Razack, Saleem MD; Maguire, Mary PhD; Hodges, Brian MD, PhD; Steinert, Yvonne PhD
The process of admission to medical school is the most high-stakes evaluation that a prospective physician will undertake in his or her career. In Canada and the United States, between 6% and 30% of applicants to medical school gain entrance, and similar odds are seen in the United Kingdom.1,2 Traditionally, discussions around ideal medical student selection practices have focused on identifying the “best and the brightest” students, who will be most able to undertake the intellectual rigors of a highly complex and constantly changing field.
Medical schools also compete for those students identified as most able to succeed in their programs. A major attraction strategy that schools employ is to highlight the school’s accomplishments as a means of fueling the attraction.3 Increasingly, faculty Web sites provide the communication spaces through which these achievements are promoted and claims of institutional excellence are represented.4
We undertook to identify and analyze the types of texts and images represented on the Web sites of Canada’s 17 medical schools, and to situate them within coherent discourses (a term we define below). We were interested in the implicit and explicit messages about institutional and applicant excellence that schools communicate through these promotional tools. We sought also to identify discourses associated with medical schools’ social accountability—principally, the concepts of equity and diversity. In particular, we focused on the interplay between the excellence discourses and the concepts of equity and diversity, given several quantitative studies showing how privileged the backgrounds of Canada’s entering classes are,5,6 and the report of the Future of Medical Education in Canada (FMEC) project,7 which calls for admissions processes to “be enhanced” to address the underrepresentation of certain social groups in the medical profession in Canada.
Discourse, as a term used by many in the social sciences and humanities disciplines, can be defined as institutionalized ways of believing, thinking, and acting that include social boundaries defining what can and cannot be said about a particular topic.8,9 Discourses can play a central role in regulating social institutional practices, including the valuing and justification of certain actions over others. For example, in an admissions process to medical school, where constructs such as “the ideal candidate for our program” or “the responsibilities of our program towards society” are defined through discourses, this would include the medical school’s making choices about applicant suitability for medical school. As a hypothetical example of how a discourse might affect selection practice in medical school admissions, consider how different the selection criteria might be if an excellent student were to be defined “as one who has potential as a clinical or basic sciences researcher” versus “as one who has demonstrated humanism through his/her references and experiences.” These examples are extremes on the ends of a spectrum in order to illustrate how discourses might regulate social institutional practices such as the selection of medical students.
Our research was influenced by the work of the 20th-century French sociologist Pierre Bourdieu.10 Bourdieu regarded power in terms of forms of “capital” to which people have access, which then would allow them to occupy a particular social “position” within a specific cultural “field.” He distinguished between different forms of capital: economic, social, symbolic, and cultural.11 In our research, we understood the Web sites we analyzed to be windows onto the various forms of capital—economic, social, and cultural—that might be linked to gaining power, influence (and admission to) the field of medicine.
We are influenced by two additional theorists, Michel Foucault and Mikhail Bakhtin.
Foucault’s12 work on discourse is particularly helpful in approaching the way in which versions of reality are constructed by discourses. He was specifically interested in how, in a given time and place, it becomes possible to say that certain things are “true” and other things are not. Foucault’s concept of discourse allowed us to begin to consider what he called the “conditions of possibility” for what is articulated on the Web sites of Canadian medical schools. With respect to Bakhtin,13 we worked with his dialogic view of language, in particular the concepts of “single-voiced” and “double-voiced” discourses. Single-voiced discourse “is directed toward its referential object and constitutes the ultimate semantic authority within the limits of a given context” and can thus be seen as authoritative in nature. Double-voiced discourse inserts “a new semantic intention into a discourse which already has, and which retains, an intention of its own” and, as such, contains an element of persuasive intent within it. Looking at discourses in this way can help in understanding how language may be used to assert power and claim “truth.” To make these complex Bakhtinian concepts accessible, we refer to these two types of discourses in this report as authoritative versus internally persuasive.
The work presented in this report forms part of the first phase of a three-phase study funded by the Social Sciences and Humanities Research Council of Canada. In List 1, we have described how this report fits with the larger study.
