Handbook of the Sociology of Medical Education

Caragh Brosnan, Bryan S. Turner, Caragh Brosnan, Bryan S. Turner

• Editorial: Routledge
• Año: 2009
• ISBN:
  9781134045259
• Edición: 1
• Categoría: Education
• Categoría: Education General

The Handbook of the Sociology of Medical Education provides a contemporary introduction to this classic area of sociology by examining the social origin and implications of the epistemological, organizational and demographic challenges facing medical education in the twenty-first century.

Beginning with reflections on the historical and theoretical foundations of the sociology of medical education, the collection then focuses on current issues affecting medical students, the profession and the faculty, before exploring medical education in different national contexts.

Leading sociologists analyze: the intersection of medical education and social structures such as gender, ethnicity and disability; the effect of changes in medical practice, such as the emergence of evidence-based medicine, on medical education; and the ongoing debates surrounding the form and content of medical curricula. By examining applied problems within a framework which draws from social theorists such as Pierre Bourdieu, this new collection suggests future directions for the sociological study of medical education and for medical education itself.

1 Introduction

The struggle over medical knowledge

Caragh Brosnan and Bryan S. Turner

Why a sociology of medical education?

Embodied in the training of any profession are the profession’s ideals about itself and its relations to the public. Answers to such questions as what work is worthwhile, which patients or clients are ‘crocks’ or ‘duds’, what treatment procedures are the best or worst, and how should professional work be organized are contained implicitly or explicitly in the training program.

(Light 1980: x)

From the first emergence of medical sociology in the 1950s, medical education enjoyed a central place on its research agenda (Hafferty 2000: 239), beginning with the publication of Robert Merton et al.’s (1957) The Student-Physician: introductory studies in the sociology of medical education. The sociology of medical education had emerged, Merton explained, owing to a number of developments within medical education itself: the need to incorporate the expansion of scientific knowledge within limited curricular time; the renewed focus on treating ‘the patient as a person’ and the sense that sociology, though not well understood within the medical profession, could play a role in developing this aspect of practice; the development of systematic research into medical education; and innovations in medical curricula. Simultaneously, sociology was beginning to focus on the professions, organizations and adult socialization processes, and was developing social-scientific research methods (Merton et al. 1957). The Student-Physician aimed to showcase some early work applying sociological methods to the study of medical education.

Howard Becker and his colleagues (1961) quickly followed Merton’s team with their publication of Boys in White: student culture in medical school, which offered a critical interpretation of medical-student socialization to counter Merton’s more conservative approach, and a lively theoretical and methodological debate between the two perspectives ensued. However, despite an auspicious beginning, in which for example Merton and colleagues were invited to address the Association of American Medical Colleges (AAMC) (Hafferty 2000: 239), the sociology of medical education has remained marginal to the discipline as a whole, managing neither to influence medical education significantly, nor to keep up with theoretical developments in the broader field of sociology. Hafferty (2007) notes that, ‘What once helped to legitimate an emerging academic field (medical sociology) in the 1950s and 1960s has fallen on hard conceptual and analytic times.’

Meanwhile, the social factors which for Merton demanded the creation of a sociology of medical education 50 years ago have each continued to be salient: medical education continues to struggle to keep up with advances in scientific knowledge while at the same time trying to focus on ‘the patient as a person’; consequently, medical curricula are in a continual process of transformation and reform. Medical sociology continues to focus on professions and organizational change, among other areas. In addition, since 1957, enormous changes have taken place in the wider society to healthcare and the medical profession, and to higher education. Each of these changes has had an impact on medical education, indicating its continuing relevance as an area of sociological enquiry.

While sociology has neglected medical education as a specific topic of research, medical education has emerged as a distinct discipline in its own right since the late twentieth century with its own journals, international conferences and professorial chairs. Medical schools often now employ dedicated medical education researchers, some of whom are social scientists. This development raises the question as to whether a sociology of medical education is actually required at all. There is certainly a considerable amount of overlap between sociology and medical-education studies. However, the strongest analytical focus of such educational studies is on questions surrounding the cognitive processes of learning and the effectiveness of specific educational techniques, with psychometric testing and surveys of medical students being the predominant research methods (although qualitative approaches are increasingly used) (Dimitroff and Davis 1996). Sociology, on the other hand, is orientated critically to consider the full spectrum of social processes shaping medical education, from student socialization to global health-policy changes, and draws from a wide range of theories and methods. Medical educationalists lament the fact that medical-education research tends towards repetition and opportunism (with the vast majority of studies being conducted within the researchers’ own institutions) and lacks theoretical grounding, being directed towards users rather than to an academic audience (Albert et al. 2007; Schuwirth and van der Vleuten 2006). Furthermore, medicine’s philosophical bias towards objectivity is carried through to research on medical education, which favours positivist models and often lacks critical reflexivity (Albert et al. 2007; Cribb and Bignold 1999). This is not to say that existing medical-education research cannot contribute towards a sociology of medical education, but that, without a more developed sociology of this area, many important issues will not be fully analysed and the field as a whole will not be developed in terms of a sophisticated theoretical framework.

