“Aspirations of people who come from state education are different”: how language reflects social exclusion in medical education

Despite much activity, investment and policy directives, people from backgrounds perceived as disadvantaged and minority, ethnic and cultural groups, remain under-represented, or excluded from, medicine worldwide on the basis of, for example, their social class or ethnic origin (e.g., AAMC 2014; Castillo-Page 2012; Behrendt et al. 2012, Cleland et al. 2012; Dickins et al. 2013; Millburn 2012; BMA 2009; see also the special issue of this journal, May 2017). In the UK, for example, evidence indicates that, while medicine has addressed issues of diversity in relation to gender and race, those from less affluent backgrounds remain less likely to apply and less likely to gain an offer to study medicine than applicants from more “traditional” (i.e. affluent and higher social class) backgrounds (Millburn 2012; Steven et al. 2016). Moreover, other research implies that the few widening access (WA: or under-represented minority [URM]) applicants who do successfully negotiate the complex medical admissions process may go on to feel unwelcome (Orom et al. 2013; Greenhalgh et al. 2004; Brown and Garlick 2007) and disadvantaged once at medical school (Dickins et al. 2013; Nicholson and Cleland 2017; Cleland et al. 2015; Stegers-Jager et al. 2012). Thus, despite repeated calls for change, the problem of widening access to medicine persists internationally, suggesting that it is important to consider what might be operating to resist change.

One barrier to change may be the language used in representing WA/URM applicants and students. The study of institutional discourse (defined as ‘amalgams of ways of talking, valuing, thinking, believing, interacting, acting; Gee 1992 p. 105) claims that language used by powerful members of institutions serves to reflect the values, norms and expectations of these institutions (Fairclough 2003; Drew and Heritage 1992). In order to understand the inner values of any institution, it is therefore fundamental to consider the language used in both how its members represent the institution itself (Habermas 1984), and how other groups outside the institution are perceived and represented (see also Benwell and Stokoe 2006). The discourse employed by powerful participants within an institution therefore serves to reinforce institutional values and may also define the codes of understanding necessary to engage and gain full membership to it (Mills 2004; Wenger 1998). This is apparent in relation to widening access. Studies have demonstrated apparent discourse(s) of difference when representing WA programmes and students (Razack et al. 2015; Alexander et al. 2017). There is a tendency to “pathologise” non-traditional students as different in terms of lacking the essential skills, attributes or knowledge to be successful in medical education and training (Orom et al. 2013; Brosnan 2009; Brown and Garlick 2007; Greenhalgh et al. 2004; Reay 1988). Applicants from non-traditional backgrounds are viewed in some ways deficient and, therefore, in need of support—via mentoring, extended programmes, pipeline programmes and so on (Cleland et al. 2012; Lakhan 2003; Mathers et al. 2011; James et al. 2008; Kamali et al. 2005; Saha et al. 2008)—before being considered suitable for medicine. Finally, the value of a diverse student population for improving service delivery to medicine (Dowell et al. 2015; Morrison and Grbic 2015; Saha et al. 2008; Whitla et al. 2003; Komaromy et al. 1996), is less prevalent to discourse that emphasizes WA as enhancing an individual’s social justice and mobility (Alexander et al. 2017; Nicholson and Cleland 2015).

While it might seem reasonable to present WA students as a distinct group to traditional students, to do so in a way that makes them seem “deficient” and “outside” may maintain social exclusion (Wertsch 1998). Moreover, by constructing widening access applicants and students as different through the use of less positive representation, the integrity and interest of the ‘ingroup’ of traditional applicants and students is maintained (Benwell and Stokoe 2006; Labronte 2004; Wodak and Reisigl 1999; Tajfel and Turner 1979). This is achieved through highlighting traditional students as having the desirable characteristics to be successful in medical education, training and working life, hence maintaining the status quo of medical schools being dominated by those from certain socio-economic groups (Sacks 1995).

In the case of WA and selection to medicine, Admissions Deans represent their medical school in a hierarchical role. Their discourse can be interpreted, therefore, as conveying the values of the institution in question (Watts 1999), which in turn may be serving to reflect and regulate the practice of widening access (Coupland 2000). For example, Deans’ representations of specific groups may have a strong influence on attitudes towards, and beliefs about, applicants and students from WA backgrounds (Fairclough 2003). Yet, to the best of our knowledge, Admissions Deans’ discourse surrounding the representations of WA applicants and students have not been directly examined in a UK context. Thus, we do not know if their language is constructed, internalized and transmitted in such a way that reflects issues of exclusion and dominance in the status quo.