Overall, then, the question for this phase of research was “What types of discourses about excellence, equity, and diversity are embedded in the medical school admissions process on institutional (faculty of medicine) Web sites, and what meanings might potential applicants infer from these discourses?”
Our discourse analytical methodology involved a line-by-line textual analysis of the specific Web pages (in either English or French) on the Web sites of Canada’s 17 medical schools, between July and December 2010. Three research assistants on our team (acknowledged at the end of this report) were specifically tasked with analyzing the texts through the conceptual lenses of Bourdieu, Foucault, or Bakhtin. We chose the specific Web pages for the analysis in each Web site by an a priori consensus, with the guiding principle of including pages where schools assert claims of excellence (typically, faculty welcome pages and deans’ messages) and pages specifically targeting applicants to medical school (typically, admissions-office-specific Web pages). We defined texts as both words and images found on the dataset Web pages, as traces of “social relations”14 represented digitally.
We worked with the following key concepts to provide consistency in our approach to the data:
* Institutional excellence: assertions made in Web site texts to position the particular medical school as desirable.
* Applicant excellence: personal qualities and accomplishments that applicants require in order to be positioned as desirable for admission to the particular medical school.
* Diversity: acknowledgment and valuing of human difference.
* Equity: expression of a commitment to the addressing of social justice issues, such as the underrepresentation of specific social groups in the profession.
The concepts of institutional and applicant excellence were chosen because these are integral to student selection for entry to medical school. The concepts of diversity and equity were chosen because these are at the heart of proposed reforms to student selection with goals of having greater representativeness of society in the profession and addressing the health care needs of marginalized populations (see the FMEC document).7
We sought to develop complementarity15 in interpretive understandings through regular, timed meetings, in which we rigorously questioned each other’s evolving interpretive understandings. We resolved differences of opinion through critical dialogue. In particular, we compared the interpretative understandings that resulted from the method of having each of us tasked with examining the data through a specific theorist’s lens, as a means of strengthening the rigor of our analysis. Box 1 gives an example of the process of analysis, using an exemplar from the McGill University Faculty of Medicine Web site, with a brief sample analysis through the three conceptual lenses we used.
The research described in this report received the approval of the institutional review board of the Faculty of Medicine of McGill University.
In Table 1, we present sample discourses identified through the review of three representative medical schools’ Web sites, organized in terms of the key concepts of institutional excellence, applicant excellence, diversity, and equity, and accompanied by text exemplars of the discourses. Institutions 1 and 2 are identified as “research intensive” (as defined by size of endowment > $100,000,000 CDN16) and were established in the 1800s. Institution 3 is a newer school that refers to itself as “founded explicitly with a social accountability mandate,” with a campus where distributed education across the Canadian North is presented as a curricular norm. We justify these choices in presenting these data as representative of the discourses found at two extremes of a continuum, from schools located at research-intensive universities versus those that are more regionally focused.
Institutions A and B show a pattern of discourses that are typical of established research-intensive universities. Institutional excellence claims for schools with this profile tended to focus on knowledge creation, scholarship, and research (with associated grant success), with appeals to a rootedness in a history of excellence. Applicant excellence discourses from such schools focused on both academic accomplishment and on possession of the suitable personal characteristics, with an implication that suitable applicants will contribute to the further contribution to the “academy.” As shown in Table 1, diversity was represented as an institutional strength by institution A, or, in the case of institution B, this concept was so omnipresent that it was considered a given (not mentioned explicitly, but with many visual images on the Web pages of diverse student populations).
Equity discourses were more difficult to identify; institution A mentioned the notion of service to vulnerable populations, whereas there was no mention of equity in the text exemplars of institution B.
On the other end of the continuum, excellence discourses in institution C focused on technology as a tool to eliminate the barriers that distributed education may pose in the delivery of a curriculum. Applicant excellence here was also seen as more rooted in a community (coming from the North), which was also the case with this institution’s discourses of diversity and equity that we encountered (accountability to a defined population).
