Understanding the relation between medical students’ collective and individual trajectories: an application of habitus

While medical educators typically attend to group trends, groups are made up of unique individuals. An exploration of Bourdieu’s concept of habitus, defined as a system of dispositions, may help medical educators think relationally about the collective trajectory of the group and the individual trajectory of each student. We built on our 4‑year, longitudinal study which reported how field, capital, and habitus worked together to explain how medical students, as a group, navigated transitions in undergraduate medical education. In this secondary analysis, we reviewed serial collections of narratives about students’ peak learning experiences in medical school (19 students, 5 narratives per student), concentrating on first-person representations of self. We then explored the relation between collective and individual trajectories in three illustrative cases. The social space of undergraduate medical education harmonized students’ experience and helped explain the collective trajectory, as evidenced by students’ consistent reports of taking initiative and staying open-minded. But individuals were not totally harmonized. They had unique dispositions that influenced their ability to access valued resources and shaped their behaviour. For example, Emily consistently spoke of being driven by her own goals; Zach focused on meeting expectations of authorities; Hilary routinely oriented toward abstract medical knowledge. Habitus provides a useful conceptual lens for thinking relationally about collective and individual trajectories of medical students. Our work may inform faculty as they seek to situate individualized learning within standardized curricula, and is a step toward researching transitions in medical training from a holistic perspective that includes, but is not limited to, individual trajectories.


Introduction
Medical educators often attend to group effects and act in ways that yield the greatest possible good for the greatest number of medical students. However, attending to the group comes with the risk of not attending to individuals who comprise that group. For example, if team-based learning is embraced by medical educators because it addresses a core competency in the medical school's formal curriculum, i. e., teamwork, then team-based learning is adopted as a teaching strategy for all students, regardless of individual learning preferences and efficiencies.
Pierre Bourdieu's Theory of Practice in general, and his concept of habitus in particular, reconciles a tendency to think in either/or terms; as applied to the team-based learning example, attending to either the collective or the individual [1][2][3][4]. Briefly, habitus is a system of durable, transposable dispositions that is shaped by one's past and present circumstances, and that shapes one's present and future [1,5,6]. Habitus provides a means of thinking relationally about objective, social structures and subjective, practical activity [2]. It also provides a means of thinking relationally about collective and individual trajectories [3]. To use Bourdieu's terminology, collective and individual trajectories are neither totally coordinated nor totally independent. He writes, Since the history of the individual is never anything other than a certain specification of the collective history of his group or class, each individual system of dispositions may be seen as a structural variant of all the other group or class habitus, expressing the difference between trajectories and positions inside or outside the class [1].
Habitus is not a standalone concept, but rather to be considered in concert with two related concepts: field and capital. A field is a structured, social space with its own rules and traditions that shape how individuals and groups interact for the purpose of acquiring resources recognized as valuable within that social space. These resources constitute capital. Individuals and groups rely on habitus to secure capital which, in turn, enhances their influence within a field [6]. In recent years, others in medical education have used Bourdieu's Theory of Practice as a conceptual lens, but not focused on habitus [7][8][9][10]. For example, Brosnan [10] reported that the field of medical education in the United Kingdom was shaped by schools' competition for different forms of capital, such that some schools oriented towards biomedical sciences and others towards clinical practice.
Building on these studies, we used Bourdieu's Theory of Practice to interpret interview data derived from a four-year, longitudinal study of medical students [11]. We observed how the field of undergraduate medical education shifted from an academic context in the preclinical phase to a clinical context in students' major clinical year. The field shifted back to an academic context as students focused on securing a residency position; however, this time the academic context had a competitive tone. When academics predominated the field in the preclinical phase, students, as a group, sought capital in the form of applicable medical knowledge and relations with attending physicians who could facili-tate connections within the medical profession. When the clinical context prevailed in students' major clinical year, they sought capital in the form of having a reputation for providing excellent care. Finally, as students prepared for residency selection, they sought capital in the form of test scores and letters of recommendation.
We also observed that to access capital within the shifting field of undergraduate medical education, students, as a collective, consistently relied on habitus oriented toward taking initiative and staying open-minded. For example, students took initiative by participating in extracurricular activities in the preclinical phase, thus forming relations with physicians who could 'open doors'. They took initiative in the clinical phase by 'pushing themselves' to excel in clinical care and to be noticed by attending physicians. And as students prepared for residency selection, they took initiative by 'making the most' of opportunities to connect with reputable physicians who could write letters of recommendation. In sum, we reported how field, capital, and habitus worked together to help explain students' transitions in undergraduate medical education.
Even upon publishing our primary study described above, we were intrigued by the interplay between group habitus, and habitus that seemed unique to individual students. On closer review of our data, we noticed that the stories students' told about their peak learning experiences varied considerably across students, but were relatively stable within an individual student over the course of four years. We believed a focused exploration of habitus might help medical educators think relationally about collective trajectories (group habitus) and individual trajectories (individual habitus), and ultimately, could inform medical educators as they seek to attend to individual learners within standardized curriculum. Thus, we posed another research question in this secondary analysis, 'How might the concept of habitus speak to the relation between collective trajectories and individual trajectories of medical students?'

