Outstanding in their field: distinguishing medicalschoolsSteve Trumble

Clinical teachers labouring at thecoalface of medical education willbe well aware that there are power-ful cultural forces at work thatshape their behaviour and that oftheir students.1 Newcomers to aclinical setting are quickly accul-turated to ‘the way we do thingshere’, both clinically and educa-tionally. Even a clinical teacher’swillingness to teach something asbasic as communication skills canbe influenced by his or her institu-tion’s prevailing culture.2

Like hospitals, medical schools aresubstantial institutions that developand perpetuate their own distinc-tive cultures. These cultures per-vade the learning environmentwithin which students learn muchof their professionalism.3,4 In fact,this ‘ecology of professionalism’5

resembles a fragile ecosystem that isripe for study.

Medical schools develop and perpetuatedistinctive cultures that pervade the

learning environment

The author of the paper ‘Makingsense of differences between med-ical schools through Bourdieu’sconcept of ‘‘field’’ ’,6 published in

this issue of Medical Education, hasapplied sociological scrutiny to themedical school ecosystem. As anygood sociologist should, CaraghBrosnan has cast around for aconcept that explains behaviour inone field of human activity andtried it for fit in her area of interest.In this case, that area refers to theinstitutional context of medicaleducation and how medical schoolsgo about distinguishing themselvesfrom one another.

Brosnan’s paper6 is based aroundthe theories of Pierre Bourdieu, aFrench sociologist and anthropolo-gist who exerted considerableinfluence throughout the secondhalf of the 20th century.7 His the-ories were successfully applied to adiverse range of topics, includingart, literature, social customs, aes-thetic taste and even the impact oftelevision,8–11 although he appearsto have had a special interest in therole of higher education in rein-forcing class distinctions.12 Threeof his major instruments fordescribing social life – practice,habitus and field – look in turn atwhat individuals do in their dailylife, how they deport themselveswhen doing it, and where theychoose to do it.13 The paper in thisissue of Medical Education focuseson this latter aspect.

Bourdieu’s concept of ‘field’describes the arena within whichmedical schools battle for capital.To use a sporting metaphor thatalludes neatly to Bourdieu’s days asa rugby player,14 we might ask: onwhich particular fields do medicalschools play their game? Central toBourdieu’s theory is the struggle to

acquire ‘capital’, which refers tomuch more than just money. Manythings can be construed as capitalby medical schools, ranging fromthe financial achievement engen-dered by successful research grantapplications through to peer rec-ognition of the school as the mostprestigious in the land. Success inacquiring this capital depends tosome extent on how well preparedfor the game individual players arewhen they enter the field. Thegame is rarely played on the pro-verbial ‘level playing field’ andsome players will gain repeatedadvantages because of their ‘habi-tus’. Thus, the rich become richerand the strong become stronger.

Central to Bourdieu’s theory is thestruggle to acquire ‘capital’, which refers

to much more than just money

The preceding paragraphs summa-rise Bourdieu’s work in a facileand expedient manner, rather likepresenting the manifold wisdoms ofSir William Osler in the singlesentence: ‘He listened to hispatients.’ Bourdieu’s thinking (andthat of the scholars who have sinceinterpreted him) is vastly morecomplex than presented here, andyet the author of the paper6 underreview manages to extract just thecore concepts to support her thesis.Clinical teachers who read thepaper will experience the sense ofrecognition that is the hallmark ofeffectively applied sociology: thesense that the author hasaccurately, clearly and conciselydescribed the medical schools inwhich we work.

Editor in chief, The clinical TeacherMelbourne, Victoria, Australia

Correspondence: Steve Trumble, MedicalEducation Unit, Melbourne Medical School,University of Melbourne, Melbourne,Victoria 3010, Australia.Tel: 00 61 3 8344 8049;Fax: 00 61 3 8344 0188;E-mail: s.trumble@unimelb.edu.au

doi: 10.1111/j.1365-2923.2010.03728.x

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640 ª Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 640–642

This is by no means the first paperto use Bourdieu’s theoreticalframework to describe medicalprofessionals and the educationthat shapes them,1,15 but Brosnan6

contends that it is the first to usethis framework to study the differ-ences between medical schools. Shedenounces the tendency ofresearchers to look no further thantheir own schools when measuringthe outcomes of medical educationrather than facing up to the chal-lenge of making meaningful com-parisons between schools and therespective ways in which they goabout fulfilling their missions – if,indeed, these medical schools everreally articulate what their missionsare. Although the websites of med-ical schools usually include a state-ment that expresses the purpose ofthe school, these statements aregenerally so anodyne as to muffleany distinction between them. Inthese days of a globalised medicalworkforce and intense competitionfor international fee-paying stu-dents, medical schools should beextremely interested in how theycan distinguish themselves from thepack.

