“Aspirations of people who come from state education are different”: how language reflects social exclusion in medical education
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Despite repeated calls for change, the problem of widening access (WA) to medicine persists globally. One factor which may be operating to maintain social exclusion is the language used in representing WA applicants and students by the gatekeepers and representatives of medical schools, Admissions Deans. We therefore examined the institutional discourse of UK Medical Admissions Deans in order to determine how values regarding WA are communicated and presented in this context. We conducted a linguistic analysis of qualitative interviews with Admissions Deans and/or Staff from 24 of 32 UK medical schools. Corpus Linguistics data analysis determined broad patterns of frequency and word lists. This informed a critical discourse analysis of the data using an “othering” lens to explore and understand the judgements made of WA students by Admissions Deans, and the practices to which these judgments give rise. Representations of WA students highlighted existing divides and preconceptions in relation to WA programmes and students. Through using discourse that can be considered othering and divisive, issues of social divide and lack of integration in medicine were highlighted. Language served to reinforce pre-existing stereotypes and a significant ‘us’ and ‘them’ rhetoric exists in medical education. Even with drivers to achieve diversity and equality in medical education, existing social structures and preconceptions still influence the representations of applicants and students from outside the ‘traditional’ medical education model in the UK. Acknowledging this is a crucial step for medical schools wishing to address barriers to the perceived challenges to diversity.
KeywordsIncreasing diversity Widening access Discourse analysis Corpus linguistics Othering
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).
We drew on “othering” as a conceptual lens for exploring and understanding the judgements made of WA students by Admissions Deans, and the practices to which these judgments give rise. Drawn from studies on ethnic and racial inequality (e.g., Van Dijk 1984), “othering” is “the process of representing an individual or a social group [through language] to render them distant, alien or deviant” (Coupland 2010a, p. 5). Linguistic representations are seen as lying “at the heart of both social integration and cohesion, and social division and exclusion” (Coupland 1999, 2010b, p. 242). By drawing on socially constructed representations, or prejudices, to describe specific social groups—for example, immigration is linked to crime, deviance, and threat (Ter Wal 1997) or widening access students are “different” and/or deficient, the speaker reinforces the perception of that group as not belonging to their own social structure, therefore reducing the others as inferior in some way (Schwalbe et al. 2000).
“Othering” is manifest in discourse: a speaker can effectively distance themselves from individuals and groups by classifying them as “anomalous” or “peculiar,” via objectification or stereotyping (Hall 1997; Riggins 1997). Whether this is unintentional or deliberately intended to create distance or segregation, the outcomes are the same (Coupland 2010b) maintaining power differences/protecting the interests of the group holding the power (e.g., Smith 2000; Sacks 1995; Van Dijk 1984), and leading to exclusion (Reisigl and Wodak 2001).
Given this focus on power in the “othering” lens, we used critical discourse analysis (CDA) to take a critical perspective in looking at the Admission’s Deans language. The central focus of CDA is to underline power structures and detail, how these are manifested in institutions through the analysis of the discourse of, and between, specific groups. According to Van Dijk (1993, p. 254) ‘Power involves control, namely by (members of) one group over (those of) other groups’. This power is enacted through the most routine forms of text and talk (Van Djik 1993), in this case, the talk of Admissions Deans. Considering the language used by the Admissions Deans to represent groups or individuals categorised as WA or “non-traditional” applicants, enabled us to examine key points of difference and institutional values associated with social divide. Applying CDA to examine the discourse of othering or difference can therefore provide insight into the presence of broader socially-constructed representations of outgroups (Tajfel and Turner 1979) and consequently allow for further discussion on the potential effects of negative representations on the integration of group members in context.
While fundamentally CDA focuses on examining what discourse structures are deployed in the reproduction of social dominance, different approaches may be theoretically and analytically quite diverse, drawing on disciplines including sociology, linguistics, media studies, political studies and psychology, among others (Van Dijk 1993). Taking the perspective of language as a social practice (Fairclough and Wodak 1997), we employed a mixed-method approach combining Corpus Linguistics (CL) and Critical Discourse Analysis (CDA) to enable a rich examination of context and content. Combining these two approaches has become increasingly popular in discourse analysis over the last 25 years or so (e.g., Fairclough et al. 2007; Koller and Mautner 2004; O’Halloran and Coffin 2004). While purely quantitative CL approaches may be criticized for disregarding context (Mautner 2007; Brown and Yule 1982), examining concordances and meanings in the way described below can help infer contextual elements (the bigger picture) in readiness for a close-up CDA analysis of the data. Our precise approach to marrying CL and CDA is explained in detail in the data management and analysis sub-section below.
