"Not a university type": focus group study of social class, ethnic, and sex differences in school pupils' perceptions about medical school
http://www.100md.com
《英国医生杂志》
1 Department of Primary Health Care, University College London, London N19 5LW
Correspondence to: TGreenhalghp.greenhalgh@pcps.ucl.ac.uk
Abstract
Objective To investigate what going to medical school means to academically able 14-16 year olds from different ethnic and socioeconomic backgrounds in order to understand the wide socioeconomic variation in applications to medical school.
Design Focus group study.
Setting Six London secondary schools.
Participants 68 academically able and scientifically oriented pupils aged 14-16 years from a wide range of social and ethnic backgrounds.
Main outcome measures Pupils' perceptions of medical school, motivation to apply, confidence in ability to stay the course, expectations of medicine as a career, and perceived sources of information and support.
Results There were few differences by sex or ethnicity, but striking differences by socioeconomic status. Pupils from lower socioeconomic groups held stereotyped and superficial perceptions of doctors, saw medical school as culturally alien and geared towards "posh" students, and greatly underestimated their own chances of gaining a place and staying the course. They saw medicine as having extrinsic rewards (money) but requiring prohibitive personal sacrifices. Pupils from affluent backgrounds saw medicine as one of a menu of challenging career options with intrinsic rewards (fulfilment, achievement). All pupils had concerns about the costs of study, but only those from poor backgrounds saw costs as constraining their choices.
Conclusions Underachievement by able pupils from poor backgrounds may be more to do with identity, motivation, and the cultural framing of career choices than with low levels of factual knowledge. Policies to widen participation in medical education must go beyond a knowledge deficit model and address the complex social and cultural environment within which individual life choices are embedded.
Introduction
The principle that medical school intake should reflect the ethnic and socioeconomic mix of the population has been endorsed by the UK Council on Heads of Medical Schools1 and underwritten by generous "Widening Participation" payments to universities that recruit from underrepresented postcodes.2 3 Despite these incentives, recruiting applicants from non-traditional groups is proving difficult,4 and major disparities by socioeconomic status and some ethnic groups remain.5-7
A high profile US initiative entitled "Project 3000 by 2000" involved a range of intensive summer schools and supplementary teaching programmes during term time to support students from non-traditional backgrounds.8 Despite impressive short term successes,9-19 it failed to meet its targets.20 Like many other early "enrichment" programmes,21-30 Project 3000 was predicated on a knowledge deficit model in which non-traditional students were seen as requiring additional input of factual knowledge, and underperformance or withdrawal from the course was attributed primarily to inability to make the grade in coursework.
Contemporary theories of recruitment and retention in higher education explain students' choices (and failures) primarily in terms of personal identity, social capital, and the cultural "frames" in which potential options are considered (see discussion). As part of a needs assessment to inform enrichment initiatives at University College London, we sought to find out what going to medical school meant to academically able 14-16 year olds from a range of ethnic and socioeconomic backgrounds, how they constructed their own identity as potential medical school applicants, and what social and material resources they felt they could draw on.
Participants and methods
We approached six schools, deliberately chosen to provide a wide mix of socioeconomic and ethnic backgrounds (table 1); all agreed to participate. Teachers were asked to identify Year 10 and 11 pupils (pre-GCSE and GCSE years, age 14-16 years old) who were predicted to gain high GCSE grades in subjects relevant to medical school application and who had shown interest in applying to medical school. (Further details of the background of each school and the research process are given in Box A on bmj.com).
Table 1 Characteristics of the six schools that participated in the focus group study
After explaining the purpose of the study to the selected pupils, the lead researcher distributed paper and invited the pupils to list any questions they had about medical school. We answered these questions after the focus group was completed; we also took away the sheets of paper for analysis. To begin the focus group, the lead researcher showed a silhouette of a face and told the group: "This is X, who is a 16 year old pupil applying to medical school this year. She/He is probably going to do well—what do you think she/he is like?" After a discussion of the qualities of this "successful" fictitious pupil, the group were shown another silhouette and told "Y is a pupil of the same age who is thinking of applying to medical school—but she/he has got some concerns. What do you think these might be? What do you think the barriers might be to her/him succeeding?" The sex and ethnicity of the fictitious pupils were varied in different groups. Further discussion prompts were introduced to explore the pupils' perceptions and aspirations:
"What help or preparation might Y need?"
"Y is at medical school now. What do you think it's like? What do you think she/he is worried about now? What do you think she/he is enjoying?"
"Do you know any doctors personally? Any relatives or friends who are doctors? What doctors do you recall from television or films? What do you think about them?"
