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Medical Education and Sociology of Medical Habitus Its Not About The Stethoscope! All Chapters Included

The book 'Medical Education and Sociology of Medical Habitus' by Haida Luke explores the cultural and social dynamics that shape junior doctors during their early professional development. It employs Pierre Bourdieu's concept of habitus to analyze how medical culture influences the identities and practices of new doctors in their first two years of training. The work emphasizes the need for a deeper understanding of these cultural forces to improve the transition from medical student to practicing physician.
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100% found this document useful (13 votes)
167 views17 pages

Medical Education and Sociology of Medical Habitus Its Not About The Stethoscope! All Chapters Included

The book 'Medical Education and Sociology of Medical Habitus' by Haida Luke explores the cultural and social dynamics that shape junior doctors during their early professional development. It employs Pierre Bourdieu's concept of habitus to analyze how medical culture influences the identities and practices of new doctors in their first two years of training. The work emphasizes the need for a deeper understanding of these cultural forces to improve the transition from medical student to practicing physician.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Medical Education and Sociology of Medical Habitus Its not

about the Stethoscope!

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Medical Education and
Sociology of Medical Habitus:
"It's not about the Stethoscope!"

by

Haida Luke
Graduate School of Education,
The University of Queensland,
Brisbane, Australia

KLUWER ACADEMIC PUBLISHERS


NEW YORK, BOSTON, DORDRECHT, LONDON, MOSCOW
eBook ISBN: 0-306-48093-X
Print ISBN: 1-4020-1238-1

©2003 Kluwer Academic Publishers


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mechanical, recording, or otherwise, without written consent from the Publisher

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PAUL, AILISH & CIAN
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TABLE OF CONTENTS

PREFACE ix

ACKNOWLEDGEMENTS xi

INTRODUCTION xiii

CHAPTER 1 Examining Medicine with New Lenses 1


Postgraduate medicine: Junior doctors 3
Production and construction: The culture of medicine 16
Why use the concept of habitus in medicine? 21
Entering medical culture: Qualitative inquiry in the medical field 22

CHAPTER 2 Theoretical Dissection of Medicine: Practice 43


Socialising medical sociology 44
Bourdieu’s theory of practice: Capital, field and habitus 53
What you are worth: Capital 56
Struggle for power: Field 59
Habitus 61

CHAPTER 3 Putting It All Together: The Culture of Junior Doctors 71


How to play the game: The postgraduate training programs 72
Catering to the senior doctors 79
Ultimate responsibility: Medical hierarchy 91
Ward rounds: Performing medical practice 103
Reflections on the first two years as a doctor 109
Ward Round Video Scenes 111

CHAPTER 4 Medical Habitus 125


Becoming somebody: Growing up a junior doctor 138
Capital(s) and field in postgraduate medicine 140
Integrating dispositions: Habitus 143
Cultural knowledge and the direction of habitus 147

