3 Medical education in its societal context
Constructivism Constructivism is a theory of knowledge (epistemology) whose philosophical roots can be traced back to Kant and whose psychological assumptions can be traced back to Piaget. It holds that the reality humans perceive is constructed by their social, historical, and individual contexts such that there can be no absolute shared truth. In an educational context, constructivism can be seen as a process whereby learners actively construct understandings based on their perceptions, previous experiences, and knowledge of the world. They assimilate new ideas and information by linking them to existing ideas and information. That is in contrast to a view of learning as having knowledge transmitted by a teacher. Constructivism is not a specific pedagogy, but it underlies many approaches to learning today. In small groups, those include ascertaining prior knowledge, challenging misconceptions, promoting active learning, and encouraging learners to take responsibility for their learning.
Critical theory A theoretical framework that assumes an oppressive relation between the powerful and the powerless; critical theorists try to use their explanations of oppression to eliminate current inequities of power.
Discourse analysis A methodology that analyses language to understand its role in constructing the social world. Critical discourse analysis focuses on the macro-level features of oral and written texts in their social contexts (as opposed to ‘linguistic discourse analysis’, which includes the micro-level analysis of grammatical features).
Normalisation A process by which ways of thinking, statements of truth, roles for individuals to play, hierarchies, processes or institutions that are socially constructed and historically contingent come to appear obvious and immutable.
Social construct An organised perception of reality that is created, shared, and modified over time by the members of a social group.
Medical education takes place in socially constructed institutions. What medical education is and the role it plays in a society are specific to the historical period and socio-cultural place in which it arises. Social science theories can be used to explore how particular modes of medical education are constructed, examine unexplored assumptions about their nature and function, and make visible implications and adverse effects of the way they have come to be. Examining medical education through this lens makes it possible to (re)construct, consciously and proactively, what medical education is and what it does vis-à-vis the societies in which particular educational institutions are located. While Chapter 2 introduced a variety of perspectives on individual learners, their learning, and the contexts in which they learn, this chapter brings a wider view to bear on the interaction between those learning contexts (specifically, institutions) and the societies within which they reside. We begin by introducing how a social scientist might view medical education, revisiting the notion introduced in Chapter 2 that reality is ‘constructed’. We then turn to a brief exploration of five different theoretical perspectives, showing how each might be used to frame questions in medical education practice and research. They are a Foucauldian discourse perspective, a Bourdieuvian perspective on education as symbolic capital, a neo-Marxist perspective, the perspective of a combined (feminist and anti-racist) equity agenda, and finally a post-colonial perspective. While those five approaches represent just a small subset of many schools, traditions, and perspectives in the rich domain of social sciences, they can together help a novice reader appreciate how a slight change of perspective can shift practice and research questions and data collection appreciably. Following that overview, we consider some implications of bringing social science perspectives to bear on medical education. We finish with some key sources for people wanting to pursue further study of the concepts we introduce.
Every medical educator has an idea in his or her own mind about what medical education should be. That idea is mediated by many things – for example, the individual’s positive and negative experiences of particular institutions, their knowledge of pedagogy and curriculum design, and their own academic training. It is also mediated by larger forces: membership of a particular society, as part of a particular cultural group, at a particular point in history. Those small- and large-scale influences come together to inform a unique perspective on medical education.
The educators who run medical schools, post-graduate training programmes, continuing education courses, and national medical education organisations are each individually subject to these contexts and contingencies, which lead them to construct their ideas about, and ideals for, medical education. Collectively they create the idea of medical education. They decide what it should be and what it should do; they operationalise those decisions as actions, institutions, and statements of ‘truth’. This shared construction of the idea of medical education may not be explicit, but it is a necessary precondition for working together towards a common goal.
The implicit, social construction of medical education leaves many preconceptions and preconditions unspoken. In North America, for example, nobody needs to say that basic sciences are important to medical education, that doctors should have good communication skills, or that health professionals should collaborate in teams. However, since such preconceptions are the product of individuals and, even more powerfully, of their socio-historical situations, they are not ‘truths’, nor are they unalterable. Indeed, they may not be as self-evident on close examination as they initially seemed.
