference between the proportion of panel members is not significant at .05 level. (3)  "Reward-oriented" value Spring  Fall  2  25  6  23 27  19  31  50  + 17  -  Difference between the proportion of panel members is not significant at .05 level.  TABLE 3.11-continued  (4-)  "Autonomy-oriented", Spring +  Eall „ + 1 5 - 2 17  :  •  1G 23  25 25  33  30  "  ' •  Difference "between the proportion of panel members is not significant.  between the ".two proportions of the students whose values changed during the year is not statistically significant. (iii) 'Multiplicity of Motives It is commonly said that people carry out acts for 26  more than one reason.  It is, therefore, of interest to  arrange Table.3.12 according to the number of categories selected.  The results are recorded in Table 3*12• Both on entrance into medical school and at the  end of a year in medical school, more than eighty per cent of the students held at least two assigned categories of values.  In the spring, as the table indicates, students  were more likely to find more than one category of values.  Then only four per cent of the students checked  any single category whereas in the fall sixteen per cent of  103 TABUS 3•12  STUDENTS ACCORDING TO TIE NUMBERS OF CATEGORIES OF VALUE SELECTED  Percentage of Students No. of ' categories by value  Fall  1  16  2  Spring  Accumulated Percentage  Fall  Spring  4  100  100  40  40  84  86  3  28  28  44  56  4  6  18  6  18  50  50  Total Students  Proportional differences are statistically significant ( 9C2= 13.2, df = 3, p<.01).  students indicated the same intention.  The proportion of  students who checked four categories in the fall increased from six per cent to eighteen per cent in the spring.  It can  he assumed,, therefore, that choice of occupation and remaining in it is not "based on any single reason, and as the students progress through medical school they tend to internalize more than one set of values.  III.  Identification:  Professional Self-image  (i) Professional Self-image One of the most compelling changes in the develop-. ment of an adult into a professional role is found in the growth of a professional personality.2"'7 It is almost inconceivable that a student will think of himself as anything but a student during the early 28  stages of his medical training.  It is, of course, evident  that students typically think of themselves primarily as students at the beginning of their medical training, and come progressively to think of themselves as doctors as they advance through medical school. In her study of the development of the professional 29  self-image of medical students,  Huntington asked students  whether they tended to think of themselves primarily as doctors rather than as students in their most recent contacts with patients. students —  She found that a substantial minority of  approximately thirty per cent —  in the first  two years of training reported that they felt more like doctors, and that by the end of third year, fifty-nine per cent indicated that they felt more like doctors, and just prior to graduation, this proportion had increased to eightythree per cent. In the light of these considerations we tried to  ascertain how many of our first year students thought of themselves as doctors.  Students were asked:  When do you expect that you will first come to think of yourself as a doctor? As Table 3.13 indicates, only two per cent, that is one student, in the fall stated that he would expect to think of himself as a doctor -during.the first year, while a majority, sixty-eight per cent, expected to have the professional self-image after graduation of medical school. Wnen students were asked this question again after one year's experience in medical school their expectations did not seem to change.  Ho student thought of himself as a  doctor during the first year.  Whereas a majority of students,  sixty-four per cent, did not expect to assume the professional image during medical school, only four per cent expected to have it in the second year. Huntington's study, mentioned above, presents a ZQ  good contrast to the present one as revealed in Table 3«14. There is a considerable difference between two groups of first year medical students with respect to the professional image.  At the end of first year, thirty-one  per cent of the students at Western Reserve University School of Medicine stated that they thought of themselves "primarily as doctors" in dealings with patients, while not one of the U.B.C. students had this self-image.  This  TABLE 2.1774 WHEN STUDENTS EXPECT TO THINK 01 THEMSELVES AS DOCTOES  lall  Spring  During first year  2  During second year  2  4  During third year  8  4  During fourth year  12  22  During internship  36  48  During residency  12  16  8  6  Total Students  50  50  lirst two years  4  4  Last two years  20  26  After graduation  68  64  8  6  50  50  Haven't given it any thought  Haven't given it any thought Total Students  Percentage difference "between the fall and spring is not significant at .05 level.  . TABLE 3.ITSELF-IMAGE AS A DOCTOR ACCORDING TO U.B.C. SIMPLE • , . IN MEDICAL SCHOOL AND OTHERS  Percentage of Students U.B.C.1  Others2  Pirst year  -  31  Second year  4  30  Third year  8  59  30  83  Fourth year  1 Accumulated frequencies are used. 2 Western Reserve University School of Medicine. University of Pennsylvania School of Medicine. Cornell University - Medical College.  differencerbetween the two first year groups as to professional image is, we presume, mainly due to the fact that the U.B.C. students had no chance to have contacts with patients while the others did to some extent. Self-images are formed through social interaction when people tend to live up to the expectations others have of them.  Students develop self-images as doctors while they  are in contact with persons who regard themselves as doctors. As one student remarked:  108 Except for a few occasions of visiting , hospitals we nevep felt ourselves as doctops in our first year. We were mostly associated with the milieu of the campus. Furthermore we had nevep "been treated as doctors "by the faculty. Even those students who ape in contact with patients have different self-images according to the type of relationship in which they find themselves. further reports,-'  As Huntington  twelve per cent of the above mentioned  first year students at Western Reserve University School of Medicine said that they thought of themselves as doctors in their relationship with nurses:  three per cent held a  professional self-image vis-a-vis their classmates; and only two per cent viewed themselves as doctors in their recent meetings with faculty members. (ii)  Identification The student's image of himself associated with a  professional role is referred to as  "identification."  Identification with significant others motivates an individual to internalize the values and goals associated with the role to which he aspires.  32  Identification also has consequences  •x-x for institutions,"^ in the sense that the more  individuals  there are committed to the occupational identity the greater the cohesion of the  institution. Tyii.  George H. Mead^ child's  and Jean Piaget"^ show h o w the  acquisition of a self-identification with the roles  109 occurs as a sequence of orchestrated phases, each phase of the total process building on what has gone before.  Thus  the product is a socialized adult. Simpson, in her study of student nurses, indicates that a sequential development of this kind can also be seen in the process of adult socialization into, and passage through training institutions.  She states:^6  ... socialization of a person into a profession takes place in three analytically distinct phases, in each of which some or all of the component aspects of cultural content and self identifications are in process of formation: (i) Transition to task orientation (ii) Attachment to significant others in the work milieu. (iii) Internalization of professional values. As the student moves through medical school, he tends to develop an image of himself as a doctor rather than merely as a student.  A similar study was done earlier by  37  Becker.  His interviews with graduate students in  physiology, philosophy, and mechanical engineering indicate that changes in social participation in the course of graduate work lead to the acquisition of specific kinds of occupational identities.  Such participation affects  identification through the operation of the socialpsychological mechanisms of development of interest in problems, and pride in skills, acquisition of ideologies, and 38 . . 59 investment,^ the internalization of motives, and 40 sponsorship.  What then, are the elements of a profession with which individuals identify?  Individuals, as Poote and  Strauss note, identify themselves in terms of the names and categories current in the groups in which they participate."4"1 .Becker further breaks down identification into 42  its components.  He indicates  how those mechanisms  mentioned above, produce work identification in four major elements; attachment to occupational title, task commitment, and commitment to particular organizations or institutional positions, and significance for one's position in the larger society. This study lacks data concerning the elements of professional identification so that further analysis of the specification of students' identification cannot be attempted,, IY.  The Image of the Physician  .  The physician is a man of many roles and in each of these he creates a different image of himself.  To his  patients, he may appear as a wise, skillful, considerate individual who heals them when they are sick, delivers their children, offers them good counsel in terms of emotional 43  stress, and is an extremely patient creditor *  To his  colleagues he may appear as an intelligent co-worker, an ingenious researcher, an able consultant, and a good teacher.  Ill One of the physician's roles that is extremely important, from the point of view of medical education, is that of role model, or as Merton puts it, as a reference individual for future physicians.  The term refers to a  person with whom the student tries to identify himself and whose behaviour and values he will seek to approximate in his several roles.  This image may be a noted figure in the  profession, a practitioner known personally or one known only by repute,  or an idealized portrait abstracted from various  characteristics of physicians the student happens to have come across. 45 As Schumacher said,  "to better understand pro-  blems of recruitment, selection, education, and guidance of medical students, it is necessary to learn what their perception of the  'physician' is and what kinds of traits or  social behaviour they found desirable or undesirable  in  members of the medical profession." A few attempts have been made to study the medical student's image of the physician.  The method of one such  investigation consisted of having students report on the attributes of people they valued highly:  the attributes of  the prized person were taken to reflect the values held by the student.  Along this line Christie and Merton asked  each student of one junior and three senior classes at three medical schools to scale attributes such as "sociability," "volatility," "dominance," and personal appearance in the  . .  4-6  physician.  The composite picture of the ideal physician  emerging from these multiple scales is one of high extroversion, slight emotionality, thorough dominance, and an amiable. and clear-cut appearance.  This is in remarkable  contrast to the student's image of patients as previously stated (pp.  59  ).  "The attributes assigned to the ideal  physician," Christie and Merton concluded, "furnish approximate indicators of values by indicating what students assume a good physician should be like."^ Another way of approaching this problem is to provide students with a list of conceivable features and ask them directly to indicate desirable features of the ideal physician. 4-8  Using the latter approach Schumacher  studied  how applicants to medical schools view the "physician" in terms of certain personal characteristics, and compared this view with the measured personality traits of medical school applicants and medical students.. He shows that, in general, the most desirable features of the physician's role to which the medical applicants respond most are:  to want to do one's  best and accomplish difficult tasks; to help others and have them confide in him about personal problems; to put in long hours of work without distraction; and to keep at a job until it is finished; to analyze his own motives and the behaviour of others; and to work in an orderly fashion.  113 As Schumacher noted, it is interesting that applicants place a slightly higher emphasis on the accomplishment of difficult tasks or helping others.49  These  characteristics seem to fit the common stereotype of the above, self-sacrificing, dedicated physician, and it does not seem surprising that they all rated high "by individuals attempting to enter the medical profession. (i)  Important Characteristics of a Good Physician In our study first year medical students were asked,  in "both fall and spring, to rate in order of importance the following four groups of characteristics considered essential in making a good physician.  Each group involves a number of  traits: First are the (inherent) personal characteristics such as good appearance, warm and pleasing personality, integrity,. and ability to get along with people. In the second group are factors associated with attachment to the 30b, which involves, for example, dedication to the profession and getting real enjoyment out of medicine. The third group is concerned with ability to undertake research which requires such traits as high intelligence, recognition of own limitations, ability to think in an organized way, scientific curiosity, laboratory skills.  Fourthly, only one aspect of the "ability to organize" the skillful management of time, was examined. Table 3.15 shows the mean trait scores obtained by our students, their rank, order.  The traits are also classified  into three grades in terms of score o r d e r —  high, middle and  low. The most highly estimated traits were, as Table 3.15 indicates, integrity, ability to think in an organized way., and. the ability to get along with people.  The dif-  ference of the mean trait score between each pair of these three is negligible. At the lower end of the scale, we find the following characteristics:  good appearance, skillful management of  time, high intelligence, scientific curiosity, and research ability.  The : more inherent personal characteristics are  regarded' as desirable in making a good physician, while actual ability for task performance is poorly weighted. .'•By the end of the first year relative changes, in each characteristic are observed in each trichotomized sector of the s c a l e d 0  At the upper end of the scale, the  students tend to put more emphasis on the  1  ability to think  In an organized way 1 rather than the other two inherent personal characteristics, namely 'integrity', and 'ability  f  TABLE 3.15 IMPORT FACTORS' IF MAKING A GOOD PHYSICIAN-*-  Fairly Of minor. No, ans- •Total Average , Rank Very important important importance wer No. score order Fall Spring Ability to think in Fall Spring an organized way Ability to get Fall along with people Spring  74 76 72 78 68 72  26 . 20 28 18 32 24  -  -  2 /'  2  Dedication to medicine Warm and pleasing personality Recognition of own limitation Getting enjoyment out of medicine  Fall Spring Fall Spring Fall Spring Fall Spring  68 50 70 32 56 56 60 56  26 44 22 42 42 38 32 34  6 4 8 4 2 4 8 8  Good appearance  Fall Spring Fall Spring Fall Spring Fall Spring Fall Spring  46 32 20 22 24 28 26 26 6 4  46 52 76 72 70 54 48 58 46 24  8 14 4 4 6 16 26 14 48 68  Integrity  High  Middle  High intelligence Low  Good management of time Scientific curiosity Research ability  2  2 -  2  2 2 2 2 -  2 2 ~  2 -  2 —  2 —  2  (50) (50) (50) (50) (50) (50) (50) (50) (50) (50) (50) (50)  2.74 2.76 2.72 2.78 2.68 2.81  1 3 2 2 3 1  2.62 2.45 2.62 2.50 2.54 2.53 2.56 2.49  4.5 7 4.5 5 7 4 6 6  2.38 2.16 2.16 2.18 2.18 2.12 2.00 2.12 1.58 1.30  8 9 9 8 10 10.05 11 10.5o 12 12  1 "In your opinion, how important is each of the following characteristics in making a good physician? (Answer for each)" 2 Rank correlation p = 0.91, significant at .03 level. j~I vn  to get along with people'. A notable change in the mean score occurred with two characteristics in the middle of the scale; that is, dedication, to medicine and warm and pleasing personality. Both formerly ranking 4.5 were lowered to the ?th and 5th rank respectively.  At the lower end of the scale the mean  score of t w o c h a r a c t e r i s t i c s ,  'good appearance,' and  '51 'research a b i l i t y , 1 r a t e d in the spring, has dropped considerably from that of the fall. Summing up, none of the characteristics moved out of the trichotomized boundary during the first year.  The  coefficient of rank correlation is 0.91. .. Changes in rank order would show the different outline of the image of the physician, while the actual changes in the score, without the shift of the rank position, indicate merely a slight change in some aspect of the image. The table sxiggests that students, as they come to the end of the first year, are more likely to emphasize the ability for actual task performance and de-emphasize the characteristics more related to personality.  The image of a good physician  held by first y e a r medical students, both in the fall and the spring, is not entirely different in its outline, but rather different in the emphasis placed on its component factors. Our questionnaires asked each student to rate, on  a four point scale the importance of several factors in creating the make-up of a good physician.  