The study of medical education as a process of professional socialization is at best a dormant and at worse a dying object of academic inquiry. What once helped to legitimate an emerging academic field (medical sociology) in the 1950s and 1960s has since fallen on hard conceptual and analytic times. Today, cutting edge work on socialization appears not in sociology journals (where many of the earlier studies were published), but in journals such as Academy of Management Journal, Administrative Science Quarterly, and the Journal of Organizational Behavior. Within sociology, current work on socialization appears in subfields such as political sociology, the sociology of family (including parenting, child, adolescent, and spousal roles), mass media, and organizational sociology. Even when we restrict our focus to the “medicine,” studies of training and socialization are more apt to highlight other professions (or ”quasi professions”) such as nursing, pharmacy, dentistry, physical therapy, mortuary science, and athletic training.
Legacy
Forty years ago, the two most frequently cited studies on medical student training and socialization were Robert Merton and colleagues’ The Student Physician (1957) and Howard Becker and colleagues’ Boys in White (1961). The same is true today – a glaring commentary on the current paucity of well-designed and comprehensive research in this field.
Both the Merton and Becker studies were large scale and well-funded efforts to study the normative impact of undergraduate medical education. What sometimes is overlooked is that both were less about medical school training than they were opportunities to advance competing theoretical perspectives. The Merton team operated from a structural functional perspective, while Becker and company approached their study from a symbolic interactionist perspective.
Neither Becker nor Merton would return to the study of medical education in any substantive way, and while neither study provided the hoped for empirical knockout punch, both studies played a highly important role in advancing the subfield of medical sociology, along with the study of socialization (at least for a while), primarily in the field of nursing.
The legacy of these studies is multifaceted. Prior to the 1950s, the prevailing view of medical education was grounded in a ”traits” perspective (Bloom 1989). Medical school admissions committees selected students who possessed ”good” traits for a medical professional career and screened out students with ”bad” traits. In turn, the education process would transmit the requisite knowledge and skills. ”Core” personality traits were seen as fixed, unalterable by medical education. At best, students might internalize, via physician role models, what might be termed ”clinical refinements.” Important work on adult (”secondary”) traits was still a decade into the future (Brim & Wheeler 1966). State of the times work on socialization is illustrated by Parsons and Platt (1970), who studied the wide spread unrest taking place during the late 1960s on college campuses (including the particulars of student demonstrations at Harvard College, of which this author was a participant) and concluded that they had identified a new (and ”important”) type of socialization: ”studenty.” Merton and Becker, in comparison, represented a bolt of lightning across a field primarily lit by fireflies.
The flurry ignited by Becker and Merton would be short lived. In 1970, Eliot Freidson published his groundbreaking ”Profession of Medicine” and ”Professional Dominance.” Freidson argued, among a great many other things, that the current work environment was more predictive of work attitudes and efforts than prior socialization – and the sociological study of medicine began to shift from a more micro focus on professionalism and identity transformation to a more macro focus on organizational dynamics and structural change. Articles on medical school training continued to be published, but with a focus on student attitude change and the relationship of personality traits to specialty choice. The age of large scale investigations of education on identity and professionalism appeared to be over.
Nursing, reflecting a concern with its own professional status, continued to direct energies to the study of socialization and the internalization of a professional identity. Over time, however, even this commitment began to fade, finding some final respite within British sociology and studies of British medical and nursing training.
Definitions and Dimensions
The theoretical clashes between the Merton and Becker studies and the subsequent preference of sociologists for a symbolic interactionist approach to the study of medical student socialization notwithstanding, socialization is a process (sometimes involving rituals, ceremonies, and/or rights of passage) by which initiates/ neophytes/”outsiders” acquire or internalize the norms (and normative behaviors), value systems (and related rationales supporting that value system), skills, and language (e.g., the culture) of a desired society, organization, or group. More colloquially, socialization involves ”learning the ropes” or the ”rules of the game.” A commonly used metaphor, particularly within organization studies, is socialization as the ”glue” that links the individual to social groups, as those groups wrestle with the dual problems of adapting to external forces and internal differentiation (Schein 1968). These definitional framings highlight (but do not exhaust) a number of important distinctions with respect to socialization. Specifically, socialization (1) involves the transmission of knowledge, skills, and values, with values sometimes assuming primacy; (2) involves the transmission of group or organizational ”culture;” and (3) is (for some theoretical orientations) a special form of learning that involves internalization and identity formation.
Evolving Frameworks
Currently, medicine is being intersected by a number of social movements, all of which have implications for the way medicine is practiced -and with the potential for impact on medical student socialization. The three most prominent movements are professionalism, patient safety, and evidence based medicine (EBM).
Beginning in the mid-1980s, and driven by fears that medicine’s ”identity” and ”soul” were being corrupted by the advent of managed care and the rise of ”corporate medicine,” organized medicine began to ”rediscover” its professional core. A variety of medical groups, led by the American Board of Internal Medicine, the Accreditation Council of Graduate Medical Education, and the Association of American Medical Colleges, began to establish ”core competencies” for medical students and residents, including ”professionalism.” Other groups (e.g., National Board of Medical Examiners) and private organizations (e.g., Arnold P. Gold Foundation) began to underwrite efforts to establish valid and reliable measures of professionalism. All of these (and related) efforts have direct implications for professional socialization, since there is still the issue of whether organized medicine will approach professional ism as something to be internalized (e.g., as a ”core professional value”) or as a ”surface” attribute. Such distinctions will have a fundamental impact on how medical education is structured and delivered.
Similarly, issues of patient safety and EBM can be approached at the level of ”knowledge” and/or ”skill,” or as an issue of ”professional identity” and thus as something that would be grounded in socialization rather than ”teaching.” Organized medicine insists that it seeks change at the level of identity, but it remains to be seen whether the education and assessment processes will be structured to reflect this claim or whether things will play out at the level of social rhetoric – and thus outside the realm of socialization.
References:
- Becker, H., Geer, B., Hughes, E., & Strauss, A. (1961) Boys in White: Student Culture in Medical School. University of Chicago Press, Chicago.
- Bloom, S. (1989) The Medical School as a Social Organization: The Sources of Resistance to Change. Medical Education 23: 228-41.
- Brim, Jr., O. & Wheeler, S. (1966) Socialization After Childhood: Two Essays. Wiley, New York.
- Hafferty, F. & Franks, R. (1994) The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education. Academic Medicine 69: 861-71.
- Merton, R., Reeder, L., & Kendall, P. (1957) The Student Physician: Introductory Studies in the Sociology of Medical Education. Harvard University Press, Cambridge, MA.
- Parsons, T. & Platt, G. (1970) Age, Social Structure, and Socialization in Higher Education. Sociology of Education 43: 1-37.
- Schein, E. (1968) Organizational Socialization and the Profession of Management. Industrial Management Review 9: 1-15.
- Wear, D. & Castellani, B. (2000) The Development of Professionalism: Curriculum Matters. Academic Medicine 75: 602-11.