Our aim was to examine the discourse of Admissions Deans in order to explore the issues and institutional values attributed to WA in medicine. We were specifically interested in the way social power, dominance, and inequality are enacted, reproduced, and resisted in relation to WA to medicine by this group. As social exclusion can be considered as a means of othering or distancing a group depending on their social status (Coupland 2010a), we considered the impact of language in maintaining social barriers through examining the Admissions Deans language in the context of selection and admissions in Medical Education. The following research questions guided the work: how do UK Admissions Deans position groups or individuals in their representations of WA or “non-traditional” applicants? How does their use of language act to regulate institutional practices, such as judging which applicants are most suitable for medical school and why?

We report here a secondary analysis of qualitative data from 26 individual telephone interviews, the purpose of which was to elicit the views, experiences and concerns relating to widening participant and access to medicine of UK medical school Admissions. The data represents 24 of the 32 UK medical schools (some schools nominated two interviewees). Full details of the study design, methodology and methods, and participant characteristics and institutions, are reported in Cleland et al. (2015).

Preliminary quantitative analysis of the data demonstrated the different terms used to directly refer to widening access students. This identified the following prominent referential strategies employed across the interviews, and their frequency of usage: “our students” (27 examples); “students from” (22); “these students” (4); “those students (4); “widening participation” (2) and “widening access” (1).

By referring to students as ‘WP students’ or ‘WP applicants’ the interviewees do not necessarily ‘other’ the students in the marginalising sense of the term. However, the most prominent form of naming was ‘our students” followed by “students from”, thus positioning WA students in a particular background, which the concordances identified as normally deprived, disadvantaged and/or from a lower social class. This is exemplified here:

To the best of our knowledge, this is the first study explicitly exploring UK medical Admission Deans use of language when speaking about applicants and students from widening access (WA/URM) backgrounds. We used Coupland’s (1999, 2010b) framework of “othering” to illustrate how language reflects existing social divides in medical education and the extent to which social exclusion/inclusion and full participation is a reality for students from WA backgrounds.

The findings of this study have shown that even within a context where achieving diversity and further equality in medical education is high on the political agenda (e.g., Millburn 2012; Cleland et al. 2012), existing social structures and preconceptions still influence the representations of applicants and students from outside the ‘traditional’ medical education model. The representations presented through “othering” seemed to confirm these pre-existing roles and generalisations, which confined applicants and students to class stereotypes and served as a consistent reminder of their social background. The data showed that even in cases where more positive constructs of students existed, there was a clear distinction between representations of WA students and traditional students. WA students were represented as having specific traits and characteristics that at times served to position them in position of academic inferiority and attributed them with a lack of contextual social awareness. These characteristics were enhanced as inferior or negative as they were considered as playing a fundamental role in the students’ success (or lack of) in medical education.

Furthermore, there was no indication in the data set that having a diverse student body may bring value to the medical school and ultimately patient care. Educating and training doctors who are representative of the society/populations they serve is considered by some as essential to improving healthcare quality (e.g., British Medical Association 2009; Cooper et al. 2003; Saha et al. 2008; Whitla et al. 2003; Xu et al. 1997). Although this may appear be rather an unachievable goal given all the different dimensions of similarity and difference between doctor and patient (e.g. gender, race, class, first language, cultural upbringing), there is some supporting evidence. For example, students who train in more diverse medical schools appear to gain a greater understanding of other people from different socio-cultural backgrounds, and this increases their ability to provide healthcare to people with backgrounds different from their own (Whitla et al. 2003). Additionally, emerging evidence suggests that students from “widening access” backgrounds believe they have a broader perspective on healthcare matters than their “traditional” fellow students and feel their ability to share a common narrative with patients from low socioeconomic backgrounds, is advantageous (unpublished Master’s thesis, University of Southampton, UK).