The traits were  judged to be of general relevance for being a good physician; no comparative weight was assigned to them-, they were merely judged as important characteristics. The next step, is to examine the weighing of the factors as they appeared for the responses.  In order to  judge the. comparative value of each factor in terms of an all pervasive standard, students were asked: . In your opinion which two of these characteristics are most important in making a good physician? The response to this question as shown in Table 3-16 brought about a different rank order of the characteristics from 52 that shown in Table 3>1.5«  Correlation between these two  rank orders both in the fall and in the spring appeared to be very low •— Spearman rho for the fall is 0.45 and for the spring 0.-50. Distortion between two rank orders in the fall occurred with two traits, 'dedication to medicine,' and 'high intelligence,' which are rated considerably higher than they were in the previous question and with ^ability to get along with people,' 'recognition of own limitation,' and 'getting real enjoyment out of medicine,' in the spring. In the fall the characteristics of the physician estimated most important for medicine when compared with other professions are, as Table 3.16 shows, 'dedication to  medicine.,' integrity,1 ' ability to think in an organized way,' and . 'ability to get along with people.'  The spring  answer, however, indicates a different order: "ability to think in an organized way," "getting real enjoyment out of medicine,"•and "integrity."  An obvious change is apparent  between the fall and spring in that the students became more realistic in their image of the physician.  At the beginning  of the first year in medical school, students put more emphasis on such categories:  "attachment to the job" —  'dedication  to medicine,' —- and "inherent personal characteristics"  —  'integrity' —- instead of the factors necessary for the "task performance" such as:  'ability for research' and  'ability to think, in an organized way.'  As the first year  comes to. an end students tend to think more highly of the category, "ability for research."  Table 3.16 indicates that  'the ability to think in an organized way' is ranked most highly, in the spring. It is interesting to note that in comparing medicine with other professions the students were inclined to attach greater importance to 'getting real enjoyment out of medicine' than to 'dedication to medicine.'  It might be suggested that  the students eventually realized the fact that dedication to medicine is only possible when you get real enjoyment out of medicine.  Another thing to be noted, however, is a minority  agreement on any specific trait which might be considered as the most Important feature of a good physician.  We cannot  119 TABLE 3.20 FREQUENCY DISTRIBUTION AID RANK ORDER OF IMPORTANT FACTORS IN MAKING A GOOD PHYSICIAN1  Pre quency  Rank Order  Dedication to medicine  Fall Spring  21 10  Integrity  Pall Spring  13 14  2 3.5  Ability to think in an organized way  Pall Spring  12 18  3 1  Ability to get along with people  Pall Spring  10 16  3.5  Getting real enjoyment out of Medicine  Pall Spring  10 16  5 2  Warm and pleasing personality  Pall Spring  7 9  6.5 6  High intelligence  Pall Spring  .7 6  6.5 8  Recognition of own limitation  Pall Spring  5 8  8 7  Skillful management of time  Pall Spring  2  9 11  Scientific curiosity  Pall Spring  1 •1.  10 9  Research ability  . Pall Spring  1 0  11 11  Good appearance  Pall Spring  —  —  —  1 -> 5  12 11  1 "In your opinion, which, two of these characteristics are most important in making a good physician. 2 Proportional difference between the fall and the spring is significant at .05 level. rank correlation £ = 0.86  definitely say one factor is more appealing to students than others. Schumacher indicated that applicants to medical school differ significantly from general college students, in several personality traits and that, in general, the applicants personality pattern follows closely his image of the v physician. 53  If this is the case, we could assume that the applicants for medical school have different standards for medicine than those which they have for other professions. We, therefore, asked the students:  "In your opinion which  two of these characteristics (above mentioned) are more important to medicine than to other professions?"  Table  3.17 indicates the frequency of each characteristic both in the fall and the spring.  In general, no significant  chahge in the frequency between the fall and the spring was observed with a few notable' exceptions.  The most frequently  checked characteristics for medicine as compared with other professions are:  dedication to medicine (forty-six per  cent), recognition of own limitation (thirty-eight per cent), ability to get along with people (thirty-six per cent), and getting real enjoyment out of medicine (thirty-four per cent). Compared with factors considered, the most important qualities of a good physician, each category indicates different characteristics as an important factor for medicine when medicine is compared with other professions.  The one exception is  "attachment to job."  Instead of integrity, 'ability to get  along with people' is more important in the category "inherent personal characteristics."  In the category, "ability for  research," 'the recognition of one's own limitations' is more highly valued than 'the ability to think in an organized way.' This remarkable contrast is not considered to be merely accidental.  To start with, medical students know that  medicine is much more involved in dealing with people than any other profession and skillful treatment of people as patients is considered to be a professional virtue. .In the spring, two traits of the!"attachment to job" category, 'dedication to medicine' and 'getting real enjoyment out of medicine' occurred with significantly reduced frequancy as compared to the fall.  In general, the two traits  considered most important in the fall were equal in their frequency in the spring, namely:  'dedication to medicine,'  and 'recognition of one's own limitations.' It is not surprising to note that the student's, image of the physician upon entering medical school is primarily based'on his idealized picture of medicine that real enjoyment of medicine depends on dedication to it.  But  the data suggest that, as the student progresses through medical school, he tends to consider as equally important other traits which were previously ignored.  On the other  hand, a m e d i c a l career, as we noted in the section on  122  TABLE 3.20 FREQUENCY DISTRIBUTION AND RANK ORDER OF CHARACTERISTICS CONSIDERED MORE IMPORTANT TO MEDICINE THAN TO OTHER PROFESSIONS  Frequency  Rank Order  Dedication to medicine  Fall Spring  23 17  1 . 2..5  Recognition of own limitations  Fall Spring  19 18  2  Ability to get along with, people  Fall Spring  18 17  3  Getting real enjoyment out of medicine  Fall Spring  17 7  4  integrity  Fall Spring  13 10  5  Warm and pleasing personality  Fall Spring  9 6  6  Skillful management of time  Fall Spring  5 8  7  Good appearance .  Fall Spring  2 0  8  Ability to think in an organized way  Fall Spring  1 6  10 0 5 7. 5  High intelligence  Fall ' Spring  1 1  I0o5 10. 5  Scientific curiosity  Fall Spring  1 3  10.5  Research ability  Fall Spring  1 1  10.5  1 2. 6 4 7. 5 5  12  9  10. 5  curriculum, was regarded as the most difficult to achieve of the given professions with the exception of getting a Ph.D. in physics.  Presumably this perception of medicine  induces the student to conclude that only a few qualified persons can enter into this field.  He then realizes that it  is necessary to "be cognizant of his limitations "before under taking medicine as a career. •  54  Parker"^  suggests that individual variations in  the perception of the physician differ according to personality factors. by Schumacher.  This suggestion was further emphasized  He says:  Applicants to medical school differ significantly from college students in general in several personality d i m e n s i o n s T h i s applicant's personality pattern follows his image of the physician fairly well with a few notable exceptions. It is -possible that, as the degree of authoritarianism increases there is more tendency for the student to regard the physician as a moral and spiritual guide of his patient. On the other hand, those who score low on authoritarianism m a y be more prone to think of the doctor-patient relationship itself as a therapeutic instrument that serves to either facilitate or hinder treatment of the specific moral problem. Very little information about our students' personality factors were collected, therefore, it is not possible to make a m o r e detailed study of the data with regard to the  relationship  of personality traits to the student's  image of the physician.  TABLE 2.1792 STUDENT - CONCEPTIONS OP RELATIVE.IMPORTANCE OF VARIOUS TYPES OF SOCIAL BEHAVIOUR TO THE SUCCESS OF A PHYSICIAN1  Percentage of Students Very important  Fairly important  Not at all important  No ans- Total wer ! students  Average score  Rank Order  F S  52 42  38 46  10 10  _  (50)  2.42 2.32  1 1  To maintain a resF trained and dignified S manner  22 8  : 62 58  16 30  _  4  (50)  2.06 1.77  2 4  To be a good conversationalist "  F S  16 12  68 70  16 14  —  4  (50)  2.06 1.97  3 2  To participate in com-F munity activities S  12 10  74 66  14 22  (50)  1.98 1.87  4 3  P S  8  64 58  28 38  4  (50)  1.80 1.60  5 5  To have a degree from F a top medical school S  6 2  46 36  48 58  4  (50)  1.58 1.42  6 6  To maintain an air of confidence  To wear conservative clothing  -  2  —  2  —  1 "How important is each of the following types of social behaviour to the success of a physician? (Answer for each)" F = Fall S = Spring  H  ^  (ii)  Important Modes of Behaviour for a Good Physician In relation to the factors regarded as necessary .  for a good physician, the students were also asked to rank six types of social behaviour according to their importance for the success of a physician.. Table 3.18 contains the average scores for each type of behaviour both in the.fall and in spring.  When they were asked this question for the  first time in the fall students tended to think that in order to succeed the physician must maintain an air of confidence,, even when he is not confident.  He must maintain  a restrained and dignified manner, and be a good conversationalist.  At the other end of this scale were found two  other types:of behaviour:  the wearing of conservative  clothes, and having a degree from a well known medical school. The physician's air of confidence is the type of behaviour most highly rated throughout the year, only ten per cent did not regard it as very or fairly important for the success of the physician. Significant changes in scores between the fall and spring occurred with the item, to maintain a restrained and dignified manner, which dropped from the second in the spring to the fourth place in the fall. A degree from a well known medical school is assessed among these students as the least important factor. Since the consequence of medical treatment is visible, a  successful physician is associated more with his individual role performance than with the high rank of the medical school he attended. 56 We have discussed various types of social behaviour in relation to the perceived importance for the success of a physician.  We are not yet able to explain why any one type  of social behaviour, for instance, air of confidence, is more highly estimated than another.  At the end of the first year  in medical school, the students, however, tend to think all the types of social behaviour are less important for the success of a physician, than;they did at the beginning of their training.  As Table 3.18 indicates none of the above  types of behaviour gained a higher score in the spring although no significant difference between the two scores has . been observed.  Furthermore, each type of behaviour has been  chosen by someone as important for success.  Further research  is suggested for the exploration of the following problems: (1) Is the first year medical student not concerned with the social behaviour of the physician?  (2) Are there any  other types of behaviour that might be considered appropriate for the success of a physician? Y.  Specialization  When the amount of knowledge in a field becomes so great that a single practitioner cannot become competent in 57 the. entire area; specialization occurs.-" There has been an  1795 increasing tendency toward specialization in medicine and a considerable proportion of ali physicians limit their work to one field. 58 Canada*^  According to the Survey of Physicians in  the number of active civilian physicians almost  doubled between 194-8 and 1954-, and. during this same period the proportion of specialists increased from 23.8 per cent to 29.1 per cent while general practitioners dropped to 4-3.2 per cent from 50*6 per cent. 5 9^ Medical practice is historically rooted in a lay clientele1s,desire for help for problems which are recognized as such by the clientele itself.  Medical practice, in its  early stages, dealt with such problems more or less in the 60  way that the clientele expected.  But as medical knowledge  grew increasingly refined and complex, so that a single practitioner could hardly be competent in all the fields, the need" for the development of specialized practice arose. This need brought about the early development of different types of professional practice, in such fields as ophthalmology, orthopedics, and urology, and later ones such as anesthesiology, pathology, and radiology.' The later specialties were not sought out by the client in answer to his own self-perceived needs, but were essentially services by physicians to facilitate the work of their colleagues.  The conscious demand  for these new specialties stemmed from the perceived needs of physicians themselves, or from the hospital, but not directly from the needs of their clients.  This division of labour in medicine leads individuals to pursue specialized tasks in a separate department of professional organization.  In individual per-  forming such a specific task is responsible for a clearly defined role.  At the same time a specialized task provides  the individual with the justification for not being fully capable of performing tasks-that fall outside the specialtie Another aspect of specialization is the establishment of a range of limited ambitions that people may pursue. As indicated thus far the defining characteristics of the medical profession is its possession of a body of specialized skills and knowledge. . Proficiency in these special skills and knowledge Is a prerequisite for limiting one's work to one's field. As we noted before, during the last few years the proportion of specialists has increased considerably while the proportion of general practitioners has decreased.  The  extent to which this trend has affected medical students' attitudes toward specialization, and the main factors that lead them to choose certain specialties, will be discussed. Students were asked: How much have you thought about the kind of medical career you would like to have: a great deal, a fair amount, only a little, or not at all?  129 Although the heginning students know relatively little about their own specific interests and talents, and also relatively little about the specialized training available to develop their interest, the majority of these students appear to have given a great deal of consideration to the question of specialization.  TABLE 3.19 .STUDENT CONSIDERATION OP SPECIALTY CHOICE  Percentage of Students ' , .  Pall  Spring  A great deal  24  16  A fair amount  52  58  Only a little  22  24  2  2  50  50  Not at all. Number of Students  Percentage difference statistically not significant at .05 level.  As Table 3•19 indicates, more than seventy per cent responded to give "a great deal" and "a fair amount" of consideration to the choice of their specialty both on entering medical school and by the end of their first year.  Only two per cent —  one student —  had not  thought"of it  at all. (i)  The Choice of Specialties We then asked students to indicate two kinds of  careers, one, the field they would most like, and the other, the field they would least like to enter. recorded in Table.3.20.  The results are  The table shows that at the  beginning of the school term the most frequently preferred fields are Surgery, twenty-six per cent; Research, eighteen per cent; Paediatrics, fourteen per cent.  On the other hand  twenty per cent chose Psychiatry; eighteen per cent, General Practice; and ten per cent Pathology as the fields of least preference.  But the pattern of choice of specialties, at  the end of the first year takes quite a different form.  As  Table 3.20 further indicates, students then most frequently chose Surgery, General Practice, Paediatrics and Medicine. The proportion of students in the spring who chose medicine or general practice is considerably larger than that in the fall, and there is a significant decrease in the choice for Research. Meanwhile on the negative side of their career plans.we found more fields which students did not prefer in the spring.  