CHAPTER 5 Future of Medical Habitus: Medical Identity 149


Concluding remarks 155

APPENDICES 159

REFERENCES 165

INDEX 177
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PREFACE

It is 7 a.m., second week in January, I walk into a room full of 50 noticeably


nervous, and fresh faced first-day interns. Yesterday they were graduated medical
students with their Bachelors of Medicine and Surgery - today they are ‘doctors’ and
will be for the rest of their lives. In this hospital for the next year, as conditionally
registered doctors by the State Medical Board, they will be under careful supervision
and guidance by the senior doctors. They will be enrolled in a junior doctor training
program. The next twelve to twenty-four months will be a time of significant
professional and personal change for them.
It is now 1:00 p.m., and I walk into a room of several junior house officers
(JHOs) who could get away from their ward duties for a non-compulsory medical
seminar. The changes that many of the JHOs (which refers to the second year of
medical training after the first year of internship) have gone through in the previous
twelve months will parallel what the interns from the morning will go through as
well. I have seen at least 150 interns start their first year in this hospital and now
several years later they have progressed to registrars and are studying to be specialist
consultants.
What is it, then, that doctors encounter in their graduate and postgraduate
training that shapes them in particular ways as identifiable medical professionals?
How is medical culture perpetuated and imbued in these human subjects? How do
they shape themselves in relation to the many overt and unwritten (and indeed
unspoken) demands and expectations of becoming a doctor? For my own purposes
importantly, what set of analytic tools enable such an investigation of such a
complex institutional phenomenon? A phenomenon that is not accessible as
evidential research data, evidence or culture in any hospital policy guidelines,
university calendar, or rulebook. These questions guide the research I report in this
book.
Traditional research on early medical professional development has focussed on
medical students, but usually it stops there. Working from a sociological framework
with a focus on medical practice, this book examines the link between the first two
years of medical practice and future professional life as a doctor. Early professional
socialisation (or development) is seen as a fundamental process for the doctor,
medical culture and health care of patients. What this volume describes and
analyses are a range of cultural forces that impinge on the development for doctors
learning about being a ‘doctor’ and how to survive in the medical system. Central to
this analysis is Pierre Bourdieu’s sociological framework and his concept of habitus.
My aim here is to highlight and describe the complex and interwoven processes of
internalising a particular medical habitus, to document structures and discourses that
junior doctors (the first two postgraduate years are referred to as junior doctors)
enter when they finish medical school. This is just the first step in their professional
development.
Research has tended to generalise and universalise findings about medical
students into claims about their professional lives as doctors. There are also studies
ix
x PREFACE

of doctors’ attitudes, beliefs and practices as mature professionals. This book looks
at the interface between initial training and career. This book is based on research
that is an in-depth exploration of the experiences of Australian intern and Junior
House Officers during their first two years of professional development. Here I
want to challenge many of the myths of the medical cultural experiences and
‘socialising’ forces that are an integral part of early medical training. Bourdieu’s
theory of habitus is reconceptualised and applied to a domain of inquiry outside
traditional sociological areas of interest such as family, social class or education.
This volume is a theoretical and qualitative exploration of the concept of habitus as
related to the professional development process of junior doctors.
The evidence here suggests that the weight of the medical culture and the
unconscious and structuring habitus developed through institutional and
medical/professional practices and ‘codes of conduct’, are mutually reinforcing in
the ‘construction’ and shaping of a particular kind of medical professional: the
junior doctor. The sociological research on interns’ and junior house officers’
(junior doctors’) medical training primarily using sociological concepts to analyse
the medical culture has indeed been lacking. Here I analyse the cultural
developmental experiences of junior doctors to see how professional cultural change
in junior doctors accounts for change across the first two years of their early hospital
work. There are qualitative interviews at two distinct training points: the entry
point, at the first weeks of internship and second year and at the exit point (after
twelve months) of the medical training years. I also describe how through an
analysis of videotaped medical and surgical ward rounds much of the video themes
complement that of the interviews.
I suggest that as part of the professional development process, junior doctors are
learning to become ‘social doctors’ as opposed to ‘clinical doctors’ through the
training experiences within the medical culture. In these pages we read about and
are drawn into the world of doctors we know as patients, colleagues, friends,
admired professionals and relatives.
ACKNOWLEDGMENTS

Doctor: I feel comfortable answering these questions to anyone. Basically, once you
are in surgery, no one can touch you.

Interviewer: Why would someone in surgery not want to answer this question?

Doctor: Well, because you imagine, if you ask someone from surgery these questions,
the first person might be their consultant and that guy has the power to crush someone’s
career.

