Within the current generation of medical trainees, there has been a trend toward growing numbers of postgraduate students pursuing additional master's or PhD degrees beyond their professional training programs.1,2 Existing literature has focused on the pursuit of “professional” degrees in fields such as nursing, where the focus is on students' ability to contribute to the advancement of clinical practice.3 In contrast, postgraduate medical trainees undertake degrees in fields such as clinical epidemiology, public health or medical education, programs whose aim is often the development of research skills.3
Although the characteristics of undergraduate medical trainees enrolled in MD/PhD programs have been studied, the particular forces that shape the above phenomenon among postgraduate trainee physicians have been relatively unexplored.4,5 Studies examining the research productivity of physicians with higher degrees have observed that physicians with a master's or PhD published more papers and were more likely to engage in significant research activities than those with a medical degree alone.6 The environment in which these physicians function presents unique mechanisms and demands for advancement and recognition. A study on mentoring among junior medical faculty in academia found that new staff felt significant pressure to align their academic identities with the values of their professional culture.7 Definitions of success in this environment did not necessarily correspond to individual physicians' own beliefs on entering academia. Our understanding of this culture's influences on educational decision making among postgraduate trainees is limited.
This study examines a particular group of learners: pediatric physicians pursuing higher degrees concurrently with their postgraduate medical fellowship training. As nearly all pediatric medical specialists in Canada practice in academic institutions for reasons of patient volume, these pediatric specialty trainees know that their future careers will almost certainly be set in an academic milieu. This study aimed to develop a preliminary understanding of students' motivation for undertaking additional degrees and of the factors that influence them during this process. We used a constructivist grounded theory approach which combines attention to emergent themes, sensitizing concepts from the existing literature, and the researcher's own subjective understanding of the phenomenon as a participant.8
Following grounded theory principles, we employed iterative data collection and analysis. Participants were identified through theoretical sampling from among the pediatric fellows training in any medical subspecialty at a large Canadian academic pediatric center and concurrently pursuing a higher degree (master's or PhD) in any discipline. Ethical approval was obtained from the University of Toronto and Hospital for Sick Children research ethics boards.
Fourteen fellows (10 female, 4 male) from a range of pediatric training programs (5 gastroenterology, 2 each of academic pediatrics, hematology/oncology, respirology and rheumatology, 1 cardiology) and higher-degree programs (10 master's, 4 PhD; 8 clinical epidemiology, 4 medical education, 1 molecular biology, 1 public health) were recruited. Disconfirming sampling was attempted by seeking fellows who had not pursued higher degrees. However, the study institution had few fellows eligible for this group, and none could be recruited. Semistructured interviews were conducted with each participant by one investigator (O.G.), who was then a pediatric fellow pursuing a master's degree. Although participants might hesitate to speak freely with a peer, an “insider” interviewer from the same culture as her interviewees can capitalize on her awareness of shared tacit values to better discern implicit elements in their discourse. For this study, the benefits of using an insider interviewer outweighed potential limitations, particularly as there was no participant–interviewer power differential. Fellows were asked open-ended questions regarding their motivations to pursue a higher degree and their experiences during this course of study, with several subprobes in both of these areas. Interviews were recorded and transcribed with deletion of identifying information.
Emergent themes were identified from the data by one researcher (O.G.), who used a constant comparative approach to analyze the interview transcripts. Interview questions were adapted for subsequent participants in order to explore emerging themes more deeply, and data collection continued until saturation of themes was achieved. With this study's closely defined and fairly homogeneous participant group, saturation was achieved at 14 interviews. The researchers met weekly to review recent data, which enabled elaboration of key themes, analysis of the relationships between them, and exploration of discrepancies. This emic/etic approach used the different perspectives of both researchers, with O.G. providing an insider's viewpoint and L.L. (an education researcher without firsthand experience of fellows making career decisions) providing an outsider's perspective. The outsider drew out unspoken knowledge from the insider that might have remained unexplored and enabled more multifaceted data analysis.9 To enhance the trustworthiness of the analysis and the authenticity of the resulting theoretical explanation, a return of findings session was held by one researcher (O.G.) and three original participants following preliminary analysis of all transcripts.