"Do you know anyone who has been to medical school ? What do they say about it? What picture do they paint?"
"X and Y are now qualified doctors. What do you think their life is like? What are they enjoying? What are they finding less good and why?"
All focus group discussions were transcribed and annotated with contemporaneous field notes. All three researchers read all transcripts independently and coded responses using the constant comparative method.31 Each item within the data was compared with the rest of the data to establish analytical categories; negative cases that ran counter to the emerging themes were used to refine the themes. Consensus of coding categories and a final list of key themes was achieved iteratively through discussion and re-reading of transcripts. We circulated this list, with verbatim quotes to illustrate the themes, to key contacts (teachers or heads of careers) in the six schools, who were asked to distribute these to participants for respondent validation. Four of the six contacted us to confirm that they agreed with the findings (comments included "Spot on" and "Agrees exactly with my own feelings"), but to our knowledge none had actually shared the preliminary interpretation with the pupils.
Results
Sixty eight pupils from diverse ethnic backgrounds took part (table 1). We found few consistent differences in perceptions and attitudes between pupils from different ethnic groups, and relatively few by sex, but marked differences by socioeconomic status as assessed by occupation of head of household. The main themes are listed below, and illustrative quotes are given in box B on bmj.com.
Focus group dynamics
One of our most striking findings was the behaviour of working class boys from both white and black backgrounds (we had few Asian boys in our sample except in the independent school). In both the inner city focus groups that included boys there was a cohort of vocal "lads" with strong peer group identity exhibited through accent, dress, and behavioural norms, whose interjections were directed at subverting the purpose of the focus group through humour and "bad boy" activities (see box B on bmj.com for examples). These boys were highly able (one disruptive pupil from school A, for example, had recently won a national scholarship to study A levels at a leading private school) but presented themselves as non-academic and not really a serious part of the research study. Careers teachers confirmed similar behaviour from these boys in class.
Reasons for wanting to do medicine
Pupils from higher socioeconomic groups viewed medicine as having high intrinsic rewards such as personal fulfilment and achievement, and saw it as one option in a menu of other high status career paths. Several had been inspired to study medicine by a positive role model or after experiencing illness in themselves or a family member. Many such pupils had done their own research and had a clear strategy for pursuing their goal. Pupils from lower socioeconomic groups, especially boys, talked more about the extrinsic (financial) rewards of medicine and about the "blood and guts" of the job. They had a stereotyped view of doctors, often derived from media images, and had not tried to flesh out the detail of particular options.
Perceptions and concerns about applying to medical school
Many pupils, especially but not exclusively from lower socioeconomic groups, had hazy perceptions of the steps needed to become a doctor ("Do you need any sciences?"). All pupils believed that entry is highly competitive and were anxious about making the grade. Inner city pupils rated their chance of an application being successful at around 1 in 10 (in reality it is around 2 in 3). Pupils from comprehensive schools felt that not having perfect grades would put them at a disadvantage compared with applicants from "better" schools, and that commitment and enthusiasm would not compensate for this.
Few pupils had made a firm commitment to medicine by Year 11 (15-16 years old). They did not feel ready to select their A levels with medicine as the goal. Many admitted to taking science subjects as a means to an end and resented cutting off alternative choices at a young age. Independent school pupils were more confident that they would achieve a place at medical school and were less prepared to "jump through hoops" to bolster their applications. Pupils from the schools in the two most deprived areas often had only a vague idea of the alternative options ("There's always cars") available to them if they failed to make the grade for medicine, and boys in particular did not plan to make strategic "insurance choices."
Who gets in?
All the groups gave a similar picture of the person who finds it easy to gain a place and succeed at medical school. Typical descriptors were intelligent, hardworking, dedicated, and tough ("stubborn," "headstrong"), interested in people, caring, enthusiastic, ambitious, and able to cope with pressure. We did not find any evidence of perceived prejudice in the admission process by sex or ethnicity. However, there was a strong perception among less affluent pupils that high social class and a privileged education would confer an advantage in the admissions process:
"The way she carries herself and her grades... like at interview if she does well."
"How would she carry herself?"
"Respectively , talking properly, and dressing appropriately, a lot of confidence."
"Not saying it in a common accent, say it properly."
"If they speak well then they'll look more well educated."
(Boys from school B)
There was a perception among pupils from all the inner city schools that there is a certain type of person who goes to university, and that having non-academic interests makes you the wrong type even if you've made the grade in school exams. But pupils from more affluent backgrounds were able to counter the stereotype of the "boring swot with no social life" with positive role models of people they knew personally.