Before going any further, it is useful to explore more fully this notion of medical education as a ‘construction’ by addressing more broadly the definition of a ‘social construct’. As we have written elsewhere, and as has been considered in Chapter 2, constructivism is a ‘belief about knowledge (epistemology) that asserts that the reality we perceive is constructed by our social, historical, and individual contexts, and so there can be no absolute shared truth’ (Kuper et al, 2008). Each of the resultant organised perceptions of reality is called a ‘construct’; when such constructs are created, shared, and modified over time by the members of a social group, they are called ‘social constructs’. Examples of social constructs include not only medical schools and other training programmes but also such deceptively obvious terms as professions (and professionals), classrooms, hospitals, and universities. Perhaps the broadest implication of the idea that knowledge, processes, and objects are social constructions is that it may be possible (though sometimes very difficult) to change them if we do not like the way they are constructed. Thus, far from being ivory tower concepts debated by armchair theorists at great remove from ‘real’ clinical and educational settings, social constructivist theories are very useful ways to analyse the nature of medical schools and the roles people play within them, in the service of imagining and enacting anything from a minor change to a radical reform. It may be difficult to conceive of our everyday roles, processes, and institutions as social constructions because they have become so familiar in their current form that we cannot imagine any other. Re-examining our situation from the perspective of a different historical time or a different cultural context is an effective way of rendering strange that which is familiar in order to see it anew.
One of the easiest ways to bring into focus the impact of the social on the construction of a practice or of an institution is to look at its history. It is helpful, then, to examine medical education in its historical context. In North America, at least, it is impossible to think about this history without considering the impact of Abraham Flexner. Today North American medical educators almost uncritically accept that the Flexnerian model of undergraduate medical education – scientifically based, with years in the classroom and years on the wards, conducted within a research-intensive university – is the only way in which medical education could be constructed. This model has become ‘normalised’ to such an extent that scant attention is paid to its constructed nature. But of course, like everyone else who has written about medical education before and since, Flexner was a product of his time. In his case this was early twentieth-century North America, a time and place in which faith that science would bring about unabated progress was combined with admiration for traditional European models of medical education.
Flexner’s reforms have since become ‘the’ canonical view of medical education in North America, where Flexner is seen as the founder of ‘modern medical education’. However, his reforms were necessarily rooted in the society in which he had been educated and in his personal experiences within that society. Any claim on behalf of these reforms to neutrality (by appealing, perhaps, to ‘academic standards’ or ‘medical necessity’) must therefore be suspect, by virtue of their social construction. Indeed, seen through the lens of early twenty-first-century equity politics, some of Flexner’s ideas seem quite reactionary, particularly when one considers both their intended and unintended consequences. Yet, like all who came before and those who came after him, he was trying to create a system of medical education that fitted his ideal of medical education as constructed in that place and at that time (Hodges, 2005).
It might come as a surprise that the Flexner report, much lauded as an heroic accomplishment in a maturing scientific profession, is framed by some contemporary authors as an oppressive and discriminatory turning point that led to the closure of medical schools for Blacks and women, groups who would not achieve admission to medical schools again in significant numbers until several decades later (Strong-Boag, 1981). Other authors have argued that the Flexner reforms marked the beginning of the economic conflation of medical education with corporate capitalism, a shift that has subsequently led to ethical problems like the conflicted relations between physicians and the pharmaceutical industry (Brown, 1979). The Flexnerian reforms provide a clearly delineated example of the construction of particular medical education institutions (in this case medical schools) as products of the society and historical period in which they arose.
Just as taking an historical perspective helps illustrate the constructed nature of current practices, so too does examining institutions, processes, and roles from the vantage point of other cultures. A few simple examples illustrate that what is taken for granted, or even framed as ‘universal’ about medical education, in one place is actually strange or unimaginable in another (Hodges et al, 2009). For example, Scandinavian countries have a cultural value called ‘Jantelov’ (loosely, the idea of not considering oneself to be too important) that renders the idea of competitive examinations inappropriate. So Scandinavian countries have very few exams. Japan, meanwhile, has a strong value of respect for elders that renders student evaluation of teachers inappropriate. Finally, Germany has traditionally held that the purpose of medical education was to develop in-depth scientific knowledge so, until very recently, there was no clinical skills teaching during the first 6 years of medical school. Contrast these observations with the taken for granted nature of rigorous examinations, frequent teacher evaluations, and early clinical training in North American medical schools and it quickly becomes apparent that ‘global’ concepts of medical education or ‘universal’ standards are tenuous at best.