Beginning of second year, male JHO

Early medical graduates’ commitment to medicine that early medical graduates have
and the tumultuous path they are about to embark upon, defines what it means to
being a junior doctor. This in part, motivated me to bring out their voices and the
stories of the junior doctors here in this book. I thank the junior doctors in particular
and their supervisors for allowing me unrestricted access through interviews and
video of their daily medical practices.
This work was originally conducted under the facilitative supervision of
Professor Robert Lingard and Associate Professor Charles Mitchell at The
University of Queensland, Brisbane, Australia. A University of Queensland
Graduate School Research Award in part supported the research reported here.
I appreciate the support and continuing friendship of Paul Martin who has
listened to and shared with me the passion for research. You have provided your
useful translation of the qualitative and interpretive habitus into the positivist
discipline of medicine. We continue to share and foster an excitement for each
other, life, family and work on a daily basis.
I also express my appreciation to you Ailish, for your laughter, sense of
enthusiasm and sharing with me your love of life. Cian, I am grateful to see your
smiles, share in your happiness and you are a pleasure to be with. Thanks to you
three for sharing, appreciating and helping me with the demands of being a partner,
working mother and reminding me how to balance the load of paid and unpaid work,
parenthood and personhood. The times with my children and partner continue to be
an honour and pleasure.
To Jennifer Celotto thank you for the last 17 years of friendship through so many
varied challenges of life and womanhood. Thank you to Simone Bannan for much
advice and stable friendship. Also to our Abyssinian cat who is appreciated for
being a steady study Buddy. Thank you to Allan and Carmen whose analogy of the
‘little train’ has stood with me as I pursue academics in line with the history of our
family tree.
My thanks also go to Kluwer for valuing this work and in particular Esther de
Jong, I appreciate your availability, time and patience with the final stages of the
manuscript preparation.

xi
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INTRODUCTION

Medical culture teaches doctors ways of negotiating their identities within the
medical hierarchy and structure. This is theorised throughout these chapters as the
construction of what I here term the ‘medical habitus’. The concept of medical
habitus suggests that junior doctors are learning more about and how to navigate
within medical culture through their professional development than previously
thought. This book develops the concept of medical habitus, through observation
and documentation of which is developed in the ‘hothouse’ effect in the first years
of junior doctor practice in a hospital. The argument here is that this knowledge
should be incorporated into an explicit professionally orientated program of teaching
to ease the transitions of medical interns to their work as fully registered medical
practitioners. At the same time, however, it is recognised that the experiences of
junior doctors reflect the powerful hierarchies of the medical field, and as such, they
will be difficult to challenge and change, as the following chapters will demonstrate.

Chapter Structures
I begin with a conceptual starting point in the first chapter “Examining medicine
with new lenses” which discusses previous research that examines medicine in terms
of professional socialisation. Much of this work leads us to examine medicine from
a sociological perspective in terms of professions and professional development.
Literature is reviewed on psychological and physical stress, workplace training,
coping, medical educational issues such as improving training and understanding
junior doctor development. In considering the role of doctors, it is necessary to look
succinctly at how traditional sociology conceptualised the social. Chapter one also
explains my methodological strategy and incorporates how knowledge of the
medical culture was central to entering the field of inquiry which, in turn, developed
strategies of access to data. I conclude by proposing a sociological case study,
describing the process of a sociological case study with description of the hospital
research site, wards and doctors. Through the description of study procedures I
explain how my own standpoint and knowledge of the medical culture allowed me
particular access.
In chapter two, “Theoretical dissection of medicine: Practice” I investigate
traditional sociological perspectives, and more relevant work in sociology
specifically focused on the fields of medicine and medical education. For instance,
the work of Nicholas Fox (1994b) on surgical practice and ward rounds is used to
focus on reproduction of values and behaviours within graduate medical training.
This analysis enables the identification of structural hierarchies of the medical
profession. Much of Fox’s work suggests that modernist sociology places human
beings in the centre stage as constructors of the social. It is with this grounding in
traditional, modernist medical sociological literature, that we turn to explore
potential explanations by pursuing a sociological theory of practice, drawing upon
the work of Pierre Bourdieu. In this second chapter, we examine Pierre Bourdieu’s