They are:  Psychiatry, eighteen per cent;  Research, sixteen per cent; Dermatology, twelve per cent;  131  TABLE 3.20  PERCENTAGE, DISTRIBUTION OP THE CHOICE OF SPECIALTY  Most like to enter  Least like to enter  Fall  Spring  Fall  Spring  Surgery  26  22  6  4  Research-  18  8  2  16  Paediatrics  14  18  4  -  6  4  6  ZJ.  20  18  -  -  Dbs . and Gyn.  8  Psychiatry  8  Medicine  6  18  Pathology;  2  -  2  2  General practice  2  22  Orthopaedics  ~  Dermatology Ear, nose, throat  .' Public health  Other No answer Total Students  \  10 -  2 20  18  4  -  6  6  --  -  6  12  2  -  4  10  10  -  18  2  2  -  2  5©  50  50  -  50  Ear, nose and throat and Public Health, ten per cent. Only Psychiatry was markedly not preferred.  It is inter-  esting to note that in the spring there is a much larger list of newly-recognized not preferred fields.  In summary, . ,  (1)  Throughout the year Surgery holds its own as  the field of positive choice while Psychiatry remains as the field of negative choice. (2) A remarkable change in student attitude to choice of specialty occurs in-three fields:  General practice,  Research, ,and Public Health. General practice, the least popular career field in the fall,, appeared in the highest rank of the preferred field in the spring being only second to Surgery.  On the  other hand, the reverse situation,obtained for the field of research. For the purpose of comparing our data with others gathered in the U. S. we rearranged Table J.20 as follows:  TABLE 3.21 STUDENTS1 PLAN'S FOR LATER CAREER  Fall  Most like to enter  Spring  Percentage of Students 2  22  Specialty Practice  66  70  Other (Research and Teaching)  28  8  General Practice  No answer Total Students  450  -  50  133-  In spite of a considerable increase in the proportion of students, general practice Is still less frequently chosen as a future career than the specialty practices. If it can be assumed that our subjects are a sample of all medical students in Canada the difference in the pattern of eareer plans of first year medical students of Canada and the U. S. are quite striking.  Table 3.22 com-  pares the career plans of the first year student in the two countries.  .TABLE 3 .22 CAREER PLAN'S OF FIRST YEAR MEDICAL STUDENTS AT U.B.C.I CORNELL UNIVERSITY2 AND OTHERS^  Plan to go into  U.B.C.  Cornell  Others  Percentage of Students General Practice  22  60  46  Specialty Practice  70  35  46  8  5  5  Others (Research or Teaching) No response Total Students  2 50  75  349  1 We use, here, only the spring answer. 2 Kendall, P., and Selvin, H., "Tendencies toward Specialization in Medical Training," Merton and others, op. cit., p. 153 „ 3 Fuhkenstein, D. H., "The Implications of Diversity," Gee and Glaser, op. cit., p. 51«  The above table indicates that the first year medical students at U.B.C. are more likely to choose specialty practice than are students in the two samples • from the U.. S. The first.year medical students at U.B.C. show in their career plans a tendency that is closer to that of fourth year students at other universities, in the United States.  Two questions should be answered in relation to  this difference between these two groups of students. (1)  Can it be assumed that the proportion of the  first year medical students who plan to go into General practice is gradually decreasing as the years go by?  It is  important in this regard to observe the dates when these data were collected:  the Cornell Study in 1952, the  ITunkensteins Study in 1956 and our study in 1959 • (2)  If the first assumption is not true, then are  there definite differences, between two countries in the perspectives of first year medical students concerning career plans? Table 5.22 also indicates that the great majority of medical students are oriented toward medical careers in general or specialty practice rather than toward academic medicine such as research and/or teaching.  All three sample  show that no more than ten per cent of the students plan to enter these fields.  (ii) Reasons for the Choice of a Specialty There are many significant factors that lead medical students to choose either a specialty or general practice.  However, we attempted to find out those factors  or characteristic features of medical practice which were considered Important. Students were asked: Below are some considerations that might enter into your selection of a specialty or general practice in medicine. Which two are most important to you as you think about your career? Which two are least important? Table 3.24 finds no significant difference between the proportion of the students in response to this question.  The  most common and frequently mentioned considerations are: (1) Meeting diagnostic problems that are particularly challenging. (2) Having opportunities to know your patient well. (3) Having patients who will appreciate your efforts. It is not surprising, then, to find the factors which are least important in selection of a specialty or of a general practice are as follows: (1)  Being able to establish your own hours of work. (2) Earning a good income. (3) Having prestige within the medical profession.  136 TABLE 3.23  MOST (LEAST) IMPORTANT CONSIDERATION EOR THE SELECTION OTA SPECIALTY OR OE GENERAL PRACTICE  Most Important Having the opportunity, to know your patients well  26  Being able to establish your own hours of work  5  Meeting diagnostic problems that are particularly challenging  33  Having enjoyable, relationship with colleagues  (5)  Making good income  (6)  Having patients who will ..appreciate your efforts  (1)  (2) (3)  (4)  (7)  Least Important  1  2  29  34  36  3  3  3  3  11  10  3  4  26  28  21  16  2  4  Having prestige within the medical profession  4  3  21  16  No answer  6  4  8  3  100  100  100  100  Total Number  33 —  It is apparent that one first year medical student is more ready to indicate common stereotyped reasons which are usually given as the factors motivating entrance into medicine.  He tends to think that role performance in medicine  is the important Consideration, and not good income or high  137-  prestige.  This task-oriented attitude applies generally  to every field in medicine.  At the outset the factors pre-  sented v/ere too common and vague to elicit specific reasons for the choice fo specific fields in medicine as shown in Table 3-24.. They became clearer when they are broken down into each field.  As Table 3•23 shows, the three most important  considerations are equally distributed into each individual field as a total proportion for each factor. Further exploration of the factors which affect the choice of a career.in medicine will be made later. 71.  Remuneration  Eemune rat ion refers to the financial and other rewards students expect to derive from their work. (i) Financial Hewards:  Income  Occupations differ, in their income; such differences 63  are a compound of both monetary and symbolic rewards.  In  the monetary sense, income brings about economic power; in the symbolic sense income determines one's relative;standing in society.  It is conceivable that students want to be  economically secure since they invest much time and a great amount of effort to achieve this goal. 64 Three out of ten of the medical students studied by Cabalan  specified financial  return or economic security as one of the primary aspects of being a doctor.  TiLBIiE 3.24-  SPECIFIC CONSIDERATIONS IN THE CHOICE OF SPECIALTY  Number of Students Medicine  Surgery . Ob s. and Gyn.  Pae di a-• Psychia- Public G.P. tries try Health  Research  N.  (1) Having oppor-  tunity to know your patient well  3  6  3  7  2  4  33  1  1  7  3  36  —  —  T—|  1  -  -  -  5  1  7  (2) Being able to  establish your own hours of work  (3) Meeting diag-  nostic problems that one finds challenging  7  8  2  7  _  1  _  —  3  1  1  3  * 6  1  2 .  O ) Having enjoyable  relationship with colleague  (5) Making a good Income  -  (6) Having patients  who will appreciate your efforts  1  1  16  (7) Having prestige  within the medical profession 2  -  1  -  -  -  3  139-  TABLE 3 .25 SPECIFIC CONSIDERATIONS IN TEE CHOICE OE SPECIALTY  Number of Students Specialty practice (1) Having opportunity to know your patient well  21  General Research practice  7  (2) Being able to establish your own hours of work (3) Meeting diagnostic problems that one finds challenging  26  7  (4) Having enjoyable, relationship with colleagues  1  >  (5) Making a good income  4  (6) Having patients who will appreciate your efforts 11 (7) Having prestige within the medical profession  3  -  4  1  N.  33  1  1  3  26  1 -  4  -  Public Health  -  1  -  -  4  16  3  Monetary income varies not only in the different specialties, but in the forms of payment: cash and checks, weekly and monthly pay.  salaries and wages, Research shows that  140-  seven out of eight medical students preferred a non-salaried to a salaried type of practice.^ In this regard our students were asked the. amount of yearly income they expected both in ten years after graduation and at the peak of their career. (a)  Income expectation of the physician  .Before asking the medical students their expectation with respect to financial returns, they were asked to estimate the average yearly income of the specialist, and of the general practitioner.  Table 3«26 indicates that students'  estimation of the annual net income (median) of general practitioners averaged $11,346 in the fall, and $10,833 in the spring, whereas specialists were expected to enjoy a higher income; the estimation was $16,500 and $15,875 in the fall and in the spring respectively. We found no significant change in the amount of . median income of specialists and general practitioners. However, it was noticed that the expected income of a physician at the end of. the first.year was less than.at the beginning of the year. Compared with the actual annual income of a p r a c t i s i n g physician which amounted to $14,000- in 1959, 66 students' estimates in general do not fall short by much. It seems to be generally agreed among the students that the  141 TABLE 3.57 STUDENTS' EXPECTATION OP AVERAGE YEARLY INCOME OP THE SPECIALIST AND OP THE GENERAL PRACTITIONER  Number of Students Specialist  Pall  General Practitioner  Spring  ' Pall  Spring  1.  Under $5,000 ;  2.  5,000 - 10,000  1  1  17  20  3.  10,000 - 15,000  17  20  26  27  4.  15,000 - 20,000  20  20  5  1  5.  20,000 - 25,000  9  8  -  1  6.  25,000 over  l  -  -  -  No answer  2  1  2  1  50  50  50  50  Total Students Median,income  $16,500  $15,875  $11,346  $10,833  The difference between the average income of the specialist and of the General Practitioner is significant at the 0.001 level both in the fall and in the spring  annual net income of a specialist is much higher than that of a general practitioner.  ("b) Students' expected income We now come to expectation of students' own income. What yearly income do you think you might realistically expect ten years,after medical school and at the peak of your career?  'As a group they anticipated annual net incomes at the height of their careers about thirty per cent greater, C$16,310 in the fall' and $15,972 in the. spring, (median)] than the earnings they expect when they have been out of medical school for ten years.  Only one student in the fall  anticipated he would be making less than $10,000 at the peak of his career.  No significant difference between the amount  estimated in the fall and in the spring is observed. It Is interesting to note that the two distribution curves of the estimated income for both general practitioners and specialists are parallel to the students' expected income ten years after medical school and at the peak of their career.  At the beginning of the year students think that  ten years after graduation they might realistically expect an annual net income amounting to $11,4-00.  This is approxi-  mately the same as the expected income of the general practitioner.  By the end of the first year they looked  forward to slightly higher incomes for themselves ten years after graduation than the general practitioner actually receives (the median is $11,875 for students, $10,833 for  143 TABLE 3 . 5 7  REALISTIC EXPECTATION OP YEARLY INCOME TEN YEARS AFTER MEDICAL SCHOOL AND AT THE PEAK OP CAREER  Number„of Students Ten years after medical school  At the peak  Pall  Spring  Pall  18  14  1  Spring  Under $5,000 5,000 -  10,000  10,000 -  15,000  25  28  18  21  15,000 -  20,000  6  6  21  18  20,000 -  25,000  1  1  6  10  25,000  or over  No answer Total Students Median income  1. 50 $11,400  50 $11,875  3  -  1  1  50  50  $16,310  $15,972  Percentage difference is not statistically significant at .05 level.  general practitioners.  (The difference between the two  incomes is statistically not significant.) If we look at both Table 3.26 and Table 3.27 again  144-  we find that their realistic expectation of a yearly income at the peak of their career is quite closer to the estimated income of the specialist. With regard to students' expected income, two other data are available.  TABLE 3.28 EXPECTED INCOME OE EIRST YEAR MEDICAL STUDENTS " AT THE PEAK OE THEIR CABEER, AND TEN IEARS AETER GRADUATION  .  Estimated Income U.B.C. (1959) Cahalan's (1956) A.A.M.C. (1957)  At the peak  115,972  In ten years  Sll, 875  $22,34-0 $14-, 2 3 0  120,595. 114-, 185  The above table indicates a difference in the expected annual income of U.B.C. first year (I960) medical students, and of two samples of U. S. first year medical students' studies by Cahalan (1956) and by the Association of American Medical Colleges (1957)'  Detailed comparison of  our subjects with U. S. medical students shows the same difference between expected income, both with regard to ten years after graduation and at the peak of their careers.  If the expected incomes are not greatly affected by the time interval between 1957 and I960, the difference may reflect the prospects of the medical profession in both countries. (c)  Perception of the peak of career  Correlation of the students' expected income in ten years after medical school with that at the peak of their career is summarized in Table 3.29 which indicates that no one expected,his income in ten years after medical school to be higher than that at the peak of his career*  TABLE 3.29 CORRELATION BETWEEN STUDENTS' EXPECTED INCOME AT TEE PEAK OP THEIR CAREER AND IN TEN TEARS AFTER MEDICAL SCHOOL. SPRING .Expected Income crt-fta PeaK of far«er tvindtr $ Sj.ooo 10-OOO IS.ooo ID.OOO If.ooi) outr °  Uwtter  V,  TC> i 10.000 u 10 A li'.ooo  •  s  U  £ £ 20 .0 0 o £  32  1  2S.OOO K. x  z  i 1  Z j  LU  • over £  V\o c\V\3Ul€A  However, a few, namely,eighteen per cent, gave the identical estimate for both points in time,  This probably  means that students do not expect to reach the peak of their careers within ten years, but at a more remote point in time. (d)  Satisfaction with the expected income  How satisfied will you be with the yearly income you think you might realistically expect, very satisfied, fairly satisfied, and dissatisfied? 6  Most of the students appeared to be quite satisfied  with their 'realistic' expectation of income both ten years after graduation, and" at the peak of their careers. Table 3.30 and Table 3.31 show the relation between the expected amount of income and the corresponding expected satisfaction with it.  Ten years after medical school the  expectation of income and of satisfaction with it appeared to have a positive correlation, i.e. the greater the expected income the more the satisfaction.  But as Table 3«31 shows,  at the peak of their career the assumption derived from Table 3.30 can hardly borne out.  Students who expected to  earn a median income of $12,500 are likely to express more satisfaction than those students whose expected median income is $17,500. This finding suggests further research is needed on the relationship between the expected income level, and the expected satisfaction with it.  TABLE 3 . 3 0  RELATION BETWEEN THE EXPECTED INCOME TEN YEARS AFTER MEDICAL SCHOOL AND EXPECTED SATISFACTION WITH IT. SPRING  Expected Income $5, 000  $10,000  $15,000  $20,000  10,000  15,000  20,000  25,000  Degree of Satisfaction  Percentage of Students  Very satisfied  64  67  83  Fairly satisfied  36  33  17  Dissatisfied Total Students  -  14  -  28  100 -  -  -  6  1  (ii) Non-financial Rewards Non-financial reward takes the form of the psychological rewards, or certain privileges which accompany enhanced positions.  Cahot6^ describes the rewards, besides  income, whieh a doctor may reasonably expect to find in his professional work.  They are:  To be able to practice a profession in which the pursuit of truth pays, and pushes itself under our very noses in the midst of our  TABLE 3 . 3 0  RELATION BETWEEN TEE STUDENT'S EXPECTED INCOME AT THE PEAK OF CAREER AND EXPECTED SATISFACTION WITH IT. SPRING  Expected Income 15,000  $10,000  $15,000  $20,000  10,000  15,000  20,000  25,000  Percentage of Students Very satisfied Fairly satisfied Dissatisfied Total Students  —  -  -  71  65  90  29  35  10  -  21  -  17  -  10  utilitarian and money making activities; its opportunities for the exercise of authority and leadership; the ability to conserve talents of youth in the facilities of sense and muscle; the opportunity to get friendly with all sorts of conditions of men, women and children; the chance to cut across the enmities and divisions of men and a flag of truce, the call'to the teacher latent in most of  us.  We will attempt to measure non-financial rewards by ascertaining the students' perceived satisfaction with their careers.  Professional satisfaction has emerged as the most  important factor in determining the student's choice of 68  career.  We-may possibly expect that the greater the satis  faction with medicine as a future career, the stronger the identification of oneself as a physician.  