What is medical school like?
Almost all pupils showed a remarkable lack of knowledge about what actually goes on at medical school and about medicine as a profession. Pupils from inner city schools had concrete concerns about the physical environment at university, especially food choices and type of "dormitories"; more affluent pupils did not raise these issues at all.
All pupils perceived medical training as a long, hard course with little time for socialising. But there were important differences in what this meant for them. Pupils from professional backgrounds saw intrinsic rewards in the coursework ("tiring but fun"). Those from the lower professional and intermediate backgrounds described a trade-off (sacrifice now for rewards later). But pupils from lower socioeconomic groups often saw no intrinsic reward from the academic work ("it's cruel") and struggled with the idea of deferred gratification.
A few inner city pupils had a perception of university as "changing your life," but this change was seen in distant, global, and somewhat unreal terms. When asked for specific examples, these same pupils could only cite individuals who had dropped out of university.
The high cost of medical training was a concern for all pupils, but those from professional families did not see it as influencing their choices. Some inner city pupils were dimly aware of scholarship schemes for which they might be eligible. Pupils from schools D and E (mostly lower professional and intermediate backgrounds) were concerned that they would be ineligible for financial benefits and that on graduation they would face severe financial hardship compounded by long hours and work stress.
There was a big fear about failing and dropping out. Inner city pupils greatly overestimated the likelihood of failing the course (one group rated this at 74%), and as the quotes on bmj.com show, this fear was closely linked to anxieties about money.
Need for information and resources
Pupils wanted information about what doctors do, what goes on at medical school, and admissions requirements, especially from independent sources that would allow them to compare the strengths and limitations of different courses. Some pupils had tried to find information to guide their choice of GCSEs or A levels, but had not found what they were looking for. University websites and prospectuses gave admissions information directed at pupils aged over 16 years, but this was not experienced as meaningful by the younger age groups in this study.
School E had received booklets from a London medical school aimed at GCSE pupils. The pupils in that focus group had clearly read the booklets and found the information helpful and credible. They were particularly inspired by a section on "dispelling myths," which had reassured them that medical students did not have to come from "posh" homes or independent schools.
Parental support was often mentioned spontaneously. Boys were more likely to see parental support in financial terms, whereas girls saw it more terms of psychological and emotional support, and, for the Asian girls, the opportunity to live at home.
All groups felt that talking to real students and recent graduates would be the best way of finding out what medical school (and medicine) is really like. The crucial characteristic of a credible person to speak to was homophily with the pupils themselves. Girls in particular wanted subjective and motivational information from someone they identified with (and who could identify with them).
The pupils from inner city schools were cynical about glossy brochures and people from universities who came round to market their courses. All groups were keen on work experience in which they met real patients and gained a flavour of what medicine is really like. The most useful placements were felt to be shadowing junior doctors. Some told stories of friends who had been given "unsuitable" placements (that is, without direct patient contact) such as microbiology labs or administration.
Several pupils commented that they would like to find out whether they would be academically able enough to cope with the medical course before "burning their bridges" for other options. One suggested that a voluntary aptitude test to be taken at age 15 could provide pupils with an indication of whether their aspirations were realistic.
Discussion
This in depth study of London schoolchildren aged 14-16 years reveals important differences by socioeconomic background in perceptions of, and aspirations to, medical school, which both outweighed and moderated the influence of sex and ethnicity. Working class boys (that is, those who identified their head of household as in a routine or semi-routine job or unemployed) showed a common pattern of intense peer group bonding, anti-school values (enacted as subversive behaviour in the focus groups), low self confidence despite high academic ability, and cynicism towards enrichment initiatives—a combination that may account for the continuing poor recruitment of both white and black pupils from lower socioeconomic groups to UK medical schools.5 6
Two main approaches have been used to study how pupils choose their post-16 options. Large scale quantitative surveys, in which participants are asked to indicate which of a long list of possible factors influenced a particular choice, can test hypotheses about macro-level links between attainment variables (such as A level points) and application success.3 32-38 In depth qualitative studies provide a rich picture of a smaller number of individual decisions and are the method of choice for exploring the reasons for particular choices in defined subgroups.39-42
Comparisons with other studies
Our findings align closely with those of other researchers. In a large questionnaire and interview survey in Britain, Ball et al showed that social class, not ethnicity or sex, was the strongest predictor of both parental choice of school for 11 year olds and post-16 choice by pupils.43 The same authors interviewed 65 school pupils from minority ethnic groups spanning all socioeconomic groups and found that socioeconomic, rather than ethnic, differences were the most critical influence on university choices.44 Foskett and Hemsley-Brown have reviewed several smaller studies that produced similar findings.40 These consistent and dramatic differences by socioeconomic background raise the question of what it is about being "working class" that puts pupils off university.