The interviews were digitally audio-recorded and anonymized through the transcription process, then entered into qualitative data analysis software (Atlas-Ti, Version 7.0). Originally, we conducted a primary level thematic Framework Analysis to determine content- and process-related themes i.e. what participants said and how they said it, respectively (Ritchie and Spencer 1993). This is published elsewhere (Cleland et al. 2015). This data suggested that Admissions Deans had powerful yet different positions in relation to widening access. These ranged from positions of relative indifference to those of full engagement, and were critical to interpreting and enacting WA policy. Participant’s use of language in terms of how WA students are represented emerged as a potentially important process-related theme which we decided to explore directly in the current study.
The analysis process
Step 1: Corpus linguistic analysis—“large pattern” identification
Step 2: Categories of representation (pronominal use, naming strategies)
Step 3: Data tagging [as per Coupland’s (2000) discursive manifestations]
Step 4: Critical discourse analysis (CDA)
After this initial CL analysis of the data for frequency list and concordances, the data was divided into categories of representation to further understand how students and their social contexts were being represented or categorized (e.g., Magalhaes 2006; Stubbs 1997). This included an examination of how the students were referred to by participants (e.g., in terms of their education, family, location/social class). Given how ‘naming’ always involves choice (Fowler 1991), pronominal use and direct naming strategies were examined to identify descriptions of WA participants and positive/negative instances of social integration through language choice respectively. Utterances considered Othering Strategies (Coupland 2010a) were then tagged and quantified before undertaking a deeper qualitative analysis.
Finally, we tagged the data in accordance with Coupland’s general discursive manifestations: homogenization (specific cultural traits or behaviours); pejoration (assigning specifically negative attributes); suppression/minoritisation (e.g., omission, selective representation or positioning group in specific roles); displaying “liberalism” (e.g., hedging offensive remarks by claiming non-prejudicial intention; achieved by constructing a favourable image of self); and subverting tolerance (e.g., ridiculing political correctness). The use of this framework enabled us to consider the level to which othering discourse was used in the text, and then consider the potential consequences of these negative representations on the integration of WA students in medical schools.
These categories were then examined qualitatively from a CDA perspective. We examined the text for structures, strategies or other properties of text, talk, verbal interaction or communicative events. Specifically we looked at the language used by Admissions Deans to represent groups or individual categorized as WA or “non-traditional”, and how their language reflected difference and distance, and exclusion. 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 1985). This approach correlates with Sacks’ (1995) view that social categorization is never neutral.
Because ‘no research is free of the biases, assumptions, and personality of the researcher and we cannot separate self from those activities in which we are intimately involved’ (Sword 1999), we constantly considered our own positions in relation to the study and the data (Berger 2013). This reflexivity was important given we were co-constructing the data from two perspectives: that of “insider” (JC) and “outsider” (TPF). We met regularly monitored our stance and possible biases in relation to the study material, and we sought critical feedback from other colleagues to help with this reflexive process.
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:
In this example, prospective WA students are referred to as being from some backgrounds, which is then followed by the assumptions that people from these backgrounds don’t think of medicine in the first place. This immediately positions WA participants as different to the norm of students who would usually undertake medicine as a career and also infers a lack of capability to think about medicine in the first instance. These findings are representative of the data and illustrate that utterances rarely conveyed a positive construction of WA students. This was similar in the use of these students and those students. The use of pronouns these and those serves to distance the speaker from the students (Benwell and Stokoe 2006). Considering the implications of discourse in the construction of a viable institutional identity, the use of such pronouns serves to render WA students distant to the traditional students referred to as our students or traditional students. Contrastingly the use of the representation traditional students served to reinforce a positive identity for this group within the institution.
So it’s very difficult to know what groups are disadvantaged. I think we do realise that, from some backgrounds, it’s a case of people don’t think of medicine in the first place. They think it’s not … I think, perhaps, they think it’s not a suitable career for them.