Because we are all constrained by our point in history and culture(s), it is inevitable that the institutions, processes, and roles that appear ‘normal’ to us disguise constructions that would be highly visible from the perspective of another time or place. The implications are not trivial. Indeed the choices that educators are making in every country of the world today will have both positive and adverse effects on graduates and on their societies, just as Flexner’s did in his day. Given the likelihood of being blind to these effects, it is important to consider ways of rendering visible the social construction of medical education and its many effects. It is in this ‘rendering visible’ that the power of the social sciences lies.
While the long view of history helps to ‘make strange’ assumptions and practices of past eras, it is more difficult to recognise how odd or even absurd some of our contemporary constructions are, or even recognise the implicit assumptions we currently make about medical education. While adverse effects of current approaches to medical education may not be fully visible to those who have not had 50 years to look back on them, there are means we can use to render visible what is tacit or implicit about medical education today. A powerful means of uncovering such preconceptions and elucidating some of the implications of particular constructions is to use social science theory (Reeves et al, 2008).
Many different theories can be used for this purpose. For example, Marxist theories illuminate the way institutions serve to channel power and privilege in societies. Feminist and anti-racist theories cast light on the ways institutions create inequities on the basis of gender or race, while anti-colonial theories examine the function of institutions in extending and maintaining the power of dominant countries and cultures. Foucauldian analysis draws attention to ways in which certain kinds of institutions are made possible by specifically sanctioned ways of thinking, of being, and of speaking, while a Bourdieuvian approach illustrates the ways in which institutions are implicated in the struggle for power, prestige, and dominance in professional fields. These five perspectives are summarised in Table 3.1.
Table 3.1 Five theoretical perspectives, assumptions, and possible adverse effects
| Theorist or school | Assumptions made visible | Examples of adverse effects made visible |
|---|---|---|
| Foucault and discourse theory | Medical schools are institutions of social control and use many mechanisms and technologies to shape the behaviours and roles of those (faculty, students, patients) engaged with them. | Both overt and ‘hidden’ curricula, as well as systems of examination, can embed and reinforce problematic or undesirable behaviours and ways of being. |
| Uncritical acceptance of concepts such as ‘professional self-regulation’ can disguise problematic power structures or ways of being. | ||
| Bourdieu and symbolic capital theory | Medical schools are ways for individuals and social groups with social, cultural, and economic capital (e.g. power, legitimacy, money, etc.) to maximise such capital. | Admissions processes and assessment of ‘professionalism’ may embed markers of social and cultural capital (e.g. ways of dressing, talking, carrying oneself) that are learnt at home by certain social groups but become important in selection processes (e.g. at interview). |
| Neo-Marxism | Medical schools function as means for privileged individuals and social groups to maximise their economic capital and exert dominance in society. | High tuition fees in many North American jurisdictions (and elsewhere) mean that only the wealthy (or those comfortable enough with risk to go into huge debt) can afford medical school, reproducing a monopoly on the wealth produced within the profession. |
| Feminist/Anti-racist theories and the combined equity agenda | Medical schools continually reproduce the power differentials visible elsewhere in society (e.g. those due to gender, race, religion, sexual orientation). | The ‘pink-collarisation’ of specialties such as Family Medicine and devaluing of medicine as a whole is linked to feminisation of the profession. |
| Professional norms reflect white, male, heterosexual, Christian standards of behaviour. | ||
| Post-colonial theories | Medical schools activities in lower-income countries may be forces of Europeanisation/Americanisation that devalue indigenous, traditional cultures and practices and contribute to economic and human resource destitution (e.g. neo-liberal Westernisation). | Inappropriate importing of Western professional norms into a very different professional context leads to loss of traditional cultural practices. Brain drain of physicians to Europe and North America. |
Michel Foucault’s work is important for medical education in many ways. Foucauldian discourse theory draws attention to ways in which certain kinds of institutions are made possible by specifically sanctioned ways of thinking, speaking, and being. Working in France in the late twentieth-century, Foucault wrote a history of the birth of clinical medicine (Foucault, 1963/2003) and an analysis of the ways in which schools, hospitals, and other post-Enlightenment institutions shape and control the behaviour of individuals (Foucault, 1975/1977). He also wrote histories and case studies about ethics, the body, sexuality, identity, and many other topics that are pivotal to medical education. Among the many ways in which scholars of medical education can incorporate the work of Foucault, no concept is more useful than that of ‘discourse’.