xiii
xiv INTRODUCTION

theory and three main concepts: capital, field and habitus. This chapter maps how
the habitus constructs the social, which, in turn, provides us with the theoretical and
conceptual framework for the fieldwork from which to begin my methodological
endeavours. Bourdieu has given significant validity to sociological analysis of
culture through habitus as a systematic and structuring phenomenon that organises
and surrounds social actors. By this account, therefore, it is the suggestion
following Bourdieu that the habitus is the means by which a particular way of
‘being’ is produced, enacted and negotiated in interactions between social structure,
and action within practice.
In chapter three, “Putting it all together: Culture of junior doctors”, much of the
doctor’s voices from the interviews are discussed following along the line of five
principal fundamental themes derived from the data. The categories were themes
and concepts generated by the data. Devising categories is largely an intuitive
process, but it is also systematic, informed by the study’s purpose, theoretical
orientation and knowledge, and the particular meanings were made explicit by the
participants themselves. The main themes I describe are: issues surrounding the
training program, the doctor mould, medical hierarchy (consultants and registrars),
medical culture (cynicism, ward rounds, paperwork, stress, critical incidents,
patients and women in medicine); and finally reflections on the junior doctor years.
This leads us to chapter four, “Medical habitus”, where we theorise and discuss
medical habitus in the context of junior doctors. Also provided is an analytical
discussion of the data and normative application of medical habitus in the medical
field. As this volume is a description of a qualitative study of junior doctors’
professional development, we find that the use of the Bourdieuian concept of habitus
useful and the previous assumptions about junior doctors extended. Here I describe
and analyse how doctors’ personal characteristics and ways of behaving are
influenced by the medical culture through the hospital as an institution of certain
(medical) practices and cultural outcomes. In chapter five, “Future of medical
habitus: Medical identity”, I conclude with a more normative commentary provided
for reflection, outlining future directions for research and for rebuilding medical
cultures and the habitus itself.
CHAPTER 1

EXAMINING MEDICINE WITH NEW LENSES

I want to say ‘I’ve got a position in society, I can actually do something’. So you spend
6 years thinking ‘I want to he there’, and when you finally get out, you think, ‘oh I’m a
somebody, I’m a somebody’. And you come to a place like this and you’re the bottom
rung of the ladder again, and you’re s t i l l a nobody.

Beginning of second year, male JHO.

This chapter introduces the volume through a discussion of the significance of this
study in relation to existing research in medical sociology. The impetus for this
study, with the author’s own location and personal testimony of entry and access to
the field are discussed, as well as particular methodological issues in conducting
sociological research in a medical field are detailed. In particular, I flag the
significance of the research, in particular, utilisation of the theory of Bourdieu and
the concept of ‘medical habitus’. Junior doctors’ own voices are used throughout to
provide evidence to establish in support of the unique institutional culture as well as
to foreground issues in gaining access to the field.
So we ask ourselves: why scrutinise medical culture? If the popularity of
television medical portrayals of hospital culture, such as ER, is any indication – the
public is fascinated by medical culture, its mythologies and stereotypes. The concept
of medical culture is today no longer an exclusively academic term but is widely
used to refer to the unwritten rules of conduct, personal dispositions and attitudes,
and normative ways of doing things within the medical profession. In recent years,
media scrutiny of the insider culture among medical professionals has brought the
notion of medical culture out of the narrow purview of academic research and into
the mainstream. Newspapers report on the closed ranks mentality of professional
accreditation bodies, on the medical holidays financed by multinational
pharmaceutical companies, on social class exclusivity and snobbery, and so on. The
notion of culture applied to professions has a long history in educational studies
where school culture, pupil cultures and teacher cultures have been the objects of
study since the late 1950s, early 1960s. Similar work has been undertaken on the
legal profession, also a focus of media and fictional portrayal. Academic
investigation of medical culture also dates back to the 1950s located principally in
field of the sociology of medicine.