To a great extent  it is a future professional satisfaction which motivates students to undertake training. In this regard students were asked: Which one of the following statements "best describes the way you feel about a career in medicine? (check one)  •  1-  It is the only career that could really satisfy me.  2.  It is one of several careers which I could find almost equally satisfying.  3'  It's not the most satisfactory career I can think of everything else considered.  4.  A career I decided on without considering whether I would find it the most satisfying.  The results are summarized in Table 3•32.  Throughout the  first year more than sixty per cent of the students feel that medicine is the only career that could really satisfy them.  Thirty-four per cent express less satisfaction than  the above group:  medicine was one of several careers which  they could find almost equally satisfying. A notable thing, in one sense, is that no one decided to choose medicine as a career without considering whether he would find it the most satisfying.  Most of these  TABLE 3 . 3 0  DESCRIPTION OP STUDENTS' PEELINGS ABOUT A CAREER IN MEDICINE  Percentage of Students Peeling about Medicine as a Career  Pall  Spring  It's,the only career that could really satisfy me  70  64-  It's one of the several careers which I could find almost equally satisfying  24-  34  6  2  50  50  It's not the most satisfying career I can think, of, everything considered A career I decided on without considering whether I would find it the most satisfying : Total Students  Proportional difference is statistically not significant at .05 level.  students appear to he well satisfied with their choice of a profession, and are looking forward with considerable confidence to achieving the particular careers in medicine that they desire.  Similar results were found by Don Cahalan  and o t h e r s , a n d also by the Association of American  151 Medical Colleges  70  for U. S. medical students.  At the same  71 time, Carwright  discovered similar findings "based on the  study of British medical students. We did not further attempt to discover the elements which contribute to the attainment of professional satisfaction..  In the study of medical students, which included  the fifth year at Edinburgh University, Cartwright asked students to indicate the degree of importance of various factors in contributing to professional satisfaction.  She  found that the variety of problems presented were most generally thought to be very important, and that diagnostic problems and contact with other professional people were also considered as very important by at least half the students. It is interesting to note that she found those factors com- , monly referred to as influential in the choice of a career, such as status in the community, gratitude of patients, and opportunities for research, at the lower end of the scale. As she further pointed out, the elements which are felt to contribute significantly to their professional satisfaction 72 vary considerably with different individuals and groups.' (iii) asked:  Future Plans for Professional Activity Besides financial income students were also If you could arrange it, in which of the following situations would you plan to  carry out the professional activity you said you prefer most? . The results.are summarized in Table 3.33.  No significant  difference in the percentage distribution between fall and spring is evident.  Hore than half of the students, sixty  per cent, would like to carry out the desired specialty in their own professional office with hospital affiliation, whereas only four per cent seem to plan to have their future work in their own professional office, but without hospital affiliation.  The proportion of the students who want to  work in large private clinics or hospitals and those who want to work in small groups proved to be almost equal — than fifteen per cent.  less  Throughout the year only a minority,  six per cent, wished to remain in medical school.  To put  this finding in another way, the majority of first year students plan to carry out their future professional activity with a great deal of autonomy.  As they stated  above, they expect to be the masters of their future professional activity. It is not surprising that in the fall and again in the spring, the majority of the students, sixty per cent, chose as their preference "own professional office with hospital affiliation."  One can easily see that the medical  student's image of the future is more likely to be drawn from the common image of a doctor enjoying autonomy in his own office.  The service orientation predominant among the  153 TABLE 3.57  STUDENTS' PEEFEEENCES POE THE WOEK SITUATION IN WHICH THEY WOULD LIKE TO CAEEY OUT THEIE PEOPESSIONAL ACTIVITY  Percentage of Students  Own professional office with his affiliation Own professional office without affiliation  Fall  Spring  60  60 4  —  Large private clinic or hospital  18  12  Small group clinic  12  14  Medical school  6  6  Others  2  4  No answer  2  -  Total Students  50  50  7-5 first year medical students'^ is seen as practicable only where they have control over the setting in which they will display their art.  Furthermore, students do not know the  advantages and disadvantages of one setting'over another. The choice at this time is only of a career, the realization of which is too remote to be looked at realistically.  B.  RELATIONSHIP BETWEEN SELECTED VARIABLES  So far we have observed separately changes In all the variables of adult socialization during the first year. Our attention has.been concentrated on group change, that is to say, how the first year medical student changes his attitudes, or values between the beginning and the end of the year. In Part B, therefore, we will try to ascertain: (!)  To what extent independent variables affect  dependent variables both at the beginning and at the end of the year. (2)  If the effects of independent variables [I]  on the dependent variables decrease (or increase) how, then, does variation in the dependent variables correspond with variation in the independent variables [II]? Thus we can compare the effects 6f both the Independent variable [I] and the independent variable [II] on the dependent variable at the end of the year. A good number of relationships between two variables, dependent- and independent, can be correlated mathematically. We cannot, however:, continue to relate independent variables one by one without some reasonable theoretical ground for doing so.  Only those relationships between variables will  be examined for which there are theoretical bases.  I.  Self-Evaluation  As we noted before, mediating "between the student and his relation with others in his role-sets is his selfevaluation.  In this regard we will look ,at the self-  evaluation in its relation to other factors of independent 73 variables .[II] .. : . Again we feel that our sample Is too small to be distributed into a six or ninefold table.  As will be shown  later, one cell of. a sixfold table often shows only one case which represents more than ten per cent.  Our findings  can hardly be conclusive, but they will suggest further investigation.  Eor convenience of discussion we will combine  the two categories of self confidence, "about average" and "below average" into one called "less confident," and designate them as Class B and we will call the more confident students "Class A." Table 3.34 summarizes the relation between the degree of self-evaluation and their opinions on competition among students.  There is little difference between Class A  and Class B students with respect to their feelings about competition.  But Class A shows a relatively more favourable  attitude toward competition.  Nineteen per cent of Class A  stated that they dislike competition while twenty-one per cent of Class B have the same attitude.  As the table  further indicates, at the other end of the scale, Class A  156 TABLE 3.57 SELE-EVALUATION AND OPINIONS ON COMPETITION AMONG STUDENTS. SPRING  Degree of Self--Confidence Percentage of Students Opinion on competition among Students.  More confident  Less confident  Dislike them somewhat  19  21  Neutral feelings  31  32  Enjoy them  :  50  Total Students  :  47  16  "  34-  TABLE 3.35  DEGREE OE SELE-EVALUATION IN RELATION TO INVOLVEMENT IN COMPETITION. SPRING  Degree of Self-Confidence Percentage of Students More confident  Less confident  Quite a bit- concerned  50  56  Little concerned  50  38  Not at all concerned :Total Students  -  16  6 34  157-  is more likely to enjoy, tlie competition than Class B.  But  when they were asked how much they were concerned with competition, almost all students stated that they were in some way concerned with competition.  Table 3.35 shows that  only six per cent of Class B responded negatively.  No  significant proportional difference between Class A and Class B according to (positive) opinions oh competition is evident. .  J  .  With regard to the relationship of the degree of  self-confidence and their opinion about the direction given by faculty, Table 3»36 indicates that, the students with high confidence tend to express less dissatisfaction with the amount of direction given by faculty than those who are less confident.  While twenty-five per cent of Class A stated  the lack of direction by faculty, thirty-eight per cent of Class B expressed the same opinion.  At the other end of the  scale, only Class A stated that faculty gave more than enough direction. II.  Motivation  In the previous part the motivation for entry into medicine, and the goals current while studying medicine were discussed in terms of the occupational value.  But choosing  to become a doctor, and choosing to continue as one are not only governed by the individuals internal dispositions but also by outside factors such as influences of Other people or situations.  158 TABLE 3.57 DEGREE OP "SELF-EVALUATION AND OPINION ON AMOUNT OF DIRECTION GIVEN BY THE MEDICAL FACULTY  Degree of Self--Confidence Percentage of Students  Opinion on direction given n '  More confident  Less confident  Too little direction  25  38  About the right amount  62  62  More than enough direction  13  Total Students  16  34  As previously suggested the student's "behaviour is primarily governed by individual motivation.  Of course this  is not to say that outside factors are negligible, but that they are secondary. Individual occupational values as a motivation may appear in different patterns according to the situations in which students find themselves.  Therefore, we shall first  try to ascertain how various occupational values are related to family background.  74  It is often.argued that values are the outcome of the socio-economic background of the individual and "his 75 current situation." According to Hyman  159It can be noted that the values are a resultant -of both the 'class history' of the individual and his current position. Individuals of equal current position reflect the values of their parents' class. It is also true however, that individuals with the same class origins have different values depending on their current position. .Owing to the fact that a majority of students, namely seventy per cent, are from the upper class? 6 we shall try to consider the relationship of the three occupational JJ  ,  ,  ...  '  . . . .  values noted above to economic pressure. Table 3.37 is the summarization of the relationship which appeared in the fall between three elements of occupational values and the degree of economic pressures. It is evident that neither a uniform pattern nor any significant difference in the distribution is evident in the relationship between the "self-oriented" value and the degree of economic pressure. Contrary to our expectation that students in difficult economic situations are more likely to stress the "reward-oriented" value, we find rather that the reverse relation is suggestedo With regard to the "autonomy-oriented" value two categories, "fairly difficult" and "not very difficult" appeared to be identical.  When all the categories are  combined into two, "difficult" and "not difficult," the  160 TABLE 3 . 5 7  VALUES A m THE DEG-HEE OE ECONOMIC . PRESSURE,OE STUDENTS. EALL  Percentage of Students Degree of Economic Pressure Very difficult • - •• JJ  Eairly Not : difficult' difficult  No answer  . . '  "Self-oriented", value Checked Unchecked  67 33  80 20  60 40  Total students  9  25  14  33 67  28 72  37 43  9  25  14  44  36 64  36 64  2  14  2  "Reward-oriented" value Checked Unchecked Total students  2  " Aut onomy- 0 r i ent e d " value Checked Unchecked Total students  36 9  5  2  result still does not show any significant difference "between the proportion of students in the two categories who stressed the "autonomy-oriented" value. In general, occupational values do not seem to be related to the degree of economic pressure.  161  Table 3-38 and 3.39 also indicate that- in tlie fall no striking relationship is established between occupational value and the dichotomies of rural-urban students, or students.with or without a physician father.  TABLE 3.38 OCCUPATIONAL- VALUES AND COMMUNITY BACKGROUND.  FALL  Percentage of Students Community Background Urban  Rural  "Self-expression-oriented" value Checked Unchecked  67 33  86  Total students  36  14  Checked Unchecked  41  36 64  Total students  36  14  "Reward-oriented" value 59  14  "Autonomy-oriented" value 21  Checked Unchecked  39  61  _79  Total students  36  14  Proportional difference is not statistically significant at .05 level.  162.TABLE. 3.39  VALUES AMD MEDICAL FAMILY.  FALL  Medical Family Percentage of Students M.D. Father  Non-M.D. Father  33 67  68 32  6  28*  "Self-expression-oriented" value Checked Unchecked Total students "Reward-oriented" value Checked Unchecked  .  Total students  33 67  36 64  6  28*  17 83  32 68  6  28*  "Autonomy^oriented" valueChecked Unchecked Total students  * Proportional difference is not statistically significant at .05 level.  In short, we found no relationship between occupational values and the three factors of family background. In the spring, however, after a year of medical training it would seem that student conceptions of  163occupational value were clarified; that is to say, new patterns "begin to emerge besides that of the "peopleoriented" complex of occupational values common to a large majority of students of entry to medical school.  In the  new patterns we see personal background playing an important role in determining more specific values. Table 3.40 indicates two characteristic aspects o f the relation between value and economic pressure: v J") . . ' ' ••• . • • ' ' The "self-oriented" value is more highly stressed by the students in a difficult current economic situation than by those who are better off.  The "reward-oriented" value is  more strongly emphasized by the latter. No such clear pattern of residential background and medical family emerges from our tables (Tables 3,41, 3.42),:as related to occupational value.  These two factors  were found not to be so influential in shaping the occupational values. In summary: i t was indicated that occupational values stressed by students in their choice of medicine as a career are not greatly influenced by personal background factors, namely, economic pressure, medical family, or residential backgroundp Occupational values which motivate students "to remain in medicine" appear i n different patterns.apparently  164 TABLE 3.57 PERCENTAGE OE STUDENTS ACCORDING TO VALUES AND THE DEGREE OE ECONOMIC PRESSURE. SPRING  Degree of Economic Pressure Percentage of Students Very difficult  Fairly difficult  Not difficult  "Self-expressionoriented" Value. Cheeked Unchecked Total students  100' -  89  11  38  4  28  18  100  36 64  £8  4  28  18  50 50  43 57  50 50  4  28  18  62  "Reward-oriented" value Checked Unchecked  1  Total; students  62  "Autonomy-oriented" value Checked Unchecked Total students  related to current economic situations. The less affluent students are more likely to stress the "self-expression-oriented" value more than the affluent students, while the reverse relationship occurred with the  165-  TABLE 3.41 VALUES AMD GOMPIDUITY BACKGEOITKD.  SPRING  Community Background Percentage of Students Urban  Eural  "Self-expression-oriented" value j'j Checked Unchecked  83  17  14  Total students  36  14*  Cheeked Unchecked  47 52  64 36  Total students  36  14*  Checked Unchecked  39 61  64 36  Total students  36  14*  86  "Eeward-oriented" value  "Autonomy-oriented" value  * Proportional difference is not statistically significant at „05 level.  "reward-oriented" value. Our next problem was to ascertain how the individual occupational value is related to the student's self-assessment of his ability to perform a given task.  166TABLE 3.42 VALUES AND MEDICAL FAMILY.  SPRING  Medical Family Percentage of Students Parent M.D.  Parent in other Occupation  f] • "Self-expressionoriented" value Checked Unchecked Total students  80 20  75 25  8  30*  "Reward-oriented" value Checked Unchecked Total students  47 53 8  62.5 37.5. 30*  "Autonomy-oriented" value Checked Unchecked Total students  50 50 8  37.5 62.5 30*  * Proportional difference is not statistically significant at .05 level.  People choose an occupation in order to satisfy their prior occupational values.  Usually these seem to be  the values commonly held by society.  But the same people may  167-  adopt other values after choosing an occupation because they consider them more appropriate in professional activity. This revising of values after commitment to an occupation is usually not based on the stereotyped values but on an individual's evaluations based on a consideration of his own ability with respect to the chosen field. We shall, therefore, try to understand now how the degree of self-evaluation of own ability Is reflected in different occupational values. '•  •• '.A'.  .  - ....  • • '  • ••• •  :  The,"people-oriented" value is stressed by most of  the first year students throughout the year both for choosing and remaining in medical school.  It will not be discussed  here because it is obviously a common value for the students. Although the "self-expression oriented" value is stressed by a majority of students, those with greater confidence are more likely to emphasize it than the less confident students.  However the proportion of students with  moderate assessment emphasized this value less than students who made a low appraisal.  When these two categories of  students are combined, i.e., those with moderate and those with low confidence the above suggestion of a positive relation between the emphasis on the "self-expressionoriented" value and the degree of self-confidence is given further confirmation. With regard to stress on the "reward-oriented" value, Table 3.43 indicates consistently that the higher the  168TABLE 3.4-3 VALUES AND DEGREE OF SELF-EVALUATION.  SPRING  Degree of Self-Evaluation Percentage of Students Better than average -  About . average  Below average  " Se If-jsscpr e s si on oriented" Value Checked Unchecked  93 __7  21  16  28  Checked Unchecked  50 50  46 54  Total students  16  28  Checked Unchecked  44 56  50 50  Total students  16  28  Total students  79  83 17  "Reward-oriented" value  33 67  "Autonomy-oriented" value  degree of confidence the greater the stress.  33 67  Fifty per cent  of students with high confidence are inclined to emphasize this value when giving their reasons for remaining in medical school.  Thus did forty-six per cent of students in the next  category of confidence, while thirty-three per cent of those  169-  with low confidence gave the same emphasis.  The "autonomy-  oriented" value does not show any consistent pattern according to different degrees of self-confidence. Up to now we have noted that the occupational values for remaining in medicine, "self-expression-oriented" value and "reward-oriented" value are highly related to two operative factors, economic pressure and self-evaluation. jry  We shall, therefore, try to ascertain how these  three factors are interrelated. Results obtained from our data are summarized in Table 3.44-.  Partly for the purpose of simple comparison,  and partly due to the scarcity of data we classified students current.economic situation into two; "difficult," and "not difficult." With respect to the "self-expression-oriented" value we can hardly discuss the students in the difficult situation, because only three students in this group did not emphasize -,this value complex, hut in the ease of the students who are not in difficult economic situations the table makes it apparent that students with higher confidence are more likely to stress the "self-expression-oriented" value complex than those who are less confident. The "reward-oriented" value indicates interesting results.  As can be seen from the table, among the less  170 TABLE 3.57  VALUES, SELF-EVALUATION AND ECONOMIC PRESSURE. SPRING  Economic Pressure Difficult Degree of Self-Evaluation  Not Difficult  Checked  Unchecked  Che eke d  better than average  89  11  100  about average ,  94  6  55  below average  83  17  better than average  25  75  86  14  about average  41  59  64  36  below average  83  17  Unche eke d  "Self-^xpressionoriented"  45  -  ~  "Re ward-orIente d"  affluent students the stress on the "reward-oriented" value complex increases as the degree of self-confidence decreases whereas among the affluent students the opposite tendencyoccurs.  Upon this point, further research is required "because  our sample is too small to make a definite conclusion.  171III.  Identification  One might -very well argue that unlike children with a father in a non-medical profession., the children of physicians have a living model whom they can observe and perhaps thereby be influenced in their choice of a career. If this is the case, would the students who are the sons of physicians more easily create a self-image as a doctor than those, who are not?  Our data seem to contradict this assump-  tion.  ifo remarkable difference was evident throughout the  year.  As Table 3.4-5 rather shows, the students with a  medical family background have less tendency than others to gain such a self-image i n the spring.?? It appears that easy access t o the role model does not necessarily create an early self-image as a doctor in the medical student.  Perhaps, paradoxically, earlier access  to this model may prolong the creation of the image, presumably because a student with this advantage is better informed about the requirements of the profession. Following Martin's proposition that the greater the students' self-confidence, the earlier the tendency to see themselves, as physicians rather than as students only, we shall try to ascertain whether the expectation of when they will have a self-image as doctors is related to their rip degree of self-confidence. We examined this proposition in our study.  The  172 TABLE 3 . 4 5 STUDENTS' EXPECTATION OP HAVING SELF-IMAGE AS DOCTORS .AND MEDICAL FAMILY  Family Percentage of Students Expected Period  M.D. Father  Non-M.D. Father  Fall During first two years in medical school  12.5  3  During last two years in medical school  12.5  20  During internship and residency .  62.5  70  Haven't given it any thought  12.5  7  Total students  8  30  Spring During first two years in medical school  7  During last two years in medical school  25  23  During internship and residency  62.5  67  Haven't given it any thought  12.5  3  Total students  8  30  173  results are summarized in Table 3.46 and turned out quite contrary to our expectation.  Among other things, out of  six students with low confidence in their ability, two expected that they would first come to think of themselves as doctors during the initial two years in medical school, while none of the students in the other categories of confidence had the same expectation.  In addition, no student  with a low confidence stated that he "liasn't given any thought." f  l  TABEE 3.46  STUDENTS' EXPECTATION OE HAVING SELE-IMAGE AS DOCTORS ACCORDING TO DEGREE OE SELE-EVALUATION  Degree of Self-Evaluation Percentage of Students  Expected period  Better than average  About average  During first two years in medical school  Below average  33  During last two years in medical school  38.5  25  During internship and residency  50  71  Haven't given it any thought  12.5  A  Total students  16  28  67  174However, since the size of this group is so small, only twelve per cent of the group, we combined, these students with the second category, "the students with moderate self assessment" to produce Table 3.4-7 which seems to suggest that the relationship between the two variables, degree of .. self-confidence and expectation, of self-image, is in accordance with Martin's proposition.  But these results are doubtful  because more students with higher confidence responded that , '  ^•  v.  ;  : .. .• TABLE 3 o 4-7  •• : -''  STUDENTS' EXPECTATION OP HAVING SELP-IMAGE AS DOCTORS , ACCORDING TO SELE-EVALUATION  Degree of Self-Evaluation Percentage of students  Expected period  Better than average  About & below average  During first two years in medical school  6  During last two years In medical school  38.5  During internship and residency  50  Haven't given it any thought  12.5  Total students  16  .  21 71 2 34-  •  "they haven't given any thought" to this consideration than did students with less confidence.  In. short, whatever the  case, it would, seem that the creation of a self-image as a doctor is associated with the occasions where the student encounters patients who consider him as a doctor.  In fact,  our students have not yet been in contact with patients. IV.,  The .Image.of the .Physician  ^In the section on the image of a physician we classified various desirable characteristics of an ideal physician into four categories, attachment to the 30b, inherent personal characteristics, ability for research, and ability to organize.  Assuming that each set of char-  acteristics of the ideal physician is not only different in its importance for first year students as a whole, but also different in its importance for each individual, we shall now try to specify which set of characteristics is more appealing to different students according to their family background, and their own assessment of their ability. We choose, one characteristic most frequently checked by students in each category.  To make comparisons  rather simple we will leave out the students who have physicians as relatives since there is little information about the influence of such a relationship. As we noted before, the larger the community,  the more likely it is that a student is aware of the extent of medical specialization, while the smaller the community the more familiar, the student is with the general practitioner., Is the pattern of students' contact with a physician reflected in his concept of an ideal role model? Table 3.48 summarizes different responses toward various characteristics drawn from each, category.  This  table indicates that a difference occurs between students from urbasu and rural communities when they think about "integrity" as a characteristic of a good physician.  Fifty  per cent of rural students are likely to stress the characteristic "integrity" in making a good physician while only seventeen per cent of urban students do so, It is, however, interesting to note that this difference between students from two areas tends to disappear at the completion of one year's study in medical school.  The  difference between the two proportions of students stressing integrity is not significant. If the students from different areas, rural or urban* have a different pattern of contacts, it is likely that the students from a medical family have more chance to observe a physician at work than other students.  How  then can the former students form a different Image of the physician when compared with the latter?  177-  TABEE 3.48 COMMUNITY BACKGROUND AND THE IMAGE OF DOCTOR  Commianity Background Percentage of Students -•. Fall , Urban  Spring  Rural:  ' Urban  Rural  Dedication.jbo medicine Checked Unchecked  44 5.6  Total students  36 :  N.S.  36. 64  22 78  14 86  14  36 14 ' N.S.  Integrity Checked Unchecked  17 83  50 50  22 78  42 58  Total students  36  14  36  14  df = i:  N.S.  3.89  p.<.05 .  Ability to think in an organized way Checked Unchecked  19 81  Total students  36  N.S.  36 64  44 56  14  36  Getting real enjoyment out of medicine Checked Unchecked Total students  •  22 78 36  N.S.  22 78 N.S.  14  • 14 86  25 75  36 64  14  36  14 N.S.  N.S. - Proportional difference is not statistically significant at .0'5, level  . 'v..:.  ;  178As can be seen from Table 3.49 two characteristics, "Integrity," and "getting real enjoyment out of medicine," show a remarkable contrast of the image of a physician of between sons of physicians and non-physicians.  Whereas- thirty-  three per cent of sons of physicians put emphasis on the 'integrity' in making a good physician, none of the rest of the students indicated this intention.  This difference held  throughout a year. In 7 contrast with this tendency, a reverse relation occurred with respect to 'getting real enjoyment out of medicine."  As Table 3.49 further shows, sons of physicians  on entry into medical school are more likely to stress the .importance of 'getting real enjoyment out of medicine' in making a good physician.  But at the end of the first year  this difference is not evident.  Consequently, in the spring  only one characteristic, 'integrity' seems to relate to the influence of a medical family, but none with residential background. Our next problem then is to ascertain the factor which makes students have different images of a physician in the, spring as compared to the fall.  Since the slight  relation between the students' image of a physician and the family background noted in the fall disappeared at the end of one"year's experience in the medical school, our attention is directed to students' assessment of how well they are  179  TABLE 3 .4-9 PERCENTAGE OF STUDENTS ACCORDING TO IMAGE OE DOCTOR AND MEDICAL FAMILY  Family Fall  Spring  Father with M.D.:  without M.D.  Father with M.D.  without M.D.  "Dedication to medicine" Checked Unchecked  50 50  Total students  30  N.S.  37.5 62.5  20 80  8  30  _  37 63  12.5 87.5 8  N.S:.  "Integrity" Checked Unchecked Total students  33 67  100  8 30 ?r=: 8.31 df =: JjK.Ol  12.5 87.5  30  8 iC- = 10.01 df == 1 p<.01  "Ability to think in an organized way" Checked Unchecked  23  Total students  30  12.5 87.5  77  8  N.S.  . 4-0 60 30  25 75 8  N.S.  "Getting real enjoyment out of medicine" Checked Unchecked  13 87  Total students  30  62.5 37.5 8  •2 x z = 7.24-  df = 1 N.S,  p<.01  23 77  37.5 63.5  30  8  N.S.  Proportional difference is not statisticallysignificant at .03 level  180-  doing in the class.  Table 3.50 indicates the different  emphases assigned to different characteristics according to the degree of"self-confidence.  Each characteristic suggests  a consistent direction according to the degree of selfconfidence.  With regard to 'integrity,' students with  higher confidence tend to emphasize it less than do low confident students. Three other characteristics:  'dedication to  medicine,' 'ability to think in an organized way,' 'getting real enjoyment out of medicine,' were more strongly emphasized by students with higher confidence in their ability. In short, students with less confidence are more likely to stress "inherent personal characteristics" in making a good physician while highly confident students put more emphasis on other characteristics, namely'attachment to the job and 'ability to do research.' Summing up our discussion, the image of a good physician held by students changes as they progress through medical school.  It was indicated that the role model at  the entry of medical school is, to some extent, associated with family background, but at the completion of year's study in medical school, this image of a doctor is more influenced by the students' assessment of their own ability. This is considered to be an.outcome of the socialization process.  181-  TABLE 3 .5O DEGEEE OF SELF-EVALUATION AND IMAGE OF PHYSICIAN  Degree ef Self-Evaluation Percentage of Students "better than average ,  about average  below average  Dedication to medicine Checked Unchecked Total students  18  25 _75  82  16  28  16 84  Integrity Checked Unchecked  17.5 82.5  Total students  16  29 _7l  50 50  28  Ability to think in an organized way Checked Unchecked  50 50  32  Total students  16  28  68  33* 67  Getting real enjoyment out of medicine Checked Unchecked  31 69  29 71  100  Total students  16  28  6  * Difference between this proportion and that of moderate confident students are negligible.  182-  V.  Specialization  As an indication of the extent to which the first year medical students think in terms of ultimate specialization, seventy per cent of the students showed a preference for entering a specialty, twenty-two per cent intended to practice general medicine, and the remainder chose research. More than two thirds of our sample can he described as interested in', or decided upon a specialized career in medicine for:the time being. To what extent is this choice of a specialized career as dependent variable associated with both independent variables? It is the Contention of Coker and others^ that there seem to be two sets of factors.which play a particularly important role in the decision to specialize.  The  first has to do with the kinds of economic pressure impinging on the medical student, the second has to do with the kind of community he comes from. We shall look at economic pressure first as revealed by our data.  Our results contained in Table 3«51  show that thirty-one per cent of the least affluent students intend to become general practitioners, fourteen per cent of those of medium affluence have the same intent, and none of those with no financial difficulty stated this intention.  OA  183 TABLE 3.57 SPECIALTY CHOICE A1H) ECONOMIC PRESSURE.  SPRING  Degree of Economic Pressure Difficult  Not difficult  Not at all  Specialty  69  86  General Practice  31  14  —  Total students  29  17  3  100  TABLE 3.52 SPECIALTY CHOICE AND MARITAL STATUS.  SPRING  Marital Status Single  Married  Specialty  79  66.5  General Practice  21  33•5  Total students  34  12  Proportional difference Is not statistically significant at .05 level.  184-  A similar result was obtained by Coker.  81  With regard to marital status, Table 3.52 indicates that the single non-engaged students are more likely to choose a specialty than the married students although the difference between the proportion is not considerable. Financial pressures are also reflected in the career choices of various age groups.  The older medical student feels that  he has less time in which to get established in practice, and can, therefore, less easily afford the. additional years of training for a specialty.82  TABLE 3 .'53. SPECIALTY CHOICE AND AGE.  SPRING  Age 1.7 - 21  22  - .26  27 -  Specialty  89  71  67  General Practice  11  29  33  9  28  6  Total students  31  32  (100;  3  * 4 - no answer  In examining the above proposition we find only eleven per cent of the medical students under twenty years of age intend to become general practitioners, but the  046*  proportion increases steadily with age until we find thirtytlar.ee per cent of those thirty years old choosing general practice.  