Foucault’s work illustrates how particular discourses ‘systematically construct versions of the social world’ (McHoul and Grace, 1993). Discourses are involved in the way we see and understand the world; they act like lenses or filters and are ‘productive’ in that we use them to create ‘reality’. Certain discourses make it possible for us to say some things but not others, act in certain ways, and have certain roles in our social worlds. The research approach associated with this perspective is called ‘discourse analysis’ and, while there are many different approaches that share this term (Hodges et al, 2008), Foucauldian discourse analysis involves both the examination of language and of the individuals and institutions that are made possible by, and make possible, particular ways of thinking and speaking. Foucault’s study of madness, for example, uncovered three distinct discourses that have constructed what madness is in different historical periods and in different places: a discourse of ‘madness as spiritual possession’ that was dominant in the Middle Ages in western countries; a discourse of ‘madness as deviancy’ that was dominant in the Victorian era; and, more recently, a discourse of ‘madness as medical illness’ that has been prominent since the beginning of the twentieth- century (Foucault, 1965). These different discourses create very different possibilities for people and institutions. For example, a discourse of ‘madness as spiritual possession’ makes visible ‘possessed individuals’ and creates a role for spiritual healers and religious institutions, while a discourse of ‘madness as deviancy’ makes visible ‘deviant individuals’ and creates a role for judges and jailors working in courts and prisons. By contrast, a discourse of ‘madness as medical illness’ makes visible ‘mentally ill individuals’ and creates a role for psychiatrists and psychologists who work in clinics and hospitals. This approach is echoed in a more recent study of how the very different terms ‘patient’, ‘consumer’, and ‘survivor’ are each made possible by particular institutions and individuals who themselves are aligned with specific discourses (Speed, 2006).
Discourse analysis can also be used to study medical education. For example, professional competence, like madness, has been defined in very different ways at different times. In the 1700s, a ‘competent’ doctor was a member of a guild who carried a blade for blood letting and emetics for purging, with the goal of balancing the humors of the body. In 1850, by contrast, a competent doctor was a gentleman (there were almost no women doctors) with a walking stick who diagnosed patients by looking at their tongue and smelling their urine. By 1950, a competent doctor, still most likely to be a man, wore a white coat rather than a suit and had at his disposition a host of physiological investigations and pharmacological treatments. Yet in the 1950s a ‘professional’ doctor was expected to discuss a woman’s health with her husband and withhold the true diagnosis from a dying patient so as not to provoke worry. In the twenty-first-century, blood letting, smelling urine, and withholding the truth from dying patients are all considered incompetent behaviours (Hodges, 2007).
So what is the interest of such an approach to medical education? It might occur to the reader that most of these changes to the associated discourses of competence simply reflect the advancement of science. Certainly, the urine-sniffing doctor of the nineteenth-century did not have the benefit of modern laboratory analysis. Similarly, the bloodletting eighteenth-century physician would have been unfamiliar with twentieth-century patho-physiological explanations of fever and inflammation. These changes in practice did indeed correspond to developments in science. But what of talking to a woman’s husband about her illness? This aspect of professional competence reflected a set of cultural expectations that have since shifted. Indeed, it would be quite imaginable today to hold a debate with doctors from different countries of the world as to whether talking to a woman’s husband about her health is ‘competent’ behaviour or not, and what regional, national, cultural or other variations might underpin the answer. There are other issues with little explanation in science. For example, why did it become important to wear a white coat rather than a 3-piece suit? Or, what is the reason that women, once thought to be too ‘feeble-minded’ to pursue studies in science, now represent more than half of medical students? Discourse analysis, in the tradition of Foucault, allows us to see many elements that are uncritically considered to be ‘normal’ aspects of medical education. It challenges us to rethink not just such notions as ‘appropriate communication skills’, ‘professional behaviours’, and dress, but also things that are more overtly ‘scientific’ like physical examination technique, history taking, laboratory investigation, and diagnostic classification. All are made possible at some level by the specific ways in which we talk, think, and act. These, in turn, are conditioned by, and particular to, our place in the world and our period of history. When we realise that such fundamental things can be constructed so easily by time, place, and discourse, it becomes obvious that the construction of dominant ways of thinking and being can potentially be harnessed for both helpful and harmful purposes and that, given enough attention, we can change them.