While othering is not always intentional, the impact of language choice in specific contexts cannot be underestimated. The effect of these representations in the interviews overall were that external social constructions or representations of the working classes were maintained and expressed accordingly. To be accepted as—or become doctors—requires leaving behind working class roots and conform to the norm of medical a schools. In this way, the discourse structures of Admissions Deans, who are in powerful positions in terms of enacting the values and beliefs of the institution they represent (Benwell and Stokoe 2006), can confirm, legitimatize and reproduce relations of power and dominance in the process of selection into medicine.UK Admissions Dean’s use of language (intentional or otherwise) suggests that the value of diversity within the medical student population is, as yet, undiscovered by this group. Shifting from thinking about WA as an initiative to address social justice for individuals, to one which values “discourses of diversity” (e.g., Beagan 2005), may be one way to change the representations of non-traditional students from negative to positive, and hence undermine the dominance of the current status quo.

There is also a lack of responsibility conveyed by the Deans in terms of the role that medical schools play in maintaining the supposed view of inaccessibility and social distance by WA applicants. In order to truly achieve integration and deconstruct the negative perceptions on both sides of the spectrum, this responsibility needs to be addressed. The values projected through language offer insight into how this could be done. For example, enhancing institutional awareness about presence of othering and the negative impact it can have on integrating communities within our systems would have the potential to bridge the social gaps which have led to the implementation of WA strategies in the first place.

Previous studies of this topic using a discourse approach have looked at one locality in depth (Razack et al. 2015). We choose breadth not depth, examining interviews from 24 of the 32 medical schools in the UK. However, although large-scale, the study was carried out in one (UK) context only and we do not know if our findings are transferable– it may be that “othering” in other countries is apparent but it is related to race or ethnicity rather than social class, as the basis for social exclusion from medicine appears to vary by context (e.g., AAMC 2014; Castillo-Page 2012; Behrendt et al. 2012, Cleland et al. 2012; Dickins et al. 2013; Millburn 2012; BMA 2009; see also the special issue of this journal, May 2017). The study could have been enrich by triangulating other sources of data, such as the mission statements of each of the participating medical schools; this is addressed in another paper from our team (see Alexander et al. 2017).

Our data draws out how Medical Admissions Deans linguistically represent applicants and students from widening access backgrounds, and thus we cannot infer from our data how these applicants and students react to the othering to which they are subject. To explore this directly, we suggest that the concept of othering could be used as an analytical starting point for understanding the social and cultural processes of considering, or not considering, medicine as an option for study in those from traditional and WA backgrounds. This lens would provide a new perspective on how potential applicants perceive their relationship to, and react to, the dominant majority (e.g., by accepting their inferior position, or by resisting it in some way.

Due to time restrictions we were not able to cover all elements of linguistic analysis. We focused on highlighting the forms of representations of WA applicants and students present in the interviews. By taking into account the context (the role of the participants, widening access policy in medicine), the social significance or pragmatic meaning (Leech 1983) behind the interviewees’ utterances could be examined. This allowed for an analysis of potential ‘othering implications’ behind utterances and also enabled us to pin point strategies that legitimated control and positioned groups in social categories (Fairclough 1995). However, further studies in the area could focus more specifically on the use of pronouns and lexical choice in actively constructing these representations. Another area to explore could consider an analysis of the actual admissions interviews in order to examine the interaction for elements of conscious or unconscious bias. However, our combined use of CL and CDA is novel in medical education research. Moreover, the combined use of CL and CDA allowed us to address criticisms of CDA—“much research in CDA has often neglected the subtle and intricate analysis of latent meanings and has left the interpretation of implicit, presupposed and inferred meanings to the intuition of the researcher and/or the readership” (Wodak 2007, p. 206)—by fully considering the meaning of the implied utterances. Hence, even with its limitations, this paper adds to the literature both in terms of findings and methodology.

Our partnership (TFP is a linguist whose areas of expertise include Institutional Discourse and Discourse Analysis, while JC is a medical educationalist with a track-record of research into selection and widening access to medicine) and the approach taken in this paper are in line with the emphasis within CDA on interdisciplinary work in order to gain a proper understanding of how language functions in constituting and transmitting knowledge, in organising social institutions or in exercising power (Wodak 2001).

In summary, through the use of Coupland’s (1999, 2010b) “othering” framework, this study highlights the very real issues of representing social groups in a way that ‘renders them different to the norm’. Labelling and categorising WA participants as different serves to confine members to specific roles and maintains lower expectations of this group. It also maintains the institutional value of the ‘traditional’ student as model norm. By maintaining a ‘them’ versus ‘us’ position, students from WA backgrounds are defined and restricted to specific roles before they even access the institution. We suggest that medical schools consider the impact of their own values surrounding WA applicants and students, and reflect on the extent to which these values are maintaining divides in medical education.