But as.Sable 3.53 indicates, three students over,  thirty-one disturb slightly the anticipated tendency. The second factor that appears to be closely related to career choice is the kind of community from which the medical students come.83  The larger the community the  more likely it is that the student is aware of the extent of medical specialization, the opportunities involved, possibly the greater prestige of the medical career, and so on.  Coker and others found that the students, from cities of  less than 1,000,000 tend to be more likely to choose general practice while only a minority from larger cities expressed • same intention. 84 the. Returning to our data concerning this aspect, we 85 find no difference between "big city" and "small city" ^ students, perhaps because our sample of small city students is not large, only twenty-eight per cent.  As Table 3.54-  indicates the proportion of students who choose specialty and general practice is identical whether they are from rural or urban areas.  '  Finally, it is Interesting to examine the contrast between those students who have at least one parent in the medical profession and those with none.  We find that all  the students who have a parent with an M.D. intend to become  186specialists, whereas twenty-five per cent of the students whose parents are not medical doctors choose general practice. Incidentally, influence of relatives in the medical profession is not reflected in the students' career choice.  This  relationship is summarized in Table 3.55.  TABLE 3.54 SPECIALTY CHOICE AND COMMUNITY BACKGROUND  Community Background Urban  Rural  Specialty  77  77  General Practice  23  23  Total students  35  11  TABLE 3.53 SPECIALTY CHOICE AND MEDICAL FAMILY.  SPRING  Family M.D. Parent  Non-M.D. Parent  100  75  Specialty General Practice  -  25  Total students  6  28  9<a= 15.4  df = 1  P < .01  1855-  It. is obvious from tlie table that sons of physicians are more likely to choose a specialty. Rogoff argues that a father with an M.D. does not play an important role in influencing his son's decision.86 But her argument presents no obstacle to our contention since our case concerns not commitment to medicine, but a specialty choice within medicine after commitment. It is conceivable that those students with M.D. fathers are likely to be more exposed to the discriminating evaluations concerning the worth of specialty and general practice made within the profession itself® Within medicine, there is a wide choice of specialties:; each of them is not merely a unit of technical work, but a position in a complex system of health institutions.  They offer alternative career lines, some of them  mutually exclusive from an early stage.  These career lines  are variously ranked within the profession itself, as well as outside; the people in each of them have their own ethics and sometimes their own system of values concerning many on  things in medicine. '  With regard to the relative rankings of a number of specialty fields, rated by both students and faculty, Reader 88 found that the students' rankings are in very close agreement with comparable rankings made by the faculty.  188-  TABLE 3.56 SPECIALTY CHOICE AND DEGREE OF SELF-EVALUATION  Degree of Self-Evaluation Percentage of Students "better than average  about average  "below average  Specialty  85  78  50  General Practice  15  22  50  Total students  13  27  6  (46)  For the purpose of simple comparison, we divide the whole field of medicine into two parts: general practice.  specialty and  It is then apparent that the existence of  a marked hierarchy in the,medical profession is an accepted fact.  In Reader's listing of the prestige rating of all  fields of medicine, we find general practice at the lower end of a twelve point scale, rated ninth by students and tenth by faculty. The prestige of each specialty within a profession is often based on the degree of technical competence required to perform It.  We can, therefore, assume that although in  individual cases many reasons may operate, the choice of a 30b of lower prestige is to a large extent generally  189-  associated with an individual's assessment of his own abilities.  It can be argued then, that the higher the  degree of self-confidence the more likely the choice of specialty.  The data obtained concerning the relationship  between self-evaluation and specialty choice which are summarized in Table 3.56 confirm our assumption. As Table 3<>56 indicates, those students with high self-confidence are more inclined to choose a specialty, whereas the students who evaluate themselves below average indicate a preference for general practice.  Whereas eighty-  five per cent of the students with above average selfassessments and seventy-eight per cent of the students with moderate confidence preferred a specialty, only fifty per cent of the students with low confidence expressed the same preference. Thus far we have found that the choice of a field or general practice is to a large extent influenced not only by economic pressures and medical family, but also by the degree of self-confidence.  The small number of students  in our sample do not allow the detailed analysis of the relation between the above variables.  Further research is  required, to ascertain to what extent the specialty choice is influenced by both individual background and self-evaluation of own ability.  190VI.  Remuneration  Coker and others found in their study of medical students at the University of North Carolina that students from rural areas are likely to have lower income expectation than those from urban.  Our data point to a similar result  in the fall, but not in the spring. When in the fall students were asked to specify the incomes they hoped to be receiving at the height of their careers, forty-eight per cent of the urban students expected to earn more than 115,000.00 and twenty-one per cent expected to earn more than $20,000.00.  Compared with  urban students, rural students had a much lower expectation. Twenty-nine per cent expected to earn more than $15,000.00 and only fourteen per cent hoped to make more than $20,000.00. At the lower end of the expectation scale, thirty-one per cent of the -urban students expected to be making less than $10,000.00, whereas at the highest income expectation an equal proportion of students both from rural and urban areas expected to earn more than $20,000.00. . We asked the students to estimate the amount of income they expected to earn in a few years after medical school.  Table 3.57 summarizes the  results obtained. The difference between the proportion of students responding to the first two categories of income level is too small to be of significance.  191 TABLE 3 . 5 7  EXPECTED INCOME AT THE PEAK OP CAREER COMMUNITY BACKGROUND Community Background Pall Expected Income 10,000 -  15,000  Urban  Spring Rural  15,000 - 20,000 20,000 - 25,000  31 48 21  57 29 14  Total Students  35  14*  Urban : 46 26 28  Rural :  36 64  35  14  Community Background Pall  Spring  Urban  Rural  Less than.15,000 More than 1 5 , 0 0 0  31 69  43  57  46 54  36 64  Total Students  35 N.S.  14  35 N.S.  14  Urban  Rural  Community Background Rural  Urban Pall  Spring  Pall  Spring  Less than 15,000 More than 15,000  31 69  46 54  57 43  36 64  Total Students  35  14  35  14  9(l= 4.38, df = 1 P < .05  9C1 = 8.86, df = 1 P <.01  * 1 110 answer N.S.  Proportional difference is:not statistically significant at .05 level.  192'The- relation between tlie expected income and residential origin becomes more unpredictable in the spring. Table 3.57 further indicates that at both extremes of expectation of income, high or low, there is a higher proportion of urban than rural students. At the high extreme of expectation, twenty-eight per cent of the urban students expected, to be making more than 120,000.00 while none of the urban students expressed this hope.  But more urban students than rural students  expected to earn less than $10,000.00.  If we combine the  last two categories of income level, the .results as Table 3.57 indicates, appear to be a reversal of those of the fall. There is no significant difference in the expected income between rural and urban students.  As can be seen from  Table 3«57 the expected income of urban students in the spring is significantly less than that in the fall, while the expected income of students from rural areas in the spring is significantly greater than that in the fall. It would seem that students from urban areas have more confidence, or e l s e higher requirements of income, than rural students on entry into medical school.  But after they  have studied for a year this expectation seems to depend less on residential background and more on self-evaluation of performance, a process we can crystalize in the phrase "self-confidence."  We found-no difference between urban and rural students in their expected income in ten years after medical school.  It was indicated, however, that the income expecta-  tion at the peak of the career appeared to be considerably different between rural and urban students when they were first asked in the fall, but the difference did not remain the same in the spring. 89 Rosenberg  J  found that the self-confident men are  most optimistic about their economic situation in the future Our data are in accordance with Rosenberg's.  With regard to  the estimation of the income students expected to earn in ten years.after medical school, Table 3.58 indicates that twenty-five per cent of the students with higher.confidence expected to earn over $25,000.00 compared with nine per cent of the less confident students.  On the other hand,  nineteen per cent of the former expected to be earning $10,000.00 to $15,000.00, while thirty-three per cent of the latter had the same expectation. 90 These findings., as Rosenberg indicated,  suggest  that the less confident or insecure student tends to be relatively discouraged about his career before he starts. He is less likely to think that his work will really give him what he wants out of it, and he is less likely to feel that he will make much money at his job.  But when students  were asked again to specify the expected amount of income "at the peak of their career," the different expectations  TABLE 3.30 INCOME EXPECTATION IN TEN IEAES AETEE MEDICAL SCHOOL AND THE DEGEEE OE SELE-E7ALUATION. SEEING  Better than average  Somewhat better than average  Below average*  $10,000 - 15,000  19  33  15,000 - 20,000  56  58  25,000 over  25  9  Total students  16  33  * Owing.to the- small numbers involved we combined these two categories, students with moderate confidence, and with lower confidence for purposes of comparison.  established by our data here are not so striking as those of ten years after graduation.  As can be seen from Table 3*59  there Is no relationship between the direction of increasing income level and that of self-evaluation.  At the two extremes  of the Income expectation we find more students with higher confidence than students with less confidence. This tendency might be explained on the assumption that the phrase "ten years after graduation from medical school" i m p l i e s different degrees of professional maturity, high for those of high confidence, low for those of low confidence, and that "the peak of career" implies a difference in the length of time required to reach the peak.  195 TABLE 3.59 INCOME EXPECTATION AT THE PEAK OP CAREER AND THE DEGREE,OP-SELF-EVALUATION  Better than average  Somewhat better than average  Below average*  115,000 - 20,000  50  39  20,000 - 25,000  25  42  25,000 over  25  16  Total students  16  33  * Owing to tlie small numbers involved we combined these two categories, students with moderate confidence and with lower confidence for purposes of comparison.  196  FOOTNOTES  1  It is reasonable to assume that group members develop through the communicative process, some measure of shared judgments about their abilities which were manifested in the past and likely to be further exhibited in the future. See Rasmussen, G., and Zander, A., "Group Membership and Self-Evaluation," Human -Relations-,  VII, No. 3 (August 1954), pp. 239-251. ~  ~~  2  Festinger,. L., Torrey, J., and Willerman, B., "SelfEvaluation as a Function of Attraction to. the .Group," Human Belations, VII, No. 2 (May 1954), pp. 161-173.  3  Martin, "Preferences for Types of Patients," in Merton, op., cit., pp. 129-206.  4 . Festinger, Torrey, .and; Willerman, op. cit., p. 173» 5. We are not completely sure about the actual difference . between the student's perception of the term, "completely sure,", and of "quite sure." However it is ; possible to assume that those two terms are perceived by students in a different way with regard to the degree of sureness. 6 7  Martin, op. cit., p. 203. However, we feel this category too ambiguous. Nothing can be evaluated without having some reference to compare with. As Festinger put it, "If objective means are not available, then people evaluate their opinions and/or abilities by comparison respectively with the opinion , and abilities of others." See Festinger,. L., "A Theory of Social Comparison Processes," Human Relations, VII, No. 2 (May .1954), pp. 117-140.  8  Gee and Glaser, op. cit., p. 252.  9  Dubln, R.. World of Work, Englewood Cliffs, Prentiee Hall, 1958, p. 216.  10  Ibid.  197  11  More, D., "Some Motives for Entering Dentistry," The American Journal of Sociology. LXVI.Nn. 1 (July I960), pp. 48-53. ' .  12  Brody, I., "The Decision to Study Medicine," Mew England Journal of Medicine. OCLII, No. 4 (January 19551^ pp.. 120-134. ^ ^  13  Cartwright, A., and a Group of Edinburgh Ph.D. Students., The. Career Ambitions and Expectation of Medical Students," The Journal of Medical Education. XXXV. No. 3 (March I960), pp. 251-257.  14  Farnsworth, 33, D.L., "Some Observation on the Attitudes and Motivations of the Harvard Medical School Students," Harvard Medical Alumni Bulletin, (January 1956), PP. 34-36.  15  Schonfield, W,, "Vocational Choice and Career Evaluation," in Gee and Glaser, op. cit., pp. 18-24.  16  Kornhauser, A., and Lazarsfeld, P , E., "The Analyses of Consumer Actions," in Lazarsfeld, P , E., and Rosenberg, M., ed., The Language.of Social Research, Glencoe, Eree Press, 1957, pp. 392-404.  17  Dead, S., "On Classifying Human Values," American Sociological Review, XVI, No. 5 (October 1951 )\ pp.. 645-653.  18  Williams, R. M., American Society, New York, Alfred •Knopf, 1957, p. 375.  19  Rosenberg, op. cit., p„ 2.  20  This classification of occupational values is mainly indebted to Rosenberg. See Ibid., pp. 11-13.  21  Blishen, op. cit., pp. 519-531. For U. S. see ' North, C. E., and Hatt, P. K., "Jobs and Occupation, " Opinion News (September 1947), pp. 3-13.  22  See Dominion Bureau of Statistics, Canada Year Book, I960, p. 1094. For U. S. see, Bureau of Census, 1950, United States Census of Population, Bull, pc-1, Washington, D. C., Government Printing Office, 1953, Table 129, "Detailed Characteristics," pp. 1-279.  23  Schonfield. op. cit., p, 21.  24  Hall, 0. "Types of Medical Career," The American Journal of Sociology, LIV, No. 6 (May 1949), pp. 243-253.  198 25  Winch, D., and More, E., "Does TAT add Information to Interviews, " Journal of Clinical Psychology, XII, No. 4 (October 1956J7 pp. 316-521, and MoreTopT'cit. , p. 48.  26  Sills, D,, "A Sociologist Looks at Motivations," Cohen, N. E., ed., The Citizen•Volunteer. New York, Harper and Brothers, I960, pp. 70-93.  2?  Becker,, H. S., and Carper, J. W., "The Development of Identification with an,Occupation," The American Journal of Sociology, LXI, No. 4 (January 1956), pp. 289-298.  28  Kendall, op. cit., p, 14.  29  Huntington, M. J., "Development of a Professional Self-image," in Merton, op. cit., pp. 179-187.  3°  Ibid., p. 182.  31  Ibid.  32  Ibid., p. 302.  33  Simpson, I. , "Patterns, of Socialization into Professions: The Case of Student Nurses," Draft of a paper presented at the annual meeting of the American Sociological Association, New York, August I960.  34  Mead, G. Hi, Mind, Self, and Society, Chicago, . University of Chicago Press, 1934.  35  Piaget, J., The Moral Judgement of the Child, New York, Harcourt, Brace, 1932, pp. 19-49.  36  Simpson, op. cit., p. 1.  37  Becker and Carper, op. cit.  38  Ginzborg, E., and Others, Occupational Choice, New York, Columbia University Press, 1951, PP« 191-196.  39  Foote, N. N., "Identification as the Basis for a Theory of Motivation." American Sociological Review, XVI, No. 1 (February 1951), pp. 14-22.  40  Hali, 0. "The Stages of the Medical Career," The American Journal of Sociology, LIII,,No. 5 (March 1948), pp. 327337, and Becker, H. S., "Some Contingencies of the Tianns Musician's Career," Human Organization, XII, No. 1 (Spring 1953), PP.. 22-26.  199  41  Foote, op. cit., and Strauss, A., Mirrors and Masks. Glencoe, Free Press, 1959, Chapter 1, pp. 15-30.  42  Becker, ; H. S., and Carper, J., "The Elements of Identification with an Occupation," American Sociological Review, XXI, No* 3 .(June 1956), pp. 341-348.. ~  43  This presentation of the image, however, may he seen as becoming a little dated.•- Recent discussion in the media particularly, with reference to the A.M.A. socialized medicine issue reveals some hostility to the profession and feeling that there is more dedication to the dollar than to the Hippocratic oath.  44  Thielens, W., Jr. , "Some Comparisons of Entrants to Medical and Law School," in Merton, op. cit., pp. 131152.  45  '•Schumacher.., C. P., "The Image of the Physician: A Study of Applicants to Medical School," Draft presented at the I960 Annual Meeting of the American Sociological Association.  46  Christie, R., and Merton, R. K., "Procedure for the Sociological Study of the Value Climate of Medical School," in Gee and Glaser, op. cit., pp. 125-153-  4?  Ibid., pp." 1 3 2 - 1 3 3 .  