The data also demonstrated cases of WA students referred to as our students. In these interviews this use of the inclusive pronoun our (Myers and Lampropoulou 2012) correlated with a higher level of integration and success in these institutions.
In the most positive discussion of WA and WA student experiences in the dataset, this interviewee consistently refers to WA students as ‘our students’. This emphasizes a sense of solidarity with the students and constructs the students as belong to the in-group and to the institution. Although the students form separate cohorts, they are still represented as belonging to the central structure of the institution. This example provides insight into the use of pronoun usage as a mechanism to include WA students as part of the social structure, however there is also a reference to traditional entry medical students who are attributed with having the confidence and resources to access medicine drawing a clear distinction between the two groups albeit for comparative purposes.
Our students get through, um, and, you know, we’ve got a lot of them, we’ve got five cohorts who’ve graduated. We, we, we’re on the right track. Because, as well, when you, when you see, um, traditional entry medical students and they, if they, and the majority do, come from schools of more affluent, ah, nature, be they private or, you know, better funded schools or whatever, um, they are prepared by their teachers or teachers and parents for interview. Um, and they have a confidence and, um, knowledge and they have the preparation behind them. But a lot of our students don’t have those facilities and resources available to them at their schools.
The examples used to reference WA students served to categorise this group specifically in terms of their socio cultural positions and the perceived challenges facing them. The examination of these quantitative results therefore led to a need to comprehend the level to which WA students were being categorised and represented as an ‘outgroup’ in medical education. The data was tagged for deeper instances of ‘othering’ in order to fully comprehend how these representations reflect institutional values and beliefs surrounding WA students and practices.
As stated above, the data was firstly tagged for instances of ‘othering’ according to Coupland’s discourse strategies of otherness. This identified a total of 109 utterances which could be considered ‘othering’ across 22 of the 26 interviews. These utterances proved examples of WA participants being represented as a group ‘outside’ the traditional medical student cohort. Four of the five othering strategies outlined by Coupland were identified in the interviews: suppression, pejoration, homogenization and displaying liberalism. Suppression/Minoritisation was the most common form of othering found in the interviews, with 39 examples. This included instances of WA participants being represented as different in a way that rendered them deficient or inadequate when compared to traditional students (see later). Pejoration and Homogenisation also ranked high in othering strategies (30 and 27 examples respectively), whereas Displaying Liberalism was the least present form of representation (with nine examples). Subverting tolerance in its purest form was not present in the data. However the five strategies can be considered interconnected, and analysis indicated that ‘displaying liberalism’ could also be considered under the area of subverting tolerance. However, for the purpose of clarity, we excluded subverting tolerance as an individual strategy for this paper.
These initial findings highlight that representations focused on the characteristics and grouping of WA participants rather than any explicit forms of discrimination. Examples of each of the othering discourse strategies are presented below, with interconnections highlighted where relevant.
Homogenisation occurs where groups are categorized or defined in terms of generalized behaviours or specific cultural traits, the function of which is in terms of ‘confirming a predictable pattern of behavior’ (Coupland 2010a). The analysis identified 27 examples of general homogenisation in the interviews, most of which referred to the background of WA participants (see example below).
This example demonstrates the speaker articulating difference through constructing representations of WA applicants as coming from poor, deprived backgrounds. Not only is the economic background of applicants referenced but their family, community and origin which leads to the construction of a group whose characteristics are determined by their economic and social circumstances. This serves to reinforce the ideology of difference as the statement people with, who come from these backgrounds are considered as different to those from backgrounds that would be more likely to do medicine. The following example conveys a similar stance:
But what is often perceived, and reality might be a little different, is the political goal is something different, and it’s, it’s more people with, who come from sort of, you know, socio uh, poorer, more deprived socioeconomic groups, in terms of their families, or their communities, or their own origin, and that and that somehow, success will be defined when you have greater numbers from those backgrounds.