1
2 CHAPTER 1

My own professional and personal history has given me years of access and
insights into medical culture. I therefore approach the task at hand with both have
formal analytic lenses and more informal personal experience lenses, which together
have shaped the conceptualisation and analysis of this research. I have engaged with
experienced doctors, nurses, hospitals as a child, as an adult and as a parent. Like
the universal experience of schooling, we all share these generic medical
experiences since few of us in the urban societies of the North and West, like the
universal experience of schooling, go through life without a formal medical
encounter. I have also experienced medical culture as a hospital-based psychologist
and medical educator, employee, friend and as a partner to a training and practicing
doctor. My take on the profession is therefore is multifaceted and informed by.
literally, in-sights from a range of formal and informal vantage points. What my
professional and personal experience, alongside my intellectual position located with
critical sociology of medicine, has taught me is that there are no simple questions to
ask. Nor are there simple analytic templates with which to identify, theorise, and
explain the dense complexity of how subjects develop in the medical culture, how it
sustains and reproduces itself, and how those values and norms become embodied
and enacted in subsequent generations of people on their way to becoming doctors.
Analytic scrutiny of junior doctors’ (interns and JHOs) medical professional
development is an essential problem for sociological inquiry. When I began
working as a medical education officer (MEO), I began to examine and document
the environment I was privy to. I was originally curious about the forces and
dynamics that transforms interns into junior doctors, and what social and cultural
elements shape their experiences of the medical profession. Much of my general
understanding of professional development had been derived from observing my
colleagues and personal friends in many different fields from accounting, finance,
academe, social work and in psychology. I began to hear the difficulties faced by
junior doctors and my location as an author is based on much of this field
experience.
There is such a lack of focus in the research on the actual professional and
cultural experiences of junior doctors. In particular, much of the work looks at the
day-to-day practical and clinical coping aspects of their jobs or focuses on
professional studentships at medical school. Further, examination of postgraduate
medical training has been undertaken from a context of the positivist scientific
perspective. No research has been conducted specifically on the first two years of
post university or college medical training using sociological concepts of culture.
My aim here then is to address and fill a knowledge gap in ‘cultural’ studies of
medical professional development by using sociological theory to interpret and
understand the professional and cultural change of junior doctors.
The first years of on the job medical training are filled with new workplace and
medical activities. Many of the clinical components for junior doctors serve as
ground work for learning how to deal with patients and illness, yet there are more
social and cultural demands which are not met in the four to six years of medical
school. Junior doctors undergo intense working weeks up of up to sixty hours and
thus encounter a lot of stress and disillusionment towards the ‘system’. The anxiety
and cynicism that develop as a result of ‘being thrown in the deep end’ affect their
EXAMINING MEDICINE WITH NEW LENSES 3

feelings about themselves as professionals, friends and partners. Professional


burnout and the desire to leave medicine are common responses which can be
attributed to a range of medical, social and cultural dimensions of junior doctor
training. Through investigation of junior doctors’ interpretations of their training,
understandings of the problems and issues, we can begin to identify strategies for
improvement in specific aspects of their formal and informal professional
development, adaptation and workplace training. There is a problem with junior
doctors being thrust into the hospital culture after four to six years of protected
student life. The methods and data in this study that are provided here offer useful
insights into these problems. It could conceivably, which serve as a template for
developing strategies for change to assist in medical student transition from
undergraduate to professional doctor.
The impetus for this research begins with a using a non-positivist (medical)
sociological theory to focus on social and cultural dynamics characteristics. This
way we can conceptualise how the demands of the job and the medical culture
inculcate junior doctors into the medical culture. The professional and personal
experiences and social dynamics of the medical workplace are underestimated as
having particular influence on how junior doctors develop professionally and
become doctors. Later in Chapter two, the cultural theory of practice developed by
French theorist Pierre Bourdieu is used to examine medical habit as a disposition. In
line with what Luckman (1989) suggests, the texture of everyday life experiences
and the meanings people give to those experiences are best documented and
understood through analysis of peoples’ interpretations of their own lives. The
process of professional development is critical to understanding how change occurs
through the many-levelled and complex experiences of junior doctors.