The work of French sociologist Pierre Bourdieu focuses on struggles for power, prestige, and dominance in various ‘fields’. Within Bourdieu’s theory, a ‘field’ refers to two things simultaneously: an arena for the production, circulation, and acquisition of goods, services, knowledge, or status that are centred on a particular issue (e.g. art, science, opera, medicine); and also the configuration of historical relations of power between the positions held by individuals, groups, or institutions who interact within this field (Bourdieu and Wacquant, 1992). Each field is characterised by a particular ‘game’, the focus of which is the legitimate definition of what is ‘good’ within that field as well as the measures used within that field for the assessment of ‘quality’. “In each field the competition for predominance of one definition over competing definitions as the recognised model of excellence in the field results in a struggle between players as each tries to promote a definition that places value on their own products and their own ways of doing things. The ultimate currency in this struggle is the acquisition of prestige, the power to influence activities within the field itself.” (Albert et al, 2007)
There are many forms in which power can be active within a field. To account for this, Bourdieu developed the concept of ‘species of capital’, whereby capital can be thought of as being, for example, cultural, economic, social, or symbolic (Bourdieu, 1986). The concept of ‘symbolic capital’ is often the most difficult to understand. It refers to those aspects of being (whether belongings, degrees, job titles, or family linkages) that endow someone with elevated status and give them a certain amount of power within a given field. Studying any field therefore requires analysis of elements that are valued within that field (Bourdieu, 1980). Thus, the focus of competition between ‘players’ in a field is the accumulation of specific symbolic capital; the amount of such capital amassed by each player determines his or her power to influence the field. This approach to understanding the game being played in individual fields has been used successfully in a number of medical education-related domains such as the field of medical education research (Albert, 2004) and the field of university academia (Bourdieu, 1988). It has also been used within medical education (along with a related Bourdieuvian concept, the ‘habitus’) to study the socialisation of individual medical students as they become physicians (Luke, 2003; Brosnan, 2009).
The field of medical education can therefore, according to Bourdieu, be conceptualised as a field in which players struggle for various forms of capital (e.g. power, legitimacy, money) in order to maximise such capital for themselves. Players compete to establish the legitimate definition of the ‘good’ doctor, painting it in their own disparate images. They naturally include in their definitions things that support and reproduce the legitimacy of their own social and cultural capital, such as legitimising certain ways of dressing and speaking as more ‘professional’ than others. For Bourdieu, medical education is (and will always be) a struggle both to attain the capital associated with being a physician (including a conservative reproduction of current norms) and to control the legitimate definition of ‘physician-ness’. An understanding of the nature of this struggle may help medical educators shift this definition in a more acceptable, and more equitable, direction in the future.
In the late nineteenth-century, Marx and Engels (1844/1970) argued that a sector of society was not profiting from economic expansion of the industrial revolution and drew attention to the negative effects of separating labour from capital. Marxist analysis focuses on the oppression of the working classes by the middle and upper classes and the unequal division of capital in society. In medical education, ‘neo-Marxists’ have explored the ways in which the medical profession and its institutions are implicated. For example, in Rockefeller Medical Men, Brown (1979) documented the rise of the medical profession ‘from ignominy and frustrated ambition to prestige, power and considerable wealth’ by harnessing the momentum of capitalist society. In a radically different version of a familiar story, Brown recounted how Abraham Flexner, whose career was made possible by funds derived from the powerful petroleum and steel industries (Rockefeller and Carnegie Foundations) wrote a report on medical education (Flexner, 1910) that ultimately resulted in the closure of all but the elite medical schools in the United States and Canada.