Paul Willis, who undertook a detailed ethnographic case study of a group of "lads" in their final year of a northern secondary modern school in the 1970s, made the controversial suggestion that the link between traditional working class identity and academic failure was embodied and reproduced in the social relations of the school itself.45 The lads' resistance to school authority and rejection of its values allowed them to build a strong counterculture of "mucking about" and resisting work—but this very counterculture inexorably destined and prepared them for working class identities and jobs. More recently, Archer and Hutchings undertook an in depth interview study of 15 year old working class boys from diverse ethnic backgrounds in inner London.46 Their participants had constructed complex masculine identities characterised by racism, sexism, and strong class awareness—and embodied through accent, speech, dress, and style (rejecting anything "posh," "smart," and "polite"). They had a strong sense of belonging to their peer group and to the local area in relation to particular spaces and ideas of safety and danger. As in our own study, the boys positioned their carefully constructed "rough" identities as barriers to getting into more middle class jobs and college courses.
The notion that, despite the rhetoric of meritocracy, working class pupils cannot be classified as active choosers in education has been developed further by Bordieu,47 48 who sees choice as part of the "normal" middle class life narrative, in which a spell at university is highly congruent with family and peer values, financial security can generally be assumed, individual identity is independent of a particular locality and peer group, and the only choice is between institutions and courses. Others, drawing on Bordieu, have described the working class decision to enter post-compulsory education as far more limited, generally discordant with personal and cultural identity, associated with major financial risk and separation from a valued local peer group, and (therefore) highly contingent on structural influences, chance, and circumstances.40 49 50
On the basis of their empirical findings, Ball et al produced a theoretical taxonomy of higher education chooser based on two "ideal types": contingent and embedded.43 44 Their model (which we have adapted slightly in table 2) accounts for many of the class differences we observed in our study.
Table 2 Two kinds of higher education choosers (adapted from Ball et al43 44)
Implications for policy
The UK government's latest policy documents on widening participation recognise that achieving diversity in higher education must go beyond the knowledge deficit model and address the root causes of low motivation and cultural disaffection in non-traditional students.51 52 US medical schools have embraced "partnership" and "pipeline" models, in which they seek long term relationships with schools in target areas, align their outreach activities with mentorship and community development initiatives, and provide a more culturally inclusive environment on campus.53-58 However, there has been little systematic research into how far these models actually address issues of identity, motivation, and "framing" in under-represented groups.
We predict that initiatives to reduce socioeconomic inequalities in medical school admission are unlikely to succeed unless they acknowledge and address the close link between self esteem, personal identity, and particular aspects of working class culture that run counter to traditional academic values and aspirations. We suggest, for example, that the next generation of enrichment initiatives should be locally developed and delivered in targeted deprived areas, use non-authoritarian approaches that embrace the unconventional, make extensive use of mentorship by role models from non-traditional backgrounds, draw on the peer networks and group identity of working class youth, and explicitly address the high personal risk and structural and financial constraints faced by applicants from low income groups.
What is already known on this topic
There are wide disparities in medical school admission by social class
Widening participation initiatives in medicine have so far had limited impact
This may be because they often seek to "top up knowledge" rather than addressing motivation, identity, and culture
What this study adds
School pupils from working class backgrounds see medical school as distant, unreal, and culturally alien
They may link their cultural identity to anti-academic values
They also associate a medical education with prohibitive personal risk and greatly underestimate their chances of successful application
Editorial by Hilton and Lewis
Details of the schools involved in the study and quotes illustrating the main themes from the study appear on bmj.com
We thank the focus group participants and wish them success in their future careers. We thank the schools, especially our key contacts, for their work in making this study possible. Marcia Rigby was project manager, and Nazia Ali kindly assisted with the fieldwork in school C. We thank Lewis Elton, Stephen Rowland, Jill Russell, Sean Hilton, and Jane Hemsley-Brown for helpful comments on earlier drafts of this manuscript. We also thank BMJ Publications for a generous donation of books on learning medicine for the schools' libraries.
Contributors: TG conceptualised the study. TG and KS did the fieldwork. All authors analysed the data. TG and KS wrote the paper.
Funding: KS undertook part of the work for this study as a dissertation for BSc in primary health care. The Widening Participation Unit at University College London provided support for study expenses.