Here, the social profile of the applicants is again evoked. The lexical choice markedly different leads to the construction of a significant distancing between the interviewee and the group to which s/he refers. This representation constructs a strong outgroup for the WA applicants. The utterance let’s put it that way indicates that the interviewee is aware of the implications of representing this social group too negatively, however the level of difference evoked in their previous comment nonetheless functions to reinforcing an outgroup. This form of hedging, or the use of language to lessen responsibility in the statement (Darian 1995; Fraser 1975) in relation to statements of difference, was found in a variety of interviews, for example:
That’s right. It’s always it’s already a restricted group, or certainly a markedly different social profile, let’s put it that way.
The use of vague language [language that softens expressions to be less direct or assertive, (Cutting, 2007)], in this excerpt (some students, from a variety of different sources, you know have come from backgrounds that, um) allows for the subtle differentiation of WA participants to traditional students without the authority and assertiveness that a more direct statement would have. Vague language allows the speaker to convey messages without claiming full responsibility for the implication of meaning thus this statement highlights a distance between WA students and others. The majority referred to here are “traditional” medical students from higher socio-economic and professional backgrounds. This example demonstrates that WA applicants are categorized as different and highlighting a point of difference leads to defining them as anoutgroup. It also leads to the minoritisation of this group as these utterances confine them to roles and characteristics which are defining, and which limit their options (Coupland 2010a).
Yes, some of them do. Some of them… there are some who come from, um… yes, there are some students who apply and join us who, um, from a variety of different sources you know have come from backgrounds that, um, are different from the majority.
Pejoration is the categorization of others under specific negative traits, characteristics or qualities, ranging from barbarism and instability or incompetence or nervousness (Coupland 2010b, p. 250). The strongest form of pejoration was found in the construction of WA students as lacking aspiration.
…that they feel, is in our area, total lack of aspiration. It’s not that they don’t have gifted children who could do it, it’s that they’ve got no aspiration.
By referring to, or implying, the lack of aspiration by those from ‘non-traditional’ backgrounds, interviewees constructed WA applicants as weaker, and less resourceful, than traditional applicants to medicine. This negatively-assigned attribute could be considered as justifying the fact that students from ‘these areas’ do not apply to medical schools and therefore serves to position them further in the outgroup.
…those candidates who might have otherwise not thought about medicine as a career or thought it was too ambitious, ah, ah, an ambition to have.
The perceived lack of aspiration presented by the interviewees corresponds to a wider social perception that in order to be successful, one must take responsibility for their own situation and therefore have the aspiration to progress socially (Valentine and Harris 2004). This notion can be observed in the following example:
By constructing the representation of students from this background as having ‘different aspirations’, the speaker immediately conveys a sense of ingroup/outgroup (Tajfel and Turner 1979). It places the students in a position of disadvantage to begin with and can be considered as a strategy of othering that creates a distance between this group and others that have more positive aspirations. The choice of the utterance aspirations of people who come from state education are different also positions the group in a less desirable role as aspiration and motivation to succeed can be considered as linked to personal responsibility rather than a construct of structural disadvantage. This notion is discussed in further detail by Valentine and Harris (2004), findings in their study of class perception highlight the perceived importance of ‘agency, self-management and personal responsibility in a meritocratic society in which poverty and disadvantage were implicitly regarded as individual failings—the result of poor investments in terms of effort and in choice-making or risk-taking’ (p. 87). By choosing to draw on the lack of aspiration as a quality that characterises this group, the speaker therefore relies on the stereotypical image of the deviant working class with no aspirations or hope for the future (Valentine and Harris 2004). This also allows the speaker to maintain his/her own position as the gatekeeper to an aspirational life through providing access to a career such as medicine.
I think, that, um, all the work the xxx has done certainly shows absolutely clearly that the aspirations of people who come from state education are different in terms of where they consider applying to, and indeed, where they’re successful in getting a place to study at university.
This statement also provides an example of a strong generalization across groups of students from state education. By reducing students from state education to a few negative characteristics (low aspirations, not suitable for access to university), the speaker constructs a ‘marginalized other’—‘they’ are different to ‘us’.