Other neo-Marxists such as Johnson (1972), Larson (1977), and Larkin (1983) further explored the links between professional power and the capitalist system, analysed medicine’s occupational dominance, and explored ways in which diagnostic categories could be modified in the service of economic goals. Larson argued that medical education, specifically, is a process that channels privilege and capital to a very select group of students:
I see professionalization as the process by which producers of special services [seek] to constitute and control a market for their expertise. Because marketable expertise is a crucial element in the structure of modern inequality, professionalization appears also as a collective assertion of special status and as a collective process of upward social mobility (Larson, 1977, p. xvi)
More recently, authors working with this paradigm have noted that, one by one, western governments are adopting ‘neo-liberal’ arguments to disassemble systems of wealth redistribution, privatise national assets, and transfer power and resources to the profit-oriented sector. Neo-liberalism, they argue, also entails giving priority to the reduction of costs and efficiency of production (Teeple, 2000). The implication for universities in general, and medical education in particular, is the restructuring of curricula, of pedagogic methods, and of governance and administration to support neo-liberal ideology and objectives (Magnusson, 2000). The objective of scholars working with this paradigm is to raise consciousness among oppressed groups and re-centre education as a vehicle of emancipation rather than a tool to enrich the privileged yet further (Freire, 1970).
The past 60 years have seen the rise of a multitude of theories that explore the systemic inequities in society perpetuated on the basis of gender, race, religion, class, sexuality, and/or physical ability. Feminist and anti-racist theories cast light on the ways in which institutions create inequities on the basis of gender or race. These perspectives have two functions: to generate understanding and to create change in order to improve the conditions of those who are subjugated by inequity. What these theories all have in common, besides their interest in inequity, is that they are ‘critical’ – that is, their mandate is to enable and foment social change.
For many years each of the ‘equity’ theories was taken up separately – written about by different authors, in different places, and addressed to different communities. More recently, however, there has been an effort to embrace commonalities between the agendas of different groups who are attempting to address inequities. This is sometimes referred to as the ‘combined equity agenda’. Exploring the intersection of inequities acknowledges that one person might simultaneously embody a multiplicity of identities (Haraway, 1991). The rapprochement of theories that address gender, race, sexuality, ability, and other dimensions of human identity through an equity lens has resulted in a body of critical equity-based theories that are sometimes referred to as ‘critical theory’. Critical perspectives are widely used within the broader education literature (Ng et al, 1995) and have been used to critique the medical profession and health care system generally (see, e.g. Witz’s, 1992; Professions and Patriarchy). More recently, a critical approach has been used to address various aspects of medical education. Wear and Aultman (2005) and Wear and Kuczewski (2004), for example, employed a number of equity-related critical perspectives to address both curricular and pedagogical aspects of undergraduate medical education, while Martimianakis (2008) addressed structural effects of equity and diversity policies in a Faculty of Medicine. Phillips (1995) has shown how decades of research conducted almost exclusively on white, middle-aged, Euro-American men means that the solid ground of ‘evidence-based medicine’ taught by medical schools is built on highly selective evidence.
An understanding of the impact of inequities on society enables us, at the simplest level, to make them visible to our students. However, we must not assume that patients suffer inequities and physicians do not. Structural inequities exist inevitably at all levels of medical education because it takes place in an inequitable society. Consistent with the critical paradigm, scholars working from this standpoint argue that, in order to address such issues as equitable access to medical education and leadership roles within the discipline, it is necessary to focus on the gendered, cultured, and racialised hierarchical nature of the profession itself and make efforts to (re)invent a more equitable society.
One of the major historical shifts of the twentieth-century was the end of the Eurocentric colonial systems that had ruled much of the non-European world for hundreds of years. This enormous political change and the accompanying economic and social upheaval have been written about from many different cultural and disciplinary perspectives. Post-colonial theories give voice to the oppressions and disparities that are the legacy of old and continuing colonial power relations. This broad school of thought has emerged from the analysis of global changes and their aftermath, as well as the colonial conditions that preceded them. Although this group of theories interacts with, and often draws on, other theoretical groupings (including Foucauldian discourse analysis, feminism, and neo-Marxism), it makes visible certain assumptions and problems that other theories do not clearly address.