Competing interests: No financial conflict of interest. KS is British Asian, TG and PB are British white. All authors were originally from social class III non-manual when they applied to university.
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Correspondence to: TGreenhalghp.greenhalgh@pcps.ucl.ac.uk
Abstract
Objective To investigate what going to medical school means to academically able 14-16 year olds from different ethnic and socioeconomic backgrounds in order to understand the wide socioeconomic variation in applications to medical school.
Design Focus group study.
Setting Six London secondary schools.
Participants 68 academically able and scientifically oriented pupils aged 14-16 years from a wide range of social and ethnic backgrounds.
Main outcome measures Pupils' perceptions of medical school, motivation to apply, confidence in ability to stay the course, expectations of medicine as a career, and perceived sources of information and support.
Results There were few differences by sex or ethnicity, but striking differences by socioeconomic status. Pupils from lower socioeconomic groups held stereotyped and superficial perceptions of doctors, saw medical school as culturally alien and geared towards "posh" students, and greatly underestimated their own chances of gaining a place and staying the course. They saw medicine as having extrinsic rewards (money) but requiring prohibitive personal sacrifices. Pupils from affluent backgrounds saw medicine as one of a menu of challenging career options with intrinsic rewards (fulfilment, achievement). All pupils had concerns about the costs of study, but only those from poor backgrounds saw costs as constraining their choices.
Conclusions Underachievement by able pupils from poor backgrounds may be more to do with identity, motivation, and the cultural framing of career choices than with low levels of factual knowledge. Policies to widen participation in medical education must go beyond a knowledge deficit model and address the complex social and cultural environment within which individual life choices are embedded.
Introduction
The principle that medical school intake should reflect the ethnic and socioeconomic mix of the population has been endorsed by the UK Council on Heads of Medical Schools1 and underwritten by generous "Widening Participation" payments to universities that recruit from underrepresented postcodes.2 3 Despite these incentives, recruiting applicants from non-traditional groups is proving difficult,4 and major disparities by socioeconomic status and some ethnic groups remain.5-7
A high profile US initiative entitled "Project 3000 by 2000" involved a range of intensive summer schools and supplementary teaching programmes during term time to support students from non-traditional backgrounds.8 Despite impressive short term successes,9-19 it failed to meet its targets.20 Like many other early "enrichment" programmes,21-30 Project 3000 was predicated on a knowledge deficit model in which non-traditional students were seen as requiring additional input of factual knowledge, and underperformance or withdrawal from the course was attributed primarily to inability to make the grade in coursework.
Contemporary theories of recruitment and retention in higher education explain students' choices (and failures) primarily in terms of personal identity, social capital, and the cultural "frames" in which potential options are considered (see discussion). As part of a needs assessment to inform enrichment initiatives at University College London, we sought to find out what going to medical school meant to academically able 14-16 year olds from a range of ethnic and socioeconomic backgrounds, how they constructed their own identity as potential medical school applicants, and what social and material resources they felt they could draw on.
Participants and methods
We approached six schools, deliberately chosen to provide a wide mix of socioeconomic and ethnic backgrounds (table 1); all agreed to participate. Teachers were asked to identify Year 10 and 11 pupils (pre-GCSE and GCSE years, age 14-16 years old) who were predicted to gain high GCSE grades in subjects relevant to medical school application and who had shown interest in applying to medical school. (Further details of the background of each school and the research process are given in Box A on bmj.com).
Table 1 Characteristics of the six schools that participated in the focus group study
After explaining the purpose of the study to the selected pupils, the lead researcher distributed paper and invited the pupils to list any questions they had about medical school. We answered these questions after the focus group was completed; we also took away the sheets of paper for analysis. To begin the focus group, the lead researcher showed a silhouette of a face and told the group: "This is X, who is a 16 year old pupil applying to medical school this year. She/He is probably going to do well—what do you think she/he is like?" After a discussion of the qualities of this "successful" fictitious pupil, the group were shown another silhouette and told "Y is a pupil of the same age who is thinking of applying to medical school—but she/he has got some concerns. What do you think these might be? What do you think the barriers might be to her/him succeeding?" The sex and ethnicity of the fictitious pupils were varied in different groups. Further discussion prompts were introduced to explore the pupils' perceptions and aspirations:
"What help or preparation might Y need?"
"Y is at medical school now. What do you think it's like? What do you think she/he is worried about now? What do you think she/he is enjoying?"
"Do you know any doctors personally? Any relatives or friends who are doctors? What doctors do you recall from television or films? What do you think about them?"
"Do you know anyone who has been to medical school ? What do they say about it? What picture do they paint?"