A sociological approach can help to strengthen medical-education studies which aim to improve medical education; at the same time, medical education warrants sociological analysis for what it can tell us about society. Medical education can be seen as a crucible in which many of the questions central to soci-ology come to the foreground, involving as it does the socialization of professional groups, the interaction of institutions such as universities, hospitals, the medical profession and the state, the collaboration of different disciplinary groups, the production of knowledge and the construction of professional values. Important sociological work on medical education has in fact been conducted over the last few decades, but it has largely appeared as isolated journal articles or book chapters, rather than in a coherent collection, with the exception in 1988 of a special issue of the Journal of Health and Social Behavior (Colombotos 1988) which is still widely cited today. In fact, there have been no full-length research monographs providing an overview of the topic since the initial contribution of Merton and his colleagues in 1957. The studies published since have usually been based on ethnographic inquiries carried out in single medical schools—for example, Atkinson (1981), Becker et al. (1961), Hafferty (1991), Sinclair (1997)—which, while often examples of good sociology, have been too disparate to advance a clearly identifiable and coherent sociology of medical education. The Handbook of the Sociology of Medical Education aims to reintroduce the field, to demonstrate the distinctiveness of a sociological approach to the study of medical education, to provide an overview of key issues, both classical and contemporary, and to suggest future directions for the sociology of medical education and for medical education itself.

The remainder of this introduction considers the main areas of change since the establishment of a sociology of medical education, examining in turn, first, the need for new theoretical perspectives in the sociology of medical education; second, changes in health, healthcare and the medical profession; and finally, struggles over knowledge in medical curricula.

The need for new theoretical perspectives in the sociology of medical education

The first section of the Handbook presents three contributions to the conceptual analysis of medical education as a social process. Although the sociology of medical education was forged within one of the key debates in twentieth-century social theory—between structural functionalism (drawn on in The Student-Physician) and symbolic interactionism (developed in Boys in White)—it has remained somewhat disconnected from subsequent theoretical developments in sociology.

Functionalism tends to emphasize the importance of stability, asking how various social structures contribute to or function in relation to the maintenance of the whole. As a result, it is seen to presuppose somewhat conservative assumptions. By contrast, interaction looks at how social actors create and construct meaning and order in their everyday lives, and how these meanings constantly change and evolve. It is seen to be a more critical approach than functionalism. When in the 1970s medical sociology turned to a much more critical analysis of macro-level structures in healthcare and the inequalities these perpetuate, Renée Fox (1979: 97) lamented that sociologists had begun to emphasize the significance of medical practice and the constraints under which physicians work, de-emphasizing the ‘anticipatory socialization’ of the medical school years. Freidson’s (1970 and 1972) influential work on the professional dominance of medicine fuelled this trend (Fox 1979), because his work concentrated on the structural organization of medical practice, rather than on medical training, as the key factor in determining physician behaviour. With the exception of a small body of feminist work on medical training around human reproduction (Davis-Floyd 1987; Kapsalis 2001; Scully 1980), the few studies of medical education since the 1970s have tended to defer to Merton et al. and Becker et al., while the influence of political economy, post-structuralism and postmodernism has largely bypassed the sociology of medical education. This lack of theoretical development has led to and been perpetuated by a narrow empirical focus, with most studies continuing to centre on student socialization. The consequence has been to limit sociology’s ability to unpack contemporary problems in medical education, many of which go well beyond the level of the individual student and involve the whole distribution of power in modern societies.