Competition for employment
Nearly every participant began the interview by explaining that accumulating higher degrees, publications, and grants was necessary for them to be competitive for faculty positions at academic institutions. Fellows rarely heard this openly discussed, but they often inferred it from hiring patterns observed in their specialties. Occasionally, fellows were given explicit direction in this regard:
I was basically told that for me to be competitive and get a job [here] … I would need to see my name in print several times over…. The way things have gone is that having just your fellowship is not enough anymore. They don't consider that enough to get a job. You need to have either a PhD or a master's in addition to your fellowship training. (Participant 8)
Proving they belong
Participants also felt a need to prove themselves to the medical community within their specialties. They needed to prove that they were deserving of membership within the group and that they would fit in with existing members. This was demonstrated in a number of contexts: Some participants had felt that declaring an interest in research and research training would make them more desirable candidates for entry into a training program. By doing so, they felt they were proving a commitment to academia:
Even prior to interviews for residency [people said], “Make sure you say you have a research interest.” But then what's even better than that is to say that “I'm actually so interested that I want to do formalized training in research” you know, so that I can continue it on my career and really be this academic that it seems that your institution is more interested in training you know. So you kind of start off saying all that stuff, doing all that stuff to convince them to take you, and then somewhere along the line you get convinced yourself. (Participant 6)
Commonly, participants described feeling that having a higher degree would change people's perceptions of them. They felt that such a degree would enhance their credibility as researchers and would result in people taking them, and their work, more seriously. Without the formal research training associated with a higher degree, some participants worried that their work would be looked down on, particularly by funding agencies and journals.
In large part, it was felt that the degree acted as proof of the individual's commitment to academia and as a predictor of future research productivity. Both in institutional hiring and in the awarding of research grants, participants felt that employers were looking to safeguard the (financial) investment they were making in an individual. A higher degree made it more likely that this investment would be profitable:
If you manage to convince his thesis committee that he's entitled to a PhD he must have done some reasonable research, although you know some may argue on that point, and therefore “our investment is more likely to succeed.” And that's what a grant is. It's an investment. (Participant 12)
In addition, participants perceived that higher degrees are becoming more common among their peers and that consequently the value associated with any given degree is gradually decreasing. Participants described feeling that more and more credentials were becoming necessary in order to distinguish themselves:
I feel like now because everybody that I know is doing more training that the significance of that or the value attributed to that has been diluted. And now I think the move is going to be that master's are no longer enough and that you have to do a PhD. (Participant 3)
Raising the bar
Academic medicine was felt to be steadily increasing the level of achievement demanded of its new members. Previous standards are no longer satisfactory, and the perception is that more and more advanced education is becoming a requirement for acceptance into academia. As one participant expressed it, some trainees accept that there are always additional stages of training to be done:
We train at these big academic hospitals, and all we know are these things, and it's just kind of like one more step … university, medical school, residency, fellowship, you don't think twice about it. And then someone says, “There's one more hurdle,” you say, “Okay I'll do it.” (Participant 8)
Value of clinical work
Most participants believed that clinical work alone was insufficient for a physician in an academic center to be considered valued and productive. “Academic” activity, particularly research, was felt to be valued more highly than clinical work, and physicians were valued and respected accordingly:
It's not enough to be a doctor. It's not enough to have a medical degree…. I've heard that said by staff members. That they feel that they're not valued as much as other people who have done research and do research or publish papers are valued. And that's actually a sad thing I think, because the contribution of people that do clinical work is immense. (Participant 4)
In some cases, a similar attitude was felt to be directed toward trainees in fellowship programs, wherein clinically focused trainees received less guidance and support than their research-oriented peers:
But you get the impression that the people who have expressed an interest in only doing clinical work are really … they're on their own. You know, like they're really going to finish their fellowship and the program will kind of just let them sort it out on their own. You don't get the impression anyone's really mentoring them or being an advocate for them. (Participant 7)
Three participants held contrasting opinions on this issue. Both trainees in academic pediatrics felt that general pediatricians with excellent clinical skills were highly respected and were treated no differently than those with a strong research focus. A participant from cardiology felt that clinical skills were actually accorded the greatest degree of respect within that field.
Some participants felt that fellows pursue higher degrees because they perceive that many of their peers are doing the same, rather than pursuing the additional training out of interest. Participants also felt that some people undertake degrees to avoid being left out or left behind: “You don't want to be the only guy on the street that hasn't done the master's” (Participant 7).
The results of this study provide the first exploration of factors motivating postgraduate medical trainees to undertake higher degrees and the role of such degrees in academic pediatrics. The recurring themes of credibility and competition, and of evolving definitions of what the academic culture values, resonate with the sociological concepts of “capital” and “field.” During the interpretive process, we explored our findings through the lens of these concepts in order to elaborate our evolving explanatory theory of higher-degree-seeking behavior and to embed it in the existing discourse in the domain.