The issue of social status and the existence of power structures between prospective students and medical schools were referred to in a number of interviews. The following example illustrates the demarking social factors at play for non-traditional applicants to medicine:
In arguing that ‘a lot’ of recourses are employed to encourage students to apply to this specific institution, the speaker refers to students as students from socially-deprived backgrounds. While this reference may derive from official elements of categorization for admissions, its use results in homogenization and the construction of distance and inferiority. This is reinforced through the use of pronouns ‘we’ and ‘they’ and the fact that ‘they’ are creating a problem by not applying. The rational provided for the lack of applications is that this group of students think it’s too posh. This directly implies that students from socially-deprived backgrounds feel ‘othered’ (inferior), and do not consider medicine as an avenue for them, as has been suggested by other studies (Greenhalgh et al. 2004). This representation is a clear example of pejoration as it implies that students from these backgrounds do not have the resources to recognize the social context of the institution, posh or not. This negative statement concerning the perceived viewpoint of applicants therefore acts to justify the presence of lack of interest or understanding of the institution. Rather than representing the university as the source of the potential problem (Alexander et al. 2017), the onus and responsibility is placed on the potential applicant.
So there is a lot that goes on centrally to try and encourage students from socially-deprived backgrounds to even think about applying to XZX. Because the problem we have is, they’ve got to apply, and they don’t because they think it’s posh.
Suppression and Minoritisation
Suppression and Minoritisation are achieved through zero representation or restricted representation or where groups’ roles and perspectives are restricted through stereotyping (Coupland 2010a). This form of othering strategy was the most frequent form of othering in the data. This could be due to numerous factors; utterances were tagged under this category where WA applicants or students were defined under specific roles or fulfilling specific expectations in the medical institution. The higher quantity of role-related representations is not unexpected as the interviewees were asked questions specifically related to the performance of WA students, however the only those considered as ‘othering’ were detailed for this study. Utterances that were perceived to highlight students’ background as influencing the quality of their contribution were considered as ‘supressing’ as they define students in a role or category based on their social background. This ‘othering’ was generally presented in the form of representing students as having a specific role within the institution based on their academic performance, their struggles, or their perception of their own background within the institution:
This example considers the role of the medical school in making students feel supported when they enter the institution. Although it can be deemed a positive statement in terms of projecting a desire to assist students, the representation of WA students as needing extra support and highlighting the issue that they’re struggling to keep up with their peers serves to render them distant to those peers and the academic expectations of the institution.
I’m not saying that necessarily needs to be delivered by the medical school but work needs to be done on that area but then another bit of work needs to be done on making sure that they’re supported so that they are performing at the same level quickly enough once they get to medical school and it’s not that, you know, they come to medical school with all these hopes and then they’re struggling to keep up with their peers.
Suppression also occurred in the form of positioning students’ own experiences to exemplify the difference of the outgroup:
The utterance one of things we’ve found is that of course we’re changing the widening access group demonstrates that these students are considered socially different before they enter the system, and this difference is not valued positively (i.e., as something to hold onto, as something that can bring a contribution to medicine (Dowell et al. 2015; Morrison and Grbic 2015; Saha et al. 2008; Whitla et al. 2003; Komaromy et al. 1996). The statement also highlights the institution’s role in actively attributing certain social values and norms to students wishing to pursue medicine. It highlights a contentious issue of the possibility of becoming a doctor if from a working class background. The example functions to exemplify the negative characteristics deemed stereotypical of the working class (friends with children from various partners, lack of aspiration (Valentine and Harris 2004) and also to highlight these representations as not relatable to someone undertaking medicine (she found it quite difficult to relate to her mum and dad because she’d been changed by becoming a doctor). The use of this example by the interviewee therefore allows for the representation of the working class in a negative light and also to reinforce the perception of medical school as a superior institution.
And actually one of the things we’ve found is that of course we’re changing the widening access group. Um, and I can remember a girl saying to me how difficult she found it going home now because all her friends were living in, um, and they’ve got one or two kids and different kids with different partners and things like this; and actually she found it difficult to relate to them anymore. Another one said actually she found it quite difficult to relate to her mum and dad because she’d been changed by becoming a doctor. Um, so, you know, it’s difficult to know whether [sighs] well, you’re giving people choices and they’re taking them.