POSTGRADUATE MEDICINE: JUNIOR DOCTORS


Existing research on junior doctors focuses and begins with the practical issues of
defining the junior doctor, what junior doctors do and what are some of the key
professional issues that they face. The following review of applied research is
essential because the subculture of junior doctor medicine within the larger
environment of medicine is unique when compared to other training levels of
doctors. This is a fundamental transition time with unique markers, characteristics
and experiences that contribute significantly to the professional development
process and experiences of junior doctor work.
The first year of practicing medicine after medical school is generally called the
internship. After the guided environment of undergraduate medical school for six
years or postgraduate four years, the first two years of medical practice after
university graduation are basic years for professional and personal development of
the junior medical practitioner. The technology in medicine is changing at a very
rapid rate, and what follows is the need to prepare doctors for the changes that will
be required of them for the future. In Australian medical institutions, the job title
‘intern’ refers to the first year after medical school graduation. Here a conditionally
registered doctor practices medicine under the supervision of other fully registered
4 CHAPTER 1

doctors that are more senior. According to the Australian Medical Workforce
Advisory Committee (1996, p. 7), this very important training period is:
principally based on inservice training across a range of supervised hospital posts to
provide a broad range of experience and training. It should provide continuing
opportunities for the acquisition of further knowledge, skills and attitudes leading to
registration for clinical practice.

Therefore, postgraduate training takes place in hospital-based settings, and formal


temporal and curricular sequences formats and in hospital-based settings that all
doctors must complete at their earliest stage of medical training. Historically in
wartime, hospitals recruited medical students to complete the duties of junior
residents (Fagan, Curry, & Gallagher, 1998). Pre-war residency training was seen as
a natural extension of the medical internship initiation experience (Thomas, 1983).
Today, the process of training to become a doctor still focuses on clinical training
aspects, which encompass clinical and social aspects of development in becoming a
lifelong doctor. These early training and clinical years lay the important foundation
for medical experiences that guide and will provide the basis for further
specialisation in medicine. As internship is the first point of professional entry into
medicine as a doctor, it is also like many entry-level jobs, most likely to be a site for
what is referred to today in North American terms ‘scut work’ or Australian terms
‘being the dog’s body’. That is, the tasks that define an entry-level job may entail:
paper work, clean up, aspects that other seniors do not do or want to do and
generally the least desirable or enjoyable aspects to the job.
In the second year of medical practice in public hospitals, doctors in Australia
are referred to as JHOs (junior house officers). This is the first year of fully
registered medical practice. Other states in Australia use terms such as residents,
house officers or post-graduate year two (PGY2). JHOs practice with more
independence, begin to study for specialty exams, have short-term practice
experience in isolated rural communities (often without obstetric, gynaecology,
anaesthetics or paediatric experience) and continue their metropolitan generalist
hospital training. Senior house officers (SHOs) are defined as doctors in the third
year of training in the hospital and work as generalist hospital doctors. This third
year of medical practice is often characterised by doctors’ preparation for specialty
exams, continuation of country relieving practice or awaiting specialist training
program vacancies. Junior doctors refers to interns and second year doctors, that is,
those doctors who have just graduated medical school and are in the first two years
of medical practice. So as we try to grasp at what is junior doctor development, let
us look at residency.
Training for a medical or surgical specialty is an important part “of a general
professional education and is a basis for responding to patients’ needs” (Pritchard,
1998, p. 33). In previous research, personal experiences of interns in internal
medicine at a major urban teaching hospital were examined in terms of the ideology
of the medical service, unofficial language of interns and residents, and the
hospital’s rituals for marking status elevation (Groopman, 1987). The stability and
perpetuation of internship is suggested as being an institutional form of training for
medicine. The loss of identity where junior staff learn that they are a ‘dogs body’, a

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