Methods
Details of our primary study have been published elsewhere [11]. As part of a longitudinal case study, we interviewed 22 medical students at Columbia University College of Physicians and Surgeons (USA) over their four years of training. The Institutional Review Board at Columbia University Medical Center approved this qualitative study. We obtained written, informed consent from medical students before interviews began.
In the primary data analysis, we inductively created codes (i. e., words that act as labels for important concepts and ideas), iteratively revised codes based on incoming  data, and then clustered coded data into three broad categories: field, capital, and habitus. Regarding the last of these three, we routinely applied two codes ('putting yourself out there' and 'staying open-minded') to segments of data in which students talked about how they gained, or planned to gain, different forms of capital within the field of undergraduate medical education. Thus, we identified taking initiative and staying open-minded as habitus shared by this group of medical students.
In the interviews, we collected narratives about medical students' peak experiences, which we defined as salient events in medical school. Peak experiences did not have to be related to the formal curriculum or even a positive experience. For this secondary data analysis, we reviewed peak experience narratives from the 19 students whom we interviewed three times in the preclinical phase (at 4, 9 and 16 months into a total of 48 months, or 4 years, of medical school) and twice in the clinical phase (at 22 and 34 months into medical school), representing 86% of students who participated in the primary study. We borrowed a novel approach to analyzing students individual habitus from longitudinal psychological research called I-poems [12,13]. In contrast to thematic analysis, which tends to focus on the holistic meaning, I-poems trace change and continuity in an individual's sense of self [13]. By listening to how students talked about themselves via I-poems, we hoped to describe and analyze their individual trajectories. Two of us (DB and MD) independently read and reread each of 95 peak experience narratives generated by 19 students in the secondary analysis (five narratives for each student). Concentrating on every first-person representation of self, (e. g., 'I felt comfortable,' 'I was worried'), we transcribed first-person passages sequentially, and vertically, so that the selections read like a poem, (i. e., I-poem). By way of illustration, Fig. 1a represents one peak experience narrative; Fig. 1b represents the I-poem constructed from that narrative.
DB, MD, and BR met regularly as a team to review and refine their thinking about the individual trajectories reflected in each student's collection of I-poems. We invited a scholar well versed in social science theories, particularly Bourdieu's Theory of Practice, to complement and sharpen our theory-informed analyses as we iteratively reflected on our understanding of habitus in general, and of the compilation of collective and individual trajectories in particular.
As a check on trustworthiness, we shared with eight medical students our description of the collective trajectory and their individual trajectory. We asked if, and how, our analysis resonated with their experiences. Their reactions and comments gave us confidence that our interpretations were aligned with their experiences. For this report, we chose three cases that we believe best enable us to think relationally about collective and individual trajectories. To maintain confidentially, we used pseudonyms and provide only general demographics.

Results
Emily, Zach, and Hilary shared membership in the Class of 2014 at a prestigious medical school at a large research institution. This social space harmonized students' experience of undergraduate medical education and helped explain the collective trajectory, as evidenced by their consistent reports of taking initiative and staying open-minded.
But Emily, Zach, and Hilary were not totally harmonized. They had unique dispositions that influenced their ability to access certain forms of capital and shaped their behaviour. Emily, for example, was older than most medical students, having worked for several years as a teacher and international volunteer. I-poems provided a window into more nuanced understanding of individual trajectories, an understanding that could not be detected in differences in gender, education, or work-related experience (Table 1). In the following section, we present the stories of Emily, Zach, and Hilary in I-poem format.