The interviewee’s use of this as an example of how the student feels alienated to her social background now that she has ‘become a doctor’ highlights that they think that medical education is a way to change, to move from being in the inferior WA group to the dominant social group (doctors). Other examples were specific in their representations of WA students as academically inferior:
The statement we had a good experience for a while is followed by statements loaded with inferential meaning. The lexical choice in the utterance every single one of them not only creates a sense of distance between speaker and subject but also leaves no room for misinterpretation of the negative representation of this group. This is continued in the utterance ended up being chucked out of the year which not only suggest a lack of academic competence but also reinforces the institutions power to expel the students. The lexical choice chucked is important to note as it conveys a sense of unworthiness of the student by drawing on the use of informal language to depict the image of being thrown out of medical school. It can also be connected with what was earlier discussed in the homogenisation section where WA applicants were represented as lacking in the social and cultural skills necessary to access medical education. The interviewee emphasizes this construction of an ‘us versus them’ stance with the statement what we won’t do is compromise our standards.
… we had a good experience for a while, last year, every single one of them, I think it was four of them, failed first year and ended up being chucked out of the year. This year, two out of the four we had to deregister because they didn’t pass their exams. So the attempts at widening, what we won’t do is compromise our standards.
Coupland defines the strategy of displaying liberalism in terms of how speakers modify the impact of their own representations of others, such as tagging these with more favourable self-identifying representations (2010b). The data thus far presented can clearly be interpreted as maintaining negative outgroup representations. It cannot be measured as to whether this was the intention of the speakers. For example,
By firstly stating that we are a fairly positive source of middle class, you know, white middle aged group in terms of parents the interviewee implies that the institution caters for a majority of one particular group, white middle class. The subsequent attempt to construct the institution as a fairly down to earth place, contrasts with this statement and can be considered an attempt to positively address the issue of attracting WA applicants. This positions the institution in a positive light as the interviewee constructs an image of openness and social equality. The statement is however again contradicted with the utterance we are keen to widen the net, as although this suggests an openness to welcome more WA participants, it also highlights that there institution focuses on a specific social group to begin with. This imagery suggests a sense of social responsibility but also aids to construct a clear outgroup of those outside the positive source of middle class described in the opening of the turn.
I think there is a view that we are a fairly positive source of middle class, you know, white middle aged group in terms of the parents. And even at our open days, you know, we do see that. But we do work very actively to try to encourage widening participation. Um, it you know, XXX is a fairly down to earth sort of place and, and we are keen to, to, um, you know, widen the net if we can.
Another example of positive self-representation contrasting with homogenising representation of the outgroup can be found in the following example:
This example indicates that the interviewee’s perception is that WA applicants are too socially distant to even wish to apply to this particular institution. By stating that the institution is a very particular place, the speaker appears to ascribe a certain stance to WA “kids”, one which helps keep them in an inferior place because they do not belong with the dominant group/in the particular place (Schwalbe et al. 2000). By drawing on the type of ‘place’ the institution is the speaker outlines the external perceptions that applicants may have. Rather than directly stating that students wouldn’t belong at the institution the speaker justifies a presumed sense of reluctance on behalf of the students. This one again serves to highlight the difference in social systems and backgrounds between potential WA applicants and the medical education institutions tasked with creating a more diverse and integrated school of professional doctors.
To be honest, is kids applying to do medicine anywhere, um, because I can: I think it’s quite understandable that some of them might not want to apply here as it’s a very particular place, and it’s a very particular type of course.
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.
Our thanks to the General Medical Council (GMC) of the UK for funding the original programme of work, and the admissions staff who gave their time to be interviewed. Our thanks also to the University of Aberdeen’s College of Life Sciences and Medicine (CLSM) Ethical Research Board for granting approval for this study. Our thanks to Kirsty Alexander, University of Aberdeen, UK, and Dr Anne O’Keeffe, University of Limerick, Ireland, for their helpful reviews of the analysis process and manuscript drafts.
JC led on the original data collection. TFP had the original idea for this secondary analysis of the data held by JC. TFP carried out the data analysis in discussion with JC. TFP wrote the first drafts of the methods and analysis sections of the document. These were reviewed and revised by JC who prepared the first draft of the introduction and discussion. Both authors revised manuscripts, and reviewed and agreed the final draft of the paper.
Compliance with ethical standards
Conflict of interest
The authors declare no competing interests. The data reported in this paper came from a programme of research funded by the General Medical Council (GMC) of the UK.
The Chair of the local ethics committee approved this study.
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