Date of Award

5-12-2024

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Social Science

Advisor(s)

Gretchen Purser

Keywords

Ethnography;Inequality;Medical Education;Qualitative Methods;Social Determinants of Health;Social Reproduction

Abstract

Social factors are the primary drivers of health inequity in the United States, and medical education has agreed that trainees should develop the skills to acknowledge and address them. However, there is evidence that medical trainees remain underprepared to address the social drivers of health in practice, despite curricular innovations dedicated to this aim. This dissertation is comprised of three papers based on a year-long hybrid ethnography of third- year medical students in the United States. Utilizing participant observation, observant participation, semi-structured interviews, and focus groups, I explore how medical students come to understand their role in addressing the social drivers that shape their learning environment and clinical practice. Chapter 1 describes the role of the word “interesting” in the medical student habitus. In this study, medical students identify “interesting” as laden with symbolic capital but also deploy it in different ways than their superiors. I find the medical students “perform interested” to climb the ladder of medical education but also extensively use the word “interesting” to capture the morally fraught and oppressive social conditions that shape their learning environment. These findings provide novel insights into the paucity of extra-clinical language in medical education which becomes a form of symbolic violence. Moreso, the study strengthens the calls for the development of a language of structure in medical education to meet the academic medicine’s aim to train physicians that both acknowledge and address the social and structural drivers of health. Chapter 2 describes “don’t rock the boat” as a guiding principle for medical students in this study. I engage the medical education literature around professional identity formation and offer an analytical turn towards social reproduction and find that students utilize practices like not reporting problematic behaviors in their learning environment to avoid “ruffling feathers,” to secure good evaluations from their preceptors. I also describe how the students acknowledge they are playing the “game” of medical education and articulate that speaking up against the status quo is inherently unsafe for medical students. The medical students communicate their regrets about this, but despite their best intentions, they resign themselves to the game. Therefore, I argue the framework of social reproduction reveals the professed professional value of social justice in medicine is incompatible with the professional dispositions of passivity and individuality inculcated within medical school. Chapter 3 describes the emergence of organic participatory action research by medical students within this ethnographic research project. Moreover, I describe the process by which medical students fed me “good data” throughout the year. I also highlight how medical students discredit their observations through a process of structural gaslighting. Therefore, I conclude with a call for ethnographies of medical education to intentionally incorporate participatory action research principles to empower medical students with the skills and tools necessary to examine their learning environment and socialization process to become active contributors to health justice. Together, I argue for a move beyond the classic debate of a sociology of medicine or a sociology in medicine towards a sociology by medicine. I conclude this dissertation with future steps for medical education to address the current misalignment of its learning environment with its professed value of social justice. I call for larger studies in varied medical school contexts to improve generalizability of the reported findings. Immediately, I urge medical education to meaningfully incorporate an extra-clinical language of structure through interdisciplinary social science curricular content. Yet, I maintain that learning a new language does not go far enough: participatory action research and community-engaged learning are two interventions where medical students can practice the work of addressing the social determinants of health. Moreover, I implicate the imbalance of power embedded in medical education as a health equity issue, extending it beyond a learning environment issue. Interdisciplinary collaborations and collective action are critical to flattening the hierarchy within medical education to transform the field from one than prevents physician trainees from addressing the social determinants of health to one that promotes active engagement in social justice efforts.

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