48  Schumacher, op. cit., p. 3»  49  Ibid.  50  Only three traits Indicate statistically significant difference between the importance both of Pall and Spring at 0.1 level. In fact, this level is not a generally accepted one.  51  The first two traits, however,: do not show statistically significant difference In two scores at .05 level.  52  In this sense, the Cornell Scale or other similar scales (for example, five point- scale) should be reconsidered with regard to their validity.  53  Schumacher, op. cit., p. 5*  54  Parker, S., "Personality Factors among Medical Students Related to their Predisposition to View the Patient as a 'Whole Man'," The Journal of Medical Education, XXXIII, No. 10 (October 1958), pp. 736-744. He says:  ,  200 "It is possible that, as tlie degree of authori— tarianism increases, there is more tendency to regard the.physician as a moral and spiritual guide of his patient. On the other hand, those who score low on authoritarianism may he more prone to think of the doctor-patient relationship itself as a therapeutic instrument that serves to' either facilitate or hinder treatment of the specific moral problem." 55  Schumacher, op. cit., p.- 5.  He finds:  "The applicant (medical) has a stronger need to achieve than the average college student, and he feels that achievement motivation is desirable In the physician. Similarly, he-has higher need to examine his own motives, to help others, and to keep at a job until finished than the college student, and he ranks each of these needs as desirable, in the physician. He feels less willing to obtain help from others or tp behave with regard for the opinions of others than the average college student, and he feels that these characteristics are generally undesirable:in the physician." 56  In personal conversation with Parsons one physicianremarked that in several years of practice only one patient had asked him from what medical school he had graduated. Parsons, op. cit,, p. 442,  57  Huntington, M. J., "Sociology of Professions, 1945-55?" in Zetterberg, H. L.,Y';ed., Sociology in the United States of America, Unesco, 1956? PP» 87-93.  58- Department of National Health and Welfare, Survey of Physicians in Panada, 6th ed., Ottawa, Department of National Health and Welfare, 1955• 59  Graduates of Canadian Medical, Schools now total almost 9OO a year, the number having been:swelled in the spring of 1954 by 54 graduates from the new medical school at U.B.C. Also the number of graduates from both Laval Medical School and from the University of Saskatchewan is increasing.  60  Eriedson, E,, "Specialties without Roots: The Utilization of New Services," Human Organization, XVIII, No. 3 (Summer 1959), PP. 112-116'.  61  Dubin, op. cit., p. 280.  62  In our questionnaire no explicit distinction was made between general (or specialty) practice and research and/or teaching. The basis of the above statement on  201 our data, however, lies in the assumption that the. student is not prepared to imagine himself teaching m .a certain specialty. 63  Naegele, K. D., "Librarians: Observation en Their Work and Their Careers in the Pacific North West," mimeographed, p. 22. :  64  Cahalan, D., Collette, P., and Hilman, N. A., "Career Interests and Expectations of U. S. Medical Students," Journal of Medical Education. XXXII. No. 8 (August 1957)  PP.- 557-563. 65 66  .  Ibid., p. 558-. ; Dominion Bureau of Statistics, Canada Year Book, I960 Ottawa, Dominion Bureau of Statistics, p. 1094. This amount is less than that of the mean gross: income of . all physicians of the United States in 1949 - $14,829. Por detailed discussion of physician's income, see Dickinson, P. G., and Gradley, C. E., "Survey of Physician's Income," Bulletin 84, Bureau of Medical Economic Research, American Medical Association, Chicago American:Medical Association, 1951. Reprinted in Committee on Medical Care Teaching, Readings in Medical Care, Chapel Hill, The University Of North Carolina Press, 195&, pp. 182-191.  67  Cabot, R., Training and Rewards of the Physician, Philadelphia and London, T. B. Lippincott Co., 1918, pp. 133-153.  68  Cartwright and a Group of Edinburgh Ph.D. Students, op. cit., p. 253«  69  Cahalan, Collette, and Hilman, op. cit.  70  Punkenstein, D. H., "Implication of Diversity," in Gee and Glaser, op. cit., p. 43.  71  Cartwright, op. cit.  72  Ibid., p. 253.  73  See the section on Motivation.  202 7  ?°p C e t h e PeoP-Le-oi'ieated" value, as: was indicated before, is strongly stressed by most of the students for both reasons, entering into, and remaining in medical school, this category.will be excluded.  75  Hyman, H., "The Yalue Systems of Different Classes," in Bendix, P., and Lipset, S. M., ed., Class, Status, and Power, A Reader in Social Stratification. Glencoe,. Free Press, 1953, pp.. 426-442.  76  Blishen, op. cit., pp.  77  The results ought to be considered cautiously. The table seems to show an imposing difference in percentage distribution between the two samples. But actual numbers involved are so small that conclusions can hardly be made definitely. To note one instance, 12.5 per cent of the students from medical family indicates only one person. . '  78  Huntington, M. J., "Self-Images and Self-Appraisals of. Medical Students," in Jaco, E., ed., Patients, Physicians and Illness, Glencoe, Free Press, 1958, p. 350.  79  Colter, R. E., Jr., Miller, N., Back, K. B., and Donnelly, D., "The Medical Student, Specialization and General Practice," Draft for presentation before the First General Session of the 105th Annual Session of the Medical Society of the State of North Carolina in Asheville, North Carolina, May 1959 •  80  If we are concerned only with the numerical data, a majority of the least affluent students tend to choose specialty practice. This proportion, however, is relatively small in comparison with the general tendency of the class as a whole i.e. seventy-five per cent for specialty, and twenty-five per cent for general practice.  81  Coker and Associates, op. cit.  82  Ibid.,  519-531.  83. Ibid. 84  Ibid.:  85  Coker and Associates cut off figure for small towns. All B. C. centers fall into the small town category according to them but relatively the distinction still holds. It is interesting to note that the Canada Year Book defines a small town as under 30,000 at 1956 census. See Canada Year Book, I960, p. 4.  203  86  Rogoff, N., "Tlie Decision to Study Medicine," in Merton and Associates, op. cit., p. 177.  87  Hughes, E. C., "The Study of Occupation," in Merton, R. K., Broom, L., and Cottrell, L. S., Jr., ed., Sociology Today, New York, Basic Books, Inc., 1959, pp. 442-458.  88  Reader, G. , "The Development of Professional Attitudes and Capacities," in Gee and Glaser, op. cit., p. 177.  89  Rosenberg, op. cit., p. 39.  90  Ibid.  CHAPTER IY SUMMARY OIL entrance into their chosen career the students* experiences in medical school are varied.  Annoyed with the  great amount of knowledge which they are required to digest in a short time they tend to, think of the first year as the least important one for their, later career.  Besides "being  the least important the first year appears to "be the.most difficult period in medical training.  They also feel pressed  for time;; there seems to "be too much to learn in.the time allowed.  Students, however, expect that, as they go through  medical school, their training will become less difficult. They feel that basically medical school is going to be an enjoyable experience, even though it will mean very hard work at times. The intensive interaction in which they are Involved In medical school and their relative isolation from the outside tend to make medical students establish a closer group among themselves.  Thus they tend to help each other to get  through the difficulties they have in common.  Although they  are in a cooperative relation with each other, they also find themselves involved in competition among themselves for  205 iiigiier status in their academic achievement.  Their attitude  toward this competitive situation is not quite favourable. At best, their perception of competition is that it is an unavoidable aspect of the training process.  This neutral  attitude and an open acceptance of competition among medical students tend to be salient as the first year comes to an end. In their relationship with the faculty, students are more likely to have a greater amount of less formal contact than they had during their undergraduate years. Throughout the year students tend to express satisfaction with,their relations with the faculty members by saying that they are given about the right amount of direction in their studies. Students were not yet in a position in their first year to form any preferential attitude towards patients, the last aspect of their interpersonal relations in medical school.  Nevertheless a gradual formation,of discriminatory  attitudes was observed at the end of the year. In the assessment/of their performance during their training, a majority of the students classify themselves as average.  They further express strong certainty in the  evaluation they have made. at the end of the year.  This tendency became apparent  Students' self-evaluation, however,  does not necessarily coincide with the rank order which results from the two examinations at Christmas and Easter.  W :  '  2 0 6  This distortion apparently Indicates the lack of consensus in the standard of excellence for both types of evaluation. Incidentally, a majority of the students tend to find the reference point, in themselves rather than in their fellow students, or in the opinion of the faculty members. With regard' to the students' attitudes and values our study indicated that throughout the first year they tend to adhere to the initial values which they had on entering medical school, that is, their "people-orientation."  In  addition.to this criterion as a common denominator for the choice of, and the stay in medicine, students also tend to add another "self-expression-orientation."  They seem to  adopt this latter orientation as they progress through the first year, in order to facilitate their continuation in medical school. With regard to the students' image of themselves as doctors, i.e. identification with profession they were not as yet in a position to consider themselves as doctors. No student ever expressed this tendency hoth on entrance and at the end of the year. Their image of the physician possesses two aspects namely desirable attributes, and preferred behaviour.  As  the attributes considered most desirable for the ideal physician the students . include integrity, ability to think in an organized way, and the ability to get along with people.  207 With, regard to tlie preferred "behaviour for the physician they propose the following:  to maintain an air of confidence,  and a restrained and dignified maimer.  The tendency to  •combine these two aspects in their ideal image was maintained with negligible change throughout their first year. Consideration of the question of specialization after their commitment to medicine occupies an important place in the students' thinking.  It is Interesting to note  that at. the beginning of the year most of , the students tend to choose a specialty rather than general practice.  However,  as the year comes to the end they indicate an inclination towards general practice. Finally, with regard to remuneration of physician It is generally agreed among students that the annual net income of the specialist is considerably higher than that of the general practitioner.  These the first year students'  expectations of their future income generally reflect fairly accurately, the present level of physicians' actual income.  They do not expect to attain the peak of their  career within ten years of graduation from medical school. Such achievement, they think, lies farther in the remote future. Tentative attempts to relate the dependent variable to both the independent variable (I) and independent variable (II) make, it, to some extent, apparent that at the  208 completion of the first year, tlie factors of personal background scarcely affect tlie dependent variable whereas independent variable (II) represented by the degree of selfevaluation plays a great role. Suggestion for a Further Research Thus far we have tried to illustrate our paradigm of adult socialization to the extent that our data are available.  And yet we could not fully discuss all the pro-  blems imposed by the paradigm due to the lack of detailed and precise data. Further comprehensive investigations, therefore, should be done in order to provide data for what we failed to discuss in evaluating the effect of each variable during the first year and In ascertaining the relationships between the; three types of variables. This study only serves as a stepping stone by which more Intensive studies may possibly be:developed.  209 APPENDIX A NOTE ON TEST 01 SIGNIFICANCE Since we used a test of significance, a few words should "be said with regard to our application of it.  We have  used such a test only for the following two purposes? (1)  To examine whether there is any significant  difference "between two proportions (percentages). , (2)  To ascertain the relationship between two  variables in a fourfold table. Ghi-square test appeared to be the most.appropriate test.  Appropriate in the sense that It gives criteria by  which we can reasonably accept or reject our assumption as to. the given data. The application of this test was avoided for multifold tables. properly.  The sample is too small for it to be applied  Since we have only fifty subjects, distribution of  the small sample Into more than a fourfold table allows chance factors to be effective.  In addition to the small  size, our sample was not well controlled.  Sometimes a six-  fold table based on two variables has a cell with only one case tried  which  represents more than ten per cent.  Therefore, we  to find the consistent direction (negative or positive)  in the relationship between two variables in the multifold table.  210 INSTRUCTIONS TO MEDICAL STPDENTS Thia questionnaire "ier 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 is to obtain an overall picture of the attitudes held by medical students. There are a few points which you should bear in mind while filling 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 yoejr class will 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 first 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 vou 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  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 (mat field?. Scientific research (mat field?...... Engineering, architecture Law 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 it the most satisfying  4. (a) How important was each of the following in your decision to enter the medical profession? (Answer for each) n • -. ^ • « j . < Fairly Of minor Not at all (l) 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)....  ...... ......  ...... ......  ......  ......  (lO) Other (mat?. (b) Which two of these were of most importance in your decision to become a, doctor? (List the appropriate numbers) #...... and #.......  ......  rrrr 5. Since you made the decision, how much have the following members of your family encouraged you to become a doctor? (Answer for each) StrongSlight Expressed Slight Strong encour* encour™ opposiDoesn't egemgut agement opinion tion tion apply Mother Father Wife or Husband Brother or Sister Other relatives  212  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 all 7. How important has each of the following been in helping you to form a picture of what medical school is like? (Answer for each) Very Fairly Of minor Not at all important important importance important Medical school bulletins Medical students at (your) school Medical students at other schools Members of your family who are doctors lour family physician Other physicians who are friends Medical school faculty College faculty Books, movies, plays (Give titles..  ......  ...... ...... ...... ......  ......  ...... ......  ...... ......  ...... ......  ...... ...... ......  ......  ......  Other (What?  ^Mngs considered, how do you think medical training compares with each of the following kinds of training? Are medical studies more difficult, less difficult, or about the same? (Answer for each) Medical Training Is Much Somewhat more more About Less diffi- difficult the difficult Don't cult than same as than Enow Studying to be a 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 in psychology • • • « • mtmm i M  -15-  213  Si i W h ^ h + ° f J"6 statements comes closest to describing the way Jyou feel about medical school? (Check one) ———• ° ^ ...... Basically, it's going to be a tough, four year grind, but I'll manage to enjoy it somehow  ...... Basically, it's going to be an enjoyable experience, even though it wall mean very hard work at times  10. Do you think that, as you move from the first to the fourth year of medical school, your studies will become more difficult for you, less difficult, or do you think they will 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 first year of medical school? (Answer for each)  Manual dexterity (with instruments, +.ools, machines, etc, )  . Very Fairly important important  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 .  Gf minor importance  Haven't Not at all thought important about it  -15com are|  P  214  appraisal of how well you will do in your first year 3 with the other members of your class? (Check one)  ....... I expect to do considerably better than average 1 expect to do somewhat better than average v V....... I expect to be about average ; I expect to be below average .