"X and Y are now qualified doctors. What do you think their life is like? What are they enjoying? What are they finding less good and why?"
All focus group discussions were transcribed and annotated with contemporaneous field notes. All three researchers read all transcripts independently and coded responses using the constant comparative method.31 Each item within the data was compared with the rest of the data to establish analytical categories; negative cases that ran counter to the emerging themes were used to refine the themes. Consensus of coding categories and a final list of key themes was achieved iteratively through discussion and re-reading of transcripts. We circulated this list, with verbatim quotes to illustrate the themes, to key contacts (teachers or heads of careers) in the six schools, who were asked to distribute these to participants for respondent validation. Four of the six contacted us to confirm that they agreed with the findings (comments included "Spot on" and "Agrees exactly with my own feelings"), but to our knowledge none had actually shared the preliminary interpretation with the pupils.
Results
Sixty eight pupils from diverse ethnic backgrounds took part (table 1). We found few consistent differences in perceptions and attitudes between pupils from different ethnic groups, and relatively few by sex, but marked differences by socioeconomic status as assessed by occupation of head of household. The main themes are listed below, and illustrative quotes are given in box B on bmj.com.
Focus group dynamics
One of our most striking findings was the behaviour of working class boys from both white and black backgrounds (we had few Asian boys in our sample except in the independent school). In both the inner city focus groups that included boys there was a cohort of vocal "lads" with strong peer group identity exhibited through accent, dress, and behavioural norms, whose interjections were directed at subverting the purpose of the focus group through humour and "bad boy" activities (see box B on bmj.com for examples). These boys were highly able (one disruptive pupil from school A, for example, had recently won a national scholarship to study A levels at a leading private school) but presented themselves as non-academic and not really a serious part of the research study. Careers teachers confirmed similar behaviour from these boys in class.
Reasons for wanting to do medicine
Pupils from higher socioeconomic groups viewed medicine as having high intrinsic rewards such as personal fulfilment and achievement, and saw it as one option in a menu of other high status career paths. Several had been inspired to study medicine by a positive role model or after experiencing illness in themselves or a family member. Many such pupils had done their own research and had a clear strategy for pursuing their goal. Pupils from lower socioeconomic groups, especially boys, talked more about the extrinsic (financial) rewards of medicine and about the "blood and guts" of the job. They had a stereotyped view of doctors, often derived from media images, and had not tried to flesh out the detail of particular options.
Perceptions and concerns about applying to medical school
Many pupils, especially but not exclusively from lower socioeconomic groups, had hazy perceptions of the steps needed to become a doctor ("Do you need any sciences?"). All pupils believed that entry is highly competitive and were anxious about making the grade. Inner city pupils rated their chance of an application being successful at around 1 in 10 (in reality it is around 2 in 3). Pupils from comprehensive schools felt that not having perfect grades would put them at a disadvantage compared with applicants from "better" schools, and that commitment and enthusiasm would not compensate for this.
Few pupils had made a firm commitment to medicine by Year 11 (15-16 years old). They did not feel ready to select their A levels with medicine as the goal. Many admitted to taking science subjects as a means to an end and resented cutting off alternative choices at a young age. Independent school pupils were more confident that they would achieve a place at medical school and were less prepared to "jump through hoops" to bolster their applications. Pupils from the schools in the two most deprived areas often had only a vague idea of the alternative options ("There's always cars") available to them if they failed to make the grade for medicine, and boys in particular did not plan to make strategic "insurance choices."
Who gets in?
All the groups gave a similar picture of the person who finds it easy to gain a place and succeed at medical school. Typical descriptors were intelligent, hardworking, dedicated, and tough ("stubborn," "headstrong"), interested in people, caring, enthusiastic, ambitious, and able to cope with pressure. We did not find any evidence of perceived prejudice in the admission process by sex or ethnicity. However, there was a strong perception among less affluent pupils that high social class and a privileged education would confer an advantage in the admissions process:
"The way she carries herself and her grades... like at interview if she does well."
"How would she carry herself?"
"Respectively , talking properly, and dressing appropriately, a lot of confidence."
"Not saying it in a common accent, say it properly."
"If they speak well then they'll look more well educated."
(Boys from school B)
There was a perception among pupils from all the inner city schools that there is a certain type of person who goes to university, and that having non-academic interests makes you the wrong type even if you've made the grade in school exams. But pupils from more affluent backgrounds were able to counter the stereotype of the "boring swot with no social life" with positive role models of people they knew personally.
What is medical school like?