For Bourdieu, a “field” is a social arena, like academic medicine, in which power relationships among members are determined by their relative amounts of desirable resources.10 Such resources are considered forms of “capital” when their ownership confers a degree of social power or status on the holder. “Cultural capital,” the dominant form in intellectual fields, refers to nontangible resources such as facility with language or educational credentials.10
In the field of academic medicine, cultural capital takes the form of higher degrees, research publications and funding. Bourdieu writes that “positions in fields are determined by the unequal distribution of relevant capitals rather than by the personal attributes of their occupants.”10 As with any form of cultural capital, educational qualifications have the potential to bring field members increased status or power. Trainees therefore seek to accumulate such capital in order to improve their standing in the competition for faculty positions. Additional educational qualifications also aid in increasing credibility within the field. Not only are such degrees considered capital in their own right, they are seen as predicting that an individual will likely amass still more capital in the future. Someone who has committed several years to the completion of a master's is felt to be more likely to complete (and publish) future research endeavors. In this field, the understanding is that capital begets more capital.
By definition, members of a field constantly struggle to define and redefine legitimate or valuable capital.10 The nature of capital is therefore ever-changing, as is the expectation of what must be accomplished to achieve status in a field. In academic medicine, this is manifested as “credential inflation.” Over time, the value of educational qualifications as capital declines as more people acquire them. Trainees experience a constant “raising of the bar,” wherein what is expected of them in academic medicine is always changing. Previously acceptable qualifications are now insufficient, and trainees feel pressure to take on further education in order to distinguish themselves.
In academic medicine, clinical acumen may not be considered a valuable form of capital. In our participants' experience, clinical skill is an insufficient basis for high regard in the academic medical community. Such skills are presumed to be present in all members and are therefore not valued as a determinant of status. Physicians who perform primarily clinical work are viewed as holding less cultural capital than those with research pursuits. Research determines what an individual's status will be; clinical work does not lead to recognition. This may be attributed to the “public,” visible nature of research products, as clinical activities occur in private settings and are thus harder to measure. Contrasting views in this area from trainees in academic general pediatrics may stem from the fact that academic pediatrics is relatively young as an academic specialty and may not yet have developed the definition of research as capital that characterizes other medical specialties. The cardiology trainee's perspective may also reflect the nature of his specialty, wherein procedural expertise is highly valued and research is considered an activity of secondary merit.
How do trainees learn the value of research pursuits in academic medicine? This occurs largely as part of a “hidden curriculum” that exists within their training environment. A hidden curriculum is present when an educational program does more than simply transmit knowledge; students absorb norms, values, and beliefs from the content and experience of learning.11 In academic medicine, the conventional and hidden curricula intersect. Trainees who aim for academically situated specialties learn that research is the cornerstone of an academic physician's professional life and that publications, grants, and credentials represent the forms of capital that are considered valuable and necessary for success within the field. Clinical skills will not commonly lead a physician in an academic specialty to a high rank among his or her peers. Only rarely was this made explicit for our study participants; more commonly, they likely absorbed their beliefs in this area from the environment in which they worked and studied. By following the messages within the hidden curriculum in academic medicine, trainees perpetuate the existing social organization of their field.
Certain limitations apply to the design of this study, as it was situated in a large, research-intensive institution. Although participants had formative educational experiences through medical training at other centers, the context of this study informs its results. Further research to examine these ideas in other academic institutions could greatly enrich our understanding of this phenomenon. In addition, exploring the pursuit of higher degrees among adult medicine trainees, who have greater choice between academic and community-based careers, could add valuable dimensions to the results of this project.
This study provides the first exploration of the motivation of postgraduate medical trainees to undertake higher degrees and the role of such credentials in academic pediatrics today. As a field, academic medicine plays an important role in influencing the choice of pediatric trainees to pursue additional degrees. Through mostly tacit means, these students absorb the values of this academic environment. They learn to regard credentials, publications, and grants as forms of capital, and they also learn that attaining success and status within their field depends largely on the accumulation of such capital. The results of this study have a role in allowing academic physicians to understand the values of the culture they shape and are shaped by, in assisting mentors in providing career guidance for future trainees, and in encouraging administrators to critically reflect on the factors involved in faculty advancement.
This study was supported by funding from the Canadian Child Health Clinician Scientist Program.
Ethical approval was obtained from the University of Toronto and Hospital for Sick Children research ethics boards.