The other 14 medical schools presented variations on these themes. We noted that the “academic excellence” discourses were most often presented in an authoritative voice (as a known truth that does not require proof), whereas the local rootedness and service discourses (i.e., equity and diversity) were presented in an internally persuasive voice (as coming from the author, with justification arguments).
Looking at the 17 schools, a picture can be seen to emerge of central positioning versus more eccentric positioning within the “field.” Central positioning tended to rely on the use of authoritative discourse (presented as a truth from a voice in authority), whereas more eccentric positioning tended to be presented as internally persuasive discourses (posited as an argument, with justifications). In situating institutions on a continuum between central and eccentric positioning in this schema, we mean to capture metaphorically that power, as witnessed by the authoritativeness of institutional excellence claims, flows toward the center. We represent this analysis graphically in Figure 1.
When we look more closely at the discourses of applicant excellence encountered, many examples of cultural, social, symbolic, and economic capital were represented. Most institutions stated explicitly that they looked at both academic accomplishments and personal characteristics in selecting their students as suitable for medicine. In the personal characteristics, there were appeals to what might be termed a “virtuousness” cluster of traits—applicants who are committed, hardworking, caring and compassionate, and the like. Because all of these terms are cultural constructs, it can be seen that there might be requisite “cultural capital” required by applicants in order to be judged suitable for a career in medicine. Social capital was encountered in the focus on possessing suitable references, which were required at most institutions. We observed examples of the valuing of volunteerism as symbolic capital representing “altruism” as a trait in most schools’ discourses of applicant excellence. Finally, economic capital implicitly underlay most characterizations of applicant excellence (volunteerism may not be available to less economically advantaged candidates, for instance).
Diversity has an interesting profile among the discourses encountered. Most schools included images to represent a diverse student body, in which there was significant racial, ethnic, and gender diversity present. There were many appeals to institutions’ cosmopolitan natures as selling points to attract students to apply to specific institutions. A picture emerged where institutions seemingly use diversity, albeit its superficial and externally visible trappings, as a commodity to assert institutional excellence and desirableness. It is noteworthy that diversity is one area where Francophone schools differed significantly from Anglophone ones; images of and appeals to diversity seemed to be less common in the French institutions’ exemplars.
Equity as a concept proved much more vague, in terms of discourses, to interpret from the Web pages. By the concept of equity, we mean social accountability discourses in which there is recognition of a social justice concern (such as underrepresentation of a particular social group in the medical profession) as part of a school’s admissions policies. For some medical school Web pages, we were unable to identify any discourses specifically related to equity. When they were present on the Web pages of specific schools, equity discourses seemed to address historical inequities in terms of access to medical education for Canada’s indigenous peoples, and occasionally for students from rural backgrounds. Schools’ predominant presentation of arguments in favor of equity focused on access to a medical education as a tool for more justice in health care delivery rather than as a tool of social advancement for the individual being educated.
Discussion and Conclusions
It is fascinating to examine the discourses of excellence, equity, and diversity on the Web sites of the Canada’s 17 faculties of medicine. Doing so allowed for us to begin to develop an understanding of how universities talk about and value these concepts and to speculate on how the discourses represented might be situated in broader societal discourses, and within a historical perspective. Understanding what medical schools might be communicating to potential applicants may help us understand how this might change or evolve for a transformed admissions practice in the future. Our review is obviously limited by its scope (the Web sites of Canada’s 17 medical schools) and needs to be compared with data derived in phase II (admissions board members) and phase III (applicants’ self-representations) (see List 1.)
Perhaps the most important understanding that we developed was that when medical schools write authoritatively in asserting claims of excellence, it is scholarship, research grantsmanship, and knowledge creation that predominate. These are clearly important pursuits, but they represent, for the most part, academic concerns rather than strictly professional concerns. A picture emerges of the “field” (in the Bourdieuvian sense) in which the different medical schools position themselves. The more centrically positioned (powerful, influential) they are in the field of medical schools, the more these authoritative assertions of excellence predominate.