For example, although neo-Marxism problematises economic exploitation of the ‘third world’, post-colonial theorists have emphasised that cultural and social dimensions of such interactions are equally important. Theorists working from a post-colonial perspective have also argued against accepting a unified discourse of colonialism in order to expose the specificity of effects on different colonies and colonisers. In addition, post-colonial theorists have focused attention on the difficulties of translating western feminist ideals (and other aspects of the combined equity agenda) into the post-colonial realm, where nationalist struggles have often taken precedence over inequities and where western notions of equality can themselves be seen as ‘colonising’ ideas. Finally, a post-colonial movement known as ‘subaltern studies’ has struggled to give voice to those who are too culturally and socio-economically marginalised even to take part in such debates.
Although there has been research into the effects of colonial dominance in medicine generally, and into the effects on diverse cultures specifically, linkage of medical education and post-colonial theory is relatively new. Such theories have, however, been taken up in an emerging discussion of globalisation in medical education. Recent papers have problematised the straightforward export of copies of European and North American medical education curricula and institutions to other parts of the world. They argue that such exportation includes not only curricula but also, more problematically, the social and cultural assumptions embedded within them (Bleakley et al, 2008). Uncritical export of medical education models, products, and institutions is particularly troubling as it is being done with an implicit acceptance that there are globally appropriate professional values (Hodges et al, 2009) – values that most often stem directly from western professional ideals.
While post-colonial thought helps explain problems of globalisation in medical education, it is also a useful theoretical tool to understand complex problems at a more local level. Analysing medical education problems based on local histories and specific cultural norms can counter some of the negative effects and artificial disjunctions that are born of uncritically adhering to sweeping position statements about ‘global standards’ and ‘best practices’, which masquerade as universally validated constructs, but which often disguise very particular socio-cultural constructions. Other strands of post-colonial theory such as subaltern studies offer intriguing possibilities to teach our students to hear and represent appropriately the perspectives of the voiceless among our patients: elderly, homeless, and mentally ill people, immigrants, refugees, and other marginalised groups.
While dramatic shifts in the nature of medical education (such as Flexner’s reforms) are rare, medical education and its institutions are continually being (re)shaped. This process is often passive, resulting from circumstance rather than deep reflection on the nature of medical education and its relationship to societies. Currently, neo-liberalism, market economics, and the globalisation of medical education are reshaping many aspects of medical education. Yet their profound impact on issues like access to medical education institutions, the financing of medical education, and the role that its graduates play in different societies has not been actively studied or proactively influenced to any great degree. Their implications are worthy of study.
Understanding and harnessing the forces of social construction offer the possibility of re-imagining medical education and its institutions in a more active fashion. Educators and students need not be swept along passively in the currents of their socio-political environments. Rather, medical education institutions and medical educators hold a great deal of power and influence in their societies. While there are significant constraints on the degree to which individuals can shape what is possible to think, say, or be, collective reflection and concerted effort could make it possible to exert influence.
In this vein, the social science perspectives that have been considered in this chapter, while theoretically bound, can be used to inform practical changes in the nature, governance, and/or management of medical education institutions. To illustrate this point, it may be helpful to consider social responsibility, a notion of central concern to medical educators and students. At the risk of cross-cultural generalisation, social responsibility implies that medical education institutions, in various parts of the world, exist through a tacit understanding with the societies in which they are located. That is, there is an unwritten agreement that, in exchange for significant financial resources, a high degree of prestige, protection for education and research activities, a set of legal, financial, and other structures that allow for self-regulation, and a relative monopoly for the professional services of their graduates, each medical school will give back in some meaningful way to the society that supports it. This ‘giving back’ is usually framed as ‘social responsibility’ or even ‘social accountability’ and its nature varies tremendously. However, were a faculty of medicine, its teachers, and its students to try to articulate the nature of their social responsibility, the various theoretical ‘lenses’ we presented in this chapter would prove most useful:
These are brief examples of what each of the five theoretical perspectives could bring to the study of medical education in one domain: social responsibility. There are many other questions that lend themselves to the rich analytic frameworks of social science theory. Each of these frameworks, and many others that are beyond the scope of this chapter, force us to question the basic assumptions of our everyday educational practice and research. This questioning is, in turn, the first step towards actively shaping medical education to respond to the needs of the societies of which we are members.
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