Emily: achieving personal goals
Emily consistently talked about her personal goal of caring for the underserved, a goal crystallized through her years of international service before medical school. At the start of medical school, Emily referred to the intense preparatory work in the basic sciences as, 'the crisis that happens in medical school'. Rather than succumbing to the crisis, Emily responded in line with her commitment to accomplish what she set out to do: get the training she needed to care for the underserved.  Emily's unique dispositions were integral to her individual trajectory. And by virtue of class membership, the collective trajectory was also evident in her narratives.

Zach: 'Stepping up' to expectations of authorities
Zach came to medical school singularly focused on a career in a highly competitive surgical subspecialty. Zach consistently spoke of 'ambition' and 'stepping up'. And while all students spoke of taking initiative, Zach seemed particularly driven to meet expectations of external authorities. For example, Zach diligently positioned himself for success in his desired subspecialty, taking on roles that led him to work outside his comfort zone in order to gain necessary skills.

I've always done things in my life that aren't what I love the most. I've just sort of done them. I do them because I know they're sort of good for me.
Near the end of his preclinical training, Zach spoke of taking initiative to engage in extracurricular learning opportunities, even when those opportunities came at cost. For example, he travelled with the transplant team rather than study for the next day's exam. Hilary's dispositions, what set her apart from her classmates, contributed to her individual trajectory. But it did so in tandem with the collective trajectory of medical students.

Discussion
The field of undergraduate medical education shaped the habitus of the students we studied, as evidenced by their tendency to take initiative and stay open-minded as they navigated transitions in medical school. And while the field of undergraduate medical education shaped habitus, it did not predict habitus. Each student had his or her own trajectory that was shaped by their individual past and would shape their individual future.
As Bourdieu reminds us, trajectories are never fully independent of others in the collective [1,5]. Students in our study experienced the social space of undergraduate medical education in step with their classmates. But trajectories are not totally coordinated. In our study, students' unique dispositions came into play as they transitioned from one phase of medical school to the next. In this way, individual trajectories were variants of the larger, collective trajectory.

Implications for medical education research
Thematic analysis involves identifying patterns and regularities in qualitative data for the purpose of creating interpretive meaning [14]. In our primary study, thematic analysis helped us detect the collective trajectory. As a complement to thematic analysis, I-poems helped us hone our ear to hear each student's individual trajectory, a story we discerned by interviewing students throughout their four years of medical school. As others suggest, research which seeks to understand the interplay between the collective and the individual should capture and analyze data from different perspectives [15].
Our findings from this four-year longitudinal study add an important temporal dimension to cross-sectional studies about how students navigate transitions in medical school. Cross-sectional studies may capture the product of change, but not the process of change [16][17][18][19]. Our conceptuallydriven, longitudinal study is a step toward researching transitions from a holistic perspective that includes, but is not limited to, individual trajectories [20].

Implications for medical education practice
If habitus as a conceptual lens helps to ensure that the research focus is broader than the targeted focus of any given study, then our findings have important implications for the practice of medical education [3]. Students come to medical school with diverse histories and life experiences. However, they encounter curricula that valorize competencies -common and potentially reductive standards -for what every physician should be, should know, and should be able to do [21]. The concept of habitus may help medical educators think relationally as they grapple with questions such as, 'How does one situate the unique learning preferences and efficiencies within a standardized, competency-based curriculum?' When mentoring, faculty can support medical students in retaining their individual trajectories, thus honouring their experience of becoming a physician as a personal journey that is shaped, but not determined, by the social space of undergraduate medical education [22,23]. At the same time, faculty can help students embrace shared experiences of the medical profession.

Limitations
We recognize the potential limitations of our secondary analysis, and our limited scope when it comes to the complex concept of habitus. By focusing on habitus as a compilation of collective and individual trajectories, we did not focus on other aspects of habitus, such as its relation to agency or the interplay of past and present [3]. In our primary study, we did not specifically ask about habitus. However, by collecting peak experience narratives, we obtained students' own identity claims, not prescriptive responses to direct questioning.
We interviewed a convenience sample of students from one institution, believing that those who volunteered for a longitudinal study would likely maintain their participation. None of the students we showcased were underrepresented minorities or were educated abroad; both could powerfully influence habitus. Our sampling strategy, however, does reflect the general makeup of Columbia University College of Physicians and Surgeons.

Concluding remarks
In closing, we believe Bourdieu's concept of habitus provides a useful conceptual lens for understanding the relation between collective trajectories (group habitus) and individual trajectories (individual habitus). In the end, we offer neither a prescription for balancing these trajectories, nor data that elevates either trajectory. Rather, we offer a reminder to hold collective trajectories and individual trajectories in our research and in our practice.