Chapters 2, 3 and 4 in the Handbook attempt to move beyond this impasse, each outlining a different theory of medical education. Fred Hafferty and Brian Castellani (Chapter 2) outline the origins of the theory of the ‘hidden curriculum’—one of the most widely used concepts in medical education and the sociology of medical education. This concept refers to the notion that the formal and official curriculum is not the only way in which the student’s education is shaped, because there is also an unofficial, hidden curriculum which moulds students’ values. The authors critically examine how the concept has been used in medical education and develop a model for mapping the relationship of the hidden curriculum to other concepts in sociology. Both they and Heidi Lempp (Chapter 5) also discuss the utility of Erving Goffman’s concepts of the ‘presentation of self’ and his dramaturgical perspective on social life in analysing medical-student socialization. In Chapter 3, Paul Atkinson and Sara Delamont argue for the application of sociologist of education Basil Bernstein’s curricular codes to medical education. Taking the United Kingdom General Medical Council’s curricular guidance, Tomorrow’s Doctors (1993 and 2003), as their focus, they explain how the shifts in medical curricula which this document has attempted to instigate can helpfully be interpreted in Bernstein’s terms.

Caragh Brosnan (Chapter 4) discusses how the division between structure and agency in studies of medical education may be overcome by following Pierre Bourdieu’s mandate to ‘think relationally’ about individual practices and institutional politics. She suggests that Bourdieu’s concepts of habitus and field, when applied together, point to the co-production of medical students’ problematic attitudes towards practice and institutional challenges to curriculum reform. Bourdieu’s influential theory of education, class and the reproduction of society, which implicates cultural practices in the perpetuation of power relations, is drawn on as a guiding framework in the Handbook. Bourdieu’s work has been the major influence on our conceptualization of the medical curriculum as the site of struggles between the medical profession, the state, the public, medical schools, medical students and various academic disciplines. Throughout this collection, medical education is essentially viewed as a competition to legitimate various forms of individual, institutional, professional and political investments which Bourdieu calls ‘capital’. In analysing what is at stake in this competition, each chapter considers both medical-educational practices and broader social shifts, and the relationships between them, offering a uniquely sociological perspective on medical education.

Much greater theoretical engagement with mainstream sociology is needed in the sociology of medical education, but these chapters may serve as a springboard for further work.

Changes in health, healthcare and the medical profession

Since Merton’s identification of medical education as an important subject, there have been significant changes in the West to the types of illness medical students can expect to encounter, to the composition of professionals involved in healthcare and to the status of the medical profession. Epidemiological transitions, requiring new forms of healthcare, challenge biomedical dominance and create uncertainties in medical knowledge. In particular there have been major demographic changes in the population which have made chronic illness a more significant challenge for medical practice. Professional medicine, driven by high technology, has traditionally ignored these geriatric diseases which are difficult to treat and largely impossible to cure in favour of acute disease. Hence these prevalent but incurable diseases do not appear prominently if at all in the medical curriculum. Similarly disability—increasingly prevalent as the population ages, but affecting people at all stages of the life course—is not something medical students have traditionally been well prepared to deal with. To change this situation, Gary Albrecht (Chapter 7) argues that disabled people must comprise an integral part of the social networks of medical students, in the roles of fellow student, doctor, patient, administrator and so on. He believes that greater incorporation of disability into medical education will not only enable better healthcare for the disabled, but will help to engender holistic perspectives, a team approach and a focus on broad-based patient outcomes among the medical profession.

People suffering from chronic illness and/or disability often turn now to complementary and alternative medicine (CAM). CAM is occasionally in competition with allopathic practice and challenges the traditional medical model in which the patient is treated in isolation from his or her social and cultural environment. Medical practice based on the traditional medical model also tends to be invasive. While the needs of the elderly, the chronically sick and the disabled may be better served by CAM, it has not been fully accepted into medical education. Alex Broom and Jon Adams (Chapter 8) demonstrate that sociology is important in understanding the place of CAM in medical education, and that sociology can simultaneously be used to provide medical students with a critical perspective on the relationship between CAM and biomedicine. Their chapter includes specific recommendations for teaching about CAM in medical curricula.

There are other important changes that have a direct bearing on the context and character of medical education. There has been a significant growth in the number of medical students entering medical faculties in recent decades amid fears of doctor shortages. Another significant change is the feminization of medical education, with women now constituting the majority of medical students in many western countries, and therefore it is clearly time to reanalyse an area of sociology whose most-cited work is ironically called Boys in White. In her chapter, Elianne Riska considers the history and implications of increasing female enrolment, how gendered medical knowledge is currently represented in medical education, and the relationship between trainee career choices and gender imbalances both across specialties and across the hierarchy of the profession. A further change has been that the intake into medical schools is more ethnically...