Clinical teachers will experience the senseof recognition that is the hallmark of

effectively applied sociology

The main part of Brosnan’s paper6

applies Bourdieu’s concept of fieldto medical schools in the UK anddraws attention to how variousmedical schools have each devel-oped their own distinctive habitusin order to attract the type ofcapital they most desire. Giventhat the employability of medicalgraduates varies little betweeninstitutions, three particular formsof capital are identified: theacademic; the economic, and thesymbolic. These distinctionsshould come as no surprise toclinical teachers, who will recog-

nise their own varying levels ofattraction to each of these formsof capital. Do we teach because ofthe intellectual challenge, thefinancial reward or the statusassociated with being a respectedteacher? It’s certainly not thesecond.

Brosnan6 dichotomises the Britishschools into those that select stu-dents with desirable interpersonalattributes into integrated, inquiry-based programmes with early clini-cal contact, versus those that havemaintained selection processes andcurricula that value academic abilityover any other aspect. Using theschools’ rankings in The Times‘Good University Guide’ as a mar-ker of success in the field, she thenmakes the interesting observationthat four of the five top-rankedmedical schools in the UK havestrongly science-oriented curriculaand are the only ones to use theadmissions test most associated withexisting science knowledge, theBiomedical Admissions Test, ratherthan the more commonly used UKClinical Aptitude Test, which con-tains no mathematics or sciencecontent. It is not clear whetherthese schools’ lofty position is thecause or effect of their scienceorientation, but it is clear that –once there – these schools are wellplaced to secure their ranking yearafter year by continuing to attractthe most capital. Bourdieu nodoubt would have approved of theAustralian Football League’s strat-egy to promote competition bygiving the last-ranked team the firstpick of new players the followingyear. Not so for medical schools, inwhich success reproduces success aslong as the capital accrued by theschool retains its value.

Do we teach for the intellectual challenge,the financial reward or the status

associated with being a respected teacher?

There must come a point at which amedical school’s capital is devaluedbecause of changing expectationsor needs. If medical schools aredelivering a desired product (suchas newly qualified doctors orsignificant research findings), theywill be valued by their ‘customers’,be they governments, communitiesor individuals. If the factors that areheld in high esteem by a schoolbegin to drift from what matters toits stakeholders, then surely thatschool must become less successfulin its field. As Brosnan states: ‘...theresources for which UK medicalschools currently compete mayhave less value at another time-point or in another geographiclocation.’6

Bourdieu’s theories as describedby Brosnan6 make a lot of sense inthe Australian context. In the faceof a significant medical workforceshortage, the Australian govern-ment has effectively doubled thenumber of medical schools acrossthe continent after a 30-year hia-tus.16 These new schools (and therural clinical schools added toexisting ones) have been given amuch clearer mission to produce aprimary medical workforce thanhad been previously expressed bygovernment.17,18

Australian medical schools there-fore have found themselves choos-ing between two distinct fields: theacademic and the vocational. Whatcounts as capital in the academicarena (such as the selection andfurther development of stellaracademic performers, gaining ahigh ranking on internationalindices, and winning competitiveresearch grants) has little value inthe vocational field in which thepreparation and retention of thebest-suited health professionals forthe region is the main game.Like British schools, Australianmedical schools are confronting

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ª Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 640–642 641

the ‘bipolar’ differentiationreferred to in Brosnan’s paper.6

What counts as capital in the academicarena has little value in the vocational

field

Brosnan6 quotes informants fromtwo UK medical schools, of whichone is long established and stronglyscience-oriented and the other isrecently established and moreadherent to the General MedicalCouncil’s curricular guidelines.19

The ‘academic’ versus ‘vocational’dichotomy is clearly demonstratedby staff and students at the twoschools. Students quickly assumethe habitus of their medicalschool,20 with a degree of resigna-tion as they recognise that theirschool will place them in the fieldof graduating doctors wherever itshabitus decrees.

There are three main messages forclinical teachers in this paper.6

Firstly, medical schools place dif-ferent values on capital; this helpsto distinguish them within theirfield. Clinical teachers should con-sider how comfortably theirschool’s habitus fits with their own.Secondly, medical schools tend tobe deeply entrenched within theirfield by the self-perpetuating nat-ure of success and so curriculumreform is exceptionally difficultwhen it devalues the capital that has‘bought’ the school its position.Finally, clinical teachers need toinfluence their medical school tovalue the sort of capital that keeps

the player with the greatest meritdominating the field.

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