•"••:;•• Don't know /13. How difficult do you think each of the following will be for you in your first year of medical school? (Answer for each) Yer  y Fairly Not very Not at all Mking: friends in your class difficult- difficult difficult difficult Keeping up with other students !"*"* '"(V J /Learning what is .expected of you ]*]]] ;Adjusting -to.- the sights- and smells ••••• ..... ..... of the anatomy lab leaning 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 first year of medical,school? (Check one) A.great deal A fair amount Only a little Don't know (b) On the whole, do you expect that your contacts with the medical school faculty during your first year will be more formal, less formal, or about the (same as your contacts with your undergraduate professors? (Cheek one) ...... Contacts in medical school vail be more formal ...... They wilj be less formal . i . . .. They will be about the same Don't know  :  15. To what extent do you think the first year medical students help each other? (Check one) ....... They try to help each other a great deal .. ...... They, try to help each other a fair amount ';  ^  ...... They try to help each other only a little  ...... They do not try to help each other at all  16. When would you like to have your first substantial amount of contact with patients? (Check one) . : . . . . I would like to have n§r first substantial contact: in my first year I would like to have it In my second year ...... I would like to have it in my third year I vould like to have it in my fourth year . . . . . . . I would like to have It during my interneship ...... Don't know  -15-  215  17. In which year of training do you expect to have your first substantial amount of contact with patients? (Check one) t>uut,ocmuxax I expect to have ...... I expect to have ...... I expect to have I expect to have ...... I expect to have Don't know  my first substantial contact In my first year it in my second year it in my third year it in my fourth year it during my interneship ..  ,18. Wten^do you expect that you will first come to think of yourself as a . doctor? (Check one) ...... During my first year in medical school During; my second year : r •••••• During my third year " ' ...... During my fourth year \ During ..my .interneship....... During my residency .•;.....,.. Haven't given it any thought 19. What things do you think you will 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 is a highly respected profession Having interesting and intelligent people for colleagues Doing work involving scientific 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) Aprofession which has high standing in the community ..... ..... ..... (2) A profession of service to the community ..... (3) A profession which is secure • and lucrative. ..... ..... ..... (4) A profession which helps individuals directly ..... ..... ..... (5) A profession in wh^'h real ability is recognized by one's colleagues ..... ..... ..... (6) A profession requiring harder work than others ..... ..... "(b). , In your opinion, which one of the above phrases best describes the medical profession? (List the appropriate number)  ' - 7;  216  PART B  :  Medical Students' Experiences and Opinions I. This Section of the questionnaire deals with your experiences in medical :  school and with your feelings about the kind of training a medical student ought to receive. •  li Many medical students seem to feel that they do not always have enough time to do all the things they want to. How do you feel in this respect - do you feel that you have enough time for each of the following activities? (Answer for each)  Ample time t • . Learning all that you are expected to know in medical school Following the latest medical advances in books and journals ..... Spending time with your family and friends Following up your own interests in the field of medicine ..... Reading the newspaper, and : keeping up with current aff airs .....  Just about / enough time  Not quite Not nearly enough . enough time time  .....  ..... ;.....'  .....  .  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 will be most important for your • later career in medicine? (Check one) ...... Fifst two years of medical school ...... Last two years of medical school ....... Interne ship Residency ......" Don't know 3  (b) Which phase of your medical training do you expect to find most difficult? (Check one)  Y  First two years-of medical school ...... Last two years of medical school Interneship Residency Don't know  217  -15-  ^ medical students are given much more factual information 7 aSS t S S ^ f iS t u d.e n t+s e n o u gThi a t e ' ^ general > d 0 you think that the faculty (Check o S ) direction in what to emphasis in their studying? ^sculty gives too little direction Jaculty gives about the right amount of direction i'acuity gives more than enough direction 5. (a) What is your realistic appraisal of how well you are doing in 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  J  (b) How . sure are you about how well you are doing?  (Check one)  Completely sure Quite sure ...... Not sure . (c) Rank the following according to their importance to you in deciding how well you are doing at the present time. (Rank all 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 in your class? (Check one) . Deeply concerned ...... Quite a hit concerned ...... Little concerned . ...... Not at all concerned 7. How do you feel about competing with other people, especially when the stakes are so high? feeling about competitive situations is that (Check one) ... ...... ...... ......  I I I I I  dislike them and prefer to avoid them completely dislike them somewhat have neutral feelings about them enjoy,them somewhat get a kick out of them and sometimes seek them out  8. How much competitiveness have you found among your classmates in medical school? (Check one) ...... A great deal of competitiveness A fair amount of competitiveness ...... Only a little competitiveness ;...... No competitiveness at all  218 -16- . 9 ' there some kinds of sick people to^ whom you feel especially drawn or ;toward whom you feel particularly sympathetic? Yes...... No!!7..  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 C ...... People who are "down and out" i... 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 ^ dravm to a patient? (Check one) ...... I'd try to control these feelings, and regain my sense of objectivity C : • take advantage of these feelings to try to draw the patient closer to' me ...... I wouldn't try to change my feelings at all ...... Other (What?. ... „ ) 10. Ire: 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 feel sorry for themselves ....... People who have physiologically improbably symptoms ...... People who make no real effort to get well ; ...... Other (Which?..,... .)  219 '  '  '  ' -  10  ;  -  section deals with the medical profession in general and with ^ ; /standards of medical care. °PinioiV how important Is each of the following characteristics m making a good physician? (Answer for each) Very Fairly Of minor Not at all 7vs r. important important " importance important (1) Good appearance (2) Warm and pleasing ..... ..... ..... Y personality ..... (3;) Dedication to medicine ^..... !!!!! (4) High intelligence ..... •!!!"•!! (5) Skillful management of time ..... ..... 1 :(6) Scientific curiosity ..... ••••• (7) Integrity L ..... ' (8) Ability to think in an organized way ..... . (9) Research ability ..... ..... '!!•.*.'! (10) Ability to get along with: . people \ ..... (11) Recognition of own limitations ..... ..... ...... ' (12) Getting real enjoyment cut of medicine . ..... ..... ..... In yom-.opinion, which two of these characteristics are most important in 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 • 4!and ....... ' ~ ;12'. How. important is each of the following types of social behavior to the success of a physician? (Answer for each) Very Fairly Not at all important important important To maintain a restrained and dignified manner ...... ..... To wear conservative clothing ..... ..... ..... -To:.participate in 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 is not feeling confident) ..... .....  220  -11 -  13. The various specialties.within the medical profession present different opportunities, and correspond to different sorts of interests and talents among V - C S S : n f ™ y o u r ^ e m n t about the following specialties in the respects listed below? Please indicate to what extent each of the following is a good description of the specialties listed. (If you think the statement is veiT~" appropriate to the specialty, please put a 1 on the corresponding lineT-If you think it is fairly appropriate., please put a 2. If you think it is not very appropriate, please put a 3. If you think it is inappropriate, pleasFptfTM.) (Please put a number for eagh specialty on every statement.) Surgery  Medi- Psycine chiatry  Paediatrics  Ob.Gyh.  General Practice  A field where one can establish his own hours of work A field in which .patients are highly appreciative of what is done for them A field, where diagnostic problems are , especially challenging A field where relationships with col— ; leagues in the same specialty are particularly enjoyable A field which is very likely to yield a good income A field which presents opportunities for knowing patients well A field 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 fall?-" 1 ~ (Check one in each group) Specialist Under 85,000 I 5,000 up to #10,000 $10,000 up to #15,000 |15,000 up to 820,000 $20,000 up to $25,000 #25,000 up to $35,000  General Practitioner .. 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 up to $35,000  221  - 16 - .  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 fair amount ..... Only a little ..... Not at all 16. Which of the. following fields of / 1st choice............. Which of the following; fields of 1st choice.,........... Medicine Surgery , Obstetrics and Gynaecology Paediatrics Pathology Psychiatry Orthopaedics Dermatology Ear, nose and throat Public Health General. Practice ' Research Other (What?  medicine would you least like to enter? 2nd choice. ..77777. medicine would you like to enter? ' 2nd choice .7777...  )  17. If you could arrange it, in vhich 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 affiliation Own professional office without hospital affiliation Large private clinic or hospital Small group clinic Medical school Other (What?..., )  (a) For the student who does exceptionally well in medical school, how would you rank the following five career plans in order of their desirability? (Rank all 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 in medical school  - 16 - .  222  17. (Cont'd) f u / h i n k tto ^culty as a whole would rate these career plans for the student who does exceptionally well? (Rank all 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 • • o • •  ; medical school 18.- What yearly income do you think you might realistically expect (Check one)  •  '  Under #5^000 I 5,000 up to $10,000 ...... 110,000. 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 will you be with the yearly income you think you might realistically expect (c) Ten years after medical school?  (Check one)  Very satisfied ...... Fairly satisfied Dissatisfied (d) At the peak of your career?  (Check one)  Very satisfied Fairly satisfied Dissatisfied 19. To 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 fair amount Only a little Not at all  223  - 14 -  you. (Answer for each) Occasionally  Regularly Reading medical journals ..... Reading medical textbooks ..... Attending local medical society meetings ..... Supplementing your practice with research activities ..... Teaching full-time in a medical school Teaching part-time in a medical .school Serving in ah out-patient clinic..... Taking post-graduate and summer , "specialty courses ..... Examination of publications of pharmaceutical houses ..... By contacts with consultants on your cases .....  Never  Unsure  !".'.'.!  .....  ... .  .....  J  . ..... .....  .....  .....  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 in each column)  Having the opportunity to know your patients well Being ablfe 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 will appreciate your efforts Having prestige within the medical profession I?  Most important  Least important ..... .....  ..... ..... .....  ..... ..... .....  .....  .....  This final section deals with your background and your interests. The information you provide here will permit a comparison of the opinions, plans, and experiences of students with different kinds of backgrounds.  22. Exact Date of Birth: Month 25. Sexj  Male,........  Day........ Year..  Female..........  .  24. Marital status: .....Single Married Engaged .....Divorced, separated, widowed If engaged: When do you plan to marry?  ,  224  - 15 25. If married:  (a) How long have you been married?  ...... Years  (b). How many children do you have? ..... ... 26  ' • (check°oneT9 ^  ^  ^  that  not be  happy in a medical career?  A great deal Somewhat Only a little Not at all 27.  How difficult is it for you to finance your medical education? (Check one) .. .. . Very difficult ..... Fairly difficult ' ..... Not very difficult . . Not at all difficult  28.  J  (For students who depend on parents for some or all of their support) How do your parents feel about having you depend on them for financial aid while you are in medical school? (Check one) ..... They are not happy about it They are willing, although it is difficult for them ..... They are willing to do it • They are very glad to do it : ..... Other (What?.. ......)  29. How much have you worried about the problems of supporting yourself (and your family): (Check one) (a) While you are in medical school? 1 • •A great deal Quite a bit Not very much Not at all (b) During your interneship? ..... ..... ..... .....  ,  (Check one)  A great deal Quite a bit Not very much Not at all  (c) During your residency? (Check one) ..... A great deal Quite a bit .....Not very much Not at all ..... Do not plan to take residency (d) During your early years in practice? ..... A great deal ..... Quite a bit ..... Not very much ..... Not at all  (Check one)  - 16 -  225  .  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 all . H1 "FULL-TIME" or "PART-TIME": Is this work related to medicine?  Yes........  No........  Will 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?, ...,,..v.... ........) :  ....)  33. What is your father's occupation? (If retired or deceased, list 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 field did you major as an undergraduate?  (b) If,you had it to do over again in what would you major in undergraduate college?  226  -17 37. Do you have any relatives who are in any of the followLng professions? .T Wo  Parents  Siblings  M.D.' s? Lawyers? Dentists? Clergymen? Teachers? Nurses? Engineers? Other professionals? (What?... )  Name; . . . . .  .• . First t  Surname  Other relatives  BIBLIOGRAPHY Adorno, T. ¥>, Frenkel-Brunswik, E., Levinson, D. T., and Sanford, R. ft. The Authoritarian Personality. New York, Harper and Brothers, 1950. Asch, S. E . , Block, H., and Hertzman, .,M. "Studies In the Principles of Judgements and Attitudes: I - Two Basic Principles of Judgement." Journal of Psychology, 5, 1938, pp. 219-251. Ashford, M., ed. Trends in Medical Education. Few York. The Commonwealth Fund, 194-9. Becker, H. S., and Geer, B. "Student Culture in Medical School."-Harvard Educational Review, XXVIII, No. 1 (Winter 1958), pp. 70-80. Becker, H. S., and Carper, J. "The Elements of Identification with an Occupation." American Sociological Review, XXI, No. 3 -(June 1956), pp. 341-348. Becker, H. S. "Some Contingencies of the Professional Dance Musician's Career." Human Organization, XII, No. 1 (Spring 1953)? pp. 22-26. Becker, H. 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"Value-orientation of Medical Students and Faculty Members." Paper delivered at the American Sociological Society, Washington, D. C., August, 1957. Carper, James W,, and Becker, Howard S. "Adjustments to Conflicting Expectations in the Development of Identification with an Occupation." Social Forces. 36,  No. 5 (October 1957), pp. 51-56,.  ~  '  Cartwright, A., and A Group of Edinburgh Ph.D. Students. The Career Ambitions and Expectation of Medical Students." The Journal.of Medical Education. XXXV, No. 3 (March I960), pp. 251-257. ! Coker, R. E. Jr., Miller,, N., Back, X. B., and Donnelly, D. The Medical Student, Specialization and General Practice." Draft for Presentation before the First General Session of the 105th Annual Session of the Medical Society of the State of North Carolina in Asheville, North Carolina, May, 1959. Coker, R. E., and Back, E. "Patterns of Influence: Medical School Faculty Members and the Values and the Specialty Interests of Medical Students." The Journal of Medical Education, XXXV, No. 6 (June I960;, pp. 518-527. " Committee on Medical Care Teaching. Readings in Medical Care. Chapel Hill, The University of North Carolina Press, 1958. Cooley, 0. H. Social Process. New York, 1918. Department of National Health and Welfare. Survey of Physicians in Canada, 6th ed. Research and Statistics Division (April 1955). Deutsche M. "Effects of Cooperation and Competition upon Group Process," in Cartwright, D., and Zander, A. Group Dynamics, Evanston, Row, Peterson and Company, 1956, pp. 70-80. Dodd, S. "On Classifying Human Values." American Sociological  Review, XVI, No. 5 (October 195'1), pp. 645-653*'  229 .  ' ^ e c t i v e s of Medical Education." N o . 3 (March  Dominion Bureau of Statistics. Canada Tear Book TQfiO.  Ottawa, Dominion Bureau, of Statistics, I960.  —  World of_¥ork. Englewood Cliffs, Prentice-Hall,  Er0n  I + i r 4 . U ? f f e ^ t ® o f Medical Education on Medical Students' Attitudes. 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