In this field of medical schools, for the ones where we see less use of authoritative claims of institutional excellence, then the positioning begins to shift eccentrically, with excellence claims taking on a more contextualized flavor. In these instances, we observe greater appeals to local rootedness and service, presented as internally persuasive arguments, with most schools engaging in both the authoritative and internally persuasive excellence claims to varying degrees. In a sense, we could say that there is a dialectic tension between the excellence claims, with scholarship excellence holding more value than social accountability excellence within the field of medical schools.
When we examine how schools’ Web sites characterize excellence in potential applicants, a picture emerges whereby the ideal applicant is the one who, by virtue of his or her possession of the requisite social, cultural, economic, and cultural capital, is going to be best placed to contribute to the perpetuation of a particular university’s excellence. This person is likely to possess a worldview that is congruent with this goal, no matter the superficial representations of diversity seen in images of the student body. This could be seen as an example of cultural reproduction.
Discourses of diversity can be analyzed in terms of superficial and deep. Medical schools (with the notable exceptions of the Francophone schools) appeal to the trappings of superficial diversity (race, ethnicity, gender, and the like) as a commodity of cosmopolitan sophistication. We wonder whether the social space of the profession might contain room for a deeper understanding of diversity—people whose worldviews differ significantly from the norm-worldview in the profession.
Looking at the discourses of equity encountered on the Web sites, it is clear that although much policy has been developed with respect to the social accountability of medical schools in Canada toward society (notably the FMEC report,7 as well as others from the United States17 and internationally),18 thoughtful discussion is needed in order to properly define and implement the recommendations to specific contexts, such as student recruitment and selection. In reference to medical schools’ obligations to society or community, what do we mean? Who is the community? Who gets to define it?
With respect to the transferability of our findings to other countries and cultures, we must recognize that the discourses identified must ultimately be understood in specific historical and political contexts. In the present report, we have thus sought to provide a detailed description and justification of the dataset choices, attempts at complementary interpretive understandings through comparison between the understandings of the different theoretical lenses used, and the social process of elaborating interpretive understandings between the researchers involved. We thus hope that the reader will then be best placed to evaluate the transferability and relevance of this work to his or her specific context.
It seems that tensions are evident in the way Canadian medical schools communicate to potential applicants. On the one hand, excellence is presented as hierarchically ordered, with university-type excellence (knowledge creation, research, scholarship) predominating over service-to-society-type definitions of excellence. On the other hand, applicants are applying for professional training that carries with it an explicit service-to-society mandate. Thus, in this tension, it becomes possible for a conflation between these two types of excellences to emerge. It would be interesting to trace the genealogy of this conflation. One of the consequences of the Flexner report19 of 1910 was the obligatory association of medical schools with universities. Perhaps the conflation between university pursuits of academic excellence and professional concerns of service excellence may be traced back to this seminal change. In their work commissioned by the Carnegie Foundation around a century after the Flexner report, Cooke et al20 propose significant changes to medical education in the United States, including an increased focus on service concerns, which can be seen as promoting a newer conceptualization of excellence in tomorrow’s doctors.
In presenting this idea of the conflation between academic and service excellence, we do not wish to promote a false dichotomy. Both are necessary for a thriving profession that is best situated in society in order to be helpful to its citizens. Our work does, however, help highlight the problems of the current situation. Much recent policy with respect to the governance and accreditation of medical schools has focused on increasing the importance of social accountability discourses in medical education, including those of equity and diversity. If discourses regulate social practices, and if we are to move beyond prestige-based characterizations of excellence and build a socially accountable profession, then open and inclusive discussion is needed to advance admissions practices toward this goal.
Acknowledgments: The authors wish to thank Hourig Attarian, Lerona Lewis, Lisa Trimble, and Hadi Karsoho, all of whom were research assistants for this work.
Funding/Support: This work was funded by grant number 410-2010-1355 from the Social Sciences and Humanities Research Council of Canada, entitled “Understanding competing discourses and creating dialogues about equity, excellence and diversity in a medical school admissions process in a diverse urban setting.”
Other disclosures: None.
Ethical approval: This study was approved by the institutional review board of the Faculty of Medicine of McGill University.
Previous presentations: The abstract of an earlier version of this report was presented at the Annual Meeting of the Association of Medical Educators of Europe, Vienna, Austria, August 31, 2011.