Almost all pupils showed a remarkable lack of knowledge about what actually goes on at medical school and about medicine as a profession. Pupils from inner city schools had concrete concerns about the physical environment at university, especially food choices and type of "dormitories"; more affluent pupils did not raise these issues at all.
All pupils perceived medical training as a long, hard course with little time for socialising. But there were important differences in what this meant for them. Pupils from professional backgrounds saw intrinsic rewards in the coursework ("tiring but fun"). Those from the lower professional and intermediate backgrounds described a trade-off (sacrifice now for rewards later). But pupils from lower socioeconomic groups often saw no intrinsic reward from the academic work ("it's cruel") and struggled with the idea of deferred gratification.
A few inner city pupils had a perception of university as "changing your life," but this change was seen in distant, global, and somewhat unreal terms. When asked for specific examples, these same pupils could only cite individuals who had dropped out of university.
The high cost of medical training was a concern for all pupils, but those from professional families did not see it as influencing their choices. Some inner city pupils were dimly aware of scholarship schemes for which they might be eligible. Pupils from schools D and E (mostly lower professional and intermediate backgrounds) were concerned that they would be ineligible for financial benefits and that on graduation they would face severe financial hardship compounded by long hours and work stress.
There was a big fear about failing and dropping out. Inner city pupils greatly overestimated the likelihood of failing the course (one group rated this at 74%), and as the quotes on bmj.com show, this fear was closely linked to anxieties about money.
Need for information and resources
Pupils wanted information about what doctors do, what goes on at medical school, and admissions requirements, especially from independent sources that would allow them to compare the strengths and limitations of different courses. Some pupils had tried to find information to guide their choice of GCSEs or A levels, but had not found what they were looking for. University websites and prospectuses gave admissions information directed at pupils aged over 16 years, but this was not experienced as meaningful by the younger age groups in this study.
School E had received booklets from a London medical school aimed at GCSE pupils. The pupils in that focus group had clearly read the booklets and found the information helpful and credible. They were particularly inspired by a section on "dispelling myths," which had reassured them that medical students did not have to come from "posh" homes or independent schools.
Parental support was often mentioned spontaneously. Boys were more likely to see parental support in financial terms, whereas girls saw it more terms of psychological and emotional support, and, for the Asian girls, the opportunity to live at home.
All groups felt that talking to real students and recent graduates would be the best way of finding out what medical school (and medicine) is really like. The crucial characteristic of a credible person to speak to was homophily with the pupils themselves. Girls in particular wanted subjective and motivational information from someone they identified with (and who could identify with them).
The pupils from inner city schools were cynical about glossy brochures and people from universities who came round to market their courses. All groups were keen on work experience in which they met real patients and gained a flavour of what medicine is really like. The most useful placements were felt to be shadowing junior doctors. Some told stories of friends who had been given "unsuitable" placements (that is, without direct patient contact) such as microbiology labs or administration.
Several pupils commented that they would like to find out whether they would be academically able enough to cope with the medical course before "burning their bridges" for other options. One suggested that a voluntary aptitude test to be taken at age 15 could provide pupils with an indication of whether their aspirations were realistic.
Discussion
This in depth study of London schoolchildren aged 14-16 years reveals important differences by socioeconomic background in perceptions of, and aspirations to, medical school, which both outweighed and moderated the influence of sex and ethnicity. Working class boys (that is, those who identified their head of household as in a routine or semi-routine job or unemployed) showed a common pattern of intense peer group bonding, anti-school values (enacted as subversive behaviour in the focus groups), low self confidence despite high academic ability, and cynicism towards enrichment initiatives—a combination that may account for the continuing poor recruitment of both white and black pupils from lower socioeconomic groups to UK medical schools.5 6
Two main approaches have been used to study how pupils choose their post-16 options. Large scale quantitative surveys, in which participants are asked to indicate which of a long list of possible factors influenced a particular choice, can test hypotheses about macro-level links between attainment variables (such as A level points) and application success.3 32-38 In depth qualitative studies provide a rich picture of a smaller number of individual decisions and are the method of choice for exploring the reasons for particular choices in defined subgroups.39-42
Comparisons with other studies
Our findings align closely with those of other researchers. In a large questionnaire and interview survey in Britain, Ball et al showed that social class, not ethnicity or sex, was the strongest predictor of both parental choice of school for 11 year olds and post-16 choice by pupils.43 The same authors interviewed 65 school pupils from minority ethnic groups spanning all socioeconomic groups and found that socioeconomic, rather than ethnic, differences were the most critical influence on university choices.44 Foskett and Hemsley-Brown have reviewed several smaller studies that produced similar findings.40 These consistent and dramatic differences by socioeconomic background raise the question of what it is about being "working class" that puts pupils off university.
Paul Willis, who undertook a detailed ethnographic case study of a group of "lads" in their final year of a northern secondary modern school in the 1970s, made the controversial suggestion that the link between traditional working class identity and academic failure was embodied and reproduced in the social relations of the school itself.45 The lads' resistance to school authority and rejection of its values allowed them to build a strong counterculture of "mucking about" and resisting work—but this very counterculture inexorably destined and prepared them for working class identities and jobs. More recently, Archer and Hutchings undertook an in depth interview study of 15 year old working class boys from diverse ethnic backgrounds in inner London.46 Their participants had constructed complex masculine identities characterised by racism, sexism, and strong class awareness—and embodied through accent, speech, dress, and style (rejecting anything "posh," "smart," and "polite"). They had a strong sense of belonging to their peer group and to the local area in relation to particular spaces and ideas of safety and danger. As in our own study, the boys positioned their carefully constructed "rough" identities as barriers to getting into more middle class jobs and college courses.
The notion that, despite the rhetoric of meritocracy, working class pupils cannot be classified as active choosers in education has been developed further by Bordieu,47 48 who sees choice as part of the "normal" middle class life narrative, in which a spell at university is highly congruent with family and peer values, financial security can generally be assumed, individual identity is independent of a particular locality and peer group, and the only choice is between institutions and courses. Others, drawing on Bordieu, have described the working class decision to enter post-compulsory education as far more limited, generally discordant with personal and cultural identity, associated with major financial risk and separation from a valued local peer group, and (therefore) highly contingent on structural influences, chance, and circumstances.40 49 50
On the basis of their empirical findings, Ball et al produced a theoretical taxonomy of higher education chooser based on two "ideal types": contingent and embedded.43 44 Their model (which we have adapted slightly in table 2) accounts for many of the class differences we observed in our study.
Table 2 Two kinds of higher education choosers (adapted from Ball et al43 44)
Implications for policy
The UK government's latest policy documents on widening participation recognise that achieving diversity in higher education must go beyond the knowledge deficit model and address the root causes of low motivation and cultural disaffection in non-traditional students.51 52 US medical schools have embraced "partnership" and "pipeline" models, in which they seek long term relationships with schools in target areas, align their outreach activities with mentorship and community development initiatives, and provide a more culturally inclusive environment on campus.53-58 However, there has been little systematic research into how far these models actually address issues of identity, motivation, and "framing" in under-represented groups.
We predict that initiatives to reduce socioeconomic inequalities in medical school admission are unlikely to succeed unless they acknowledge and address the close link between self esteem, personal identity, and particular aspects of working class culture that run counter to traditional academic values and aspirations. We suggest, for example, that the next generation of enrichment initiatives should be locally developed and delivered in targeted deprived areas, use non-authoritarian approaches that embrace the unconventional, make extensive use of mentorship by role models from non-traditional backgrounds, draw on the peer networks and group identity of working class youth, and explicitly address the high personal risk and structural and financial constraints faced by applicants from low income groups.
What is already known on this topic
There are wide disparities in medical school admission by social class
Widening participation initiatives in medicine have so far had limited impact
This may be because they often seek to "top up knowledge" rather than addressing motivation, identity, and culture
What this study adds
School pupils from working class backgrounds see medical school as distant, unreal, and culturally alien
They may link their cultural identity to anti-academic values
They also associate a medical education with prohibitive personal risk and greatly underestimate their chances of successful application
Editorial by Hilton and Lewis
Details of the schools involved in the study and quotes illustrating the main themes from the study appear on bmj.com
We thank the focus group participants and wish them success in their future careers. We thank the schools, especially our key contacts, for their work in making this study possible. Marcia Rigby was project manager, and Nazia Ali kindly assisted with the fieldwork in school C. We thank Lewis Elton, Stephen Rowland, Jill Russell, Sean Hilton, and Jane Hemsley-Brown for helpful comments on earlier drafts of this manuscript. We also thank BMJ Publications for a generous donation of books on learning medicine for the schools' libraries.
Contributors: TG conceptualised the study. TG and KS did the fieldwork. All authors analysed the data. TG and KS wrote the paper.
Funding: KS undertook part of the work for this study as a dissertation for BSc in primary health care. The Widening Participation Unit at University College London provided support for study expenses.
Competing interests: No financial conflict of interest. KS is British Asian, TG and PB are British white. All authors were originally from social class III non-manual when they applied to university.
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