A. Participant habitus and aspiration for prosocial professionalism
1. An international participant at School B gave poor responses and was excluded from the study. The remaining total was 39 participants: 19 from School A and 20 from School B.
2. More females volunteered for the study than males. The objective female to male gender ratio was 12:7 (School A) and 12:9 (School B). A First Year outsider at School A self-identified as gender fluid.
3. Based on demographic and interview data, School B cohorts had a higher proportion of students of outsider habitus compared to School A (2.5 to 1.1).
4. Participants’ equity identities, social health knowledges, and intentions for prosocial practice were asymmetrical. Specifically, those with single equity identities indicated higher preference for practice in an underserved community than those with nil, or two or more (intersectional) identities (Figure 4). This result mirrors those of Griffin, Porteli & Hu (2017) of lower intentions to work in underserved areas of medical practice among students of low and high SES at an urban Australian medical school.
5. No insiders chose professionalism Type G. (Practice in an area of need); a prediction of Bourdieu’s theory of practice. Preferred ‘type of professionalism’ was distributed by social equity identities, not by Year level or medical program. ‘Outsiders’ at School B were more likely to choose Type F. professionalism (Follow your own morality. What works for you.) and Type G. (Practice in an area of need).
B. School and Year cohorts and prosocial professionalism
1. There was unanimous support for the learning of social justice in medical education.
2. There was agreement among all Year cohorts of the groups most disadvantaged in Australian health care: Indigenous, refugees and migrants. Participants witnessed the same racism, sexism and poverty shaming in health care as found in Australian society.
3. School A First Year participants, the youngest cohort, more often reported recent developmental awareness of abstract social justice concepts. More concrete concerns for local, national, and global health injustices were voiced by School B cohorts (Fig 5, below). Several participants of Asian background (at both schools) reported personal or family experiences of racism.
4. The private-public gap in health care quality was regarded unfair by First Year Chinese participants in School B; and Chinese medicine proposed an alternative to western medicine for Indigenous health care.
5. Just one (School B, Final Year male) participant referred to historical ethical failures of professionalism.
6. Role models of social justice clustered into categories of personally known, professionals and prosocial celebrities or religious figures.
C. Discourse themes
The diversity of discourses for understanding social accountability in medical practice are listed in Fig. 5 and outlined in more detail, below.
Theme 1. Critiques of medical professionalism
Most critiques of medical professionalism were made by Final Year participants reflecting on training experiences in the health system. First Years drew on personal and service-learning experiences for their responses. Yet, the most trenchant critiques of ‘the rules of the game’ of medical professionalism was made by School A First Year (PA1); the participant with the highest intersectionality of equity identities. PA1 reported personal observations of the mistreatment of LGBQTI patients in the Singapore health system; and physician attitudes resembling legal not social justice, to pressing health needs of low SES families, citizens with addictions, and residents of a chronic care psychiatric facility. She understood how these misrecognitions, in the manner of complex adaptive systems theory (CAS), could worsen the health prospects of these groups.
Participant vignettes revealed several ‘code clashes’ between medical professionalism and social health contexts. Final Year cohorts voiced concerns about the following contemporary biomedical practices.
a. the hegemony of pharmaceutical treatments as the ultimate ‘answer’ in clinical care.
b. a silent curriculum that labels patients with low social capital and disputed hospital status ‘acopics’; the result of inadequate funding of community-based disability care.
c. the irony of ‘getting rid of patients’  with no sustainable solution for preventing their recycling through hospitals nor prevention of their chronic illnesses.
d. scepticism about political distribution of public health system funding.
e. anguish related to reduced opportunities and time for patient-centred care.
f. dismay at physician jargon conveying outmoded colonial attitudes (hierarchy, sexism, racism, ageism, poverty shaming) and victim blaming for addictions.
g. deception about the true nature of health production by poverty and social conflicts by proximal risk factor and behavioural approaches that unfairly responsibilize patients.
h. the neutralizing of equity differences between patients ; a form of knowledge blindness.
The resulting professional consciousness reflects what Savransky & Rosengarten (2014) refer to as ‘what was excluded by what was taught’ . A First Year female at School B vented discontent: “They teach us about the social determinants of health, but not what to do about them.” Time required for medical care protocols can represent loss of active student learning of patient-centred care needs .
Theme 2. Transformation to a justice mindset
Understood as a transformative learning process, discourses of social accountability were grouped in sequence ‘from informative, to formative, to transformative’ .
a. Insider participants were informed about social health inequity in secondary education, and in medical student organisations which directed charity to resourcing disadvantaged (e.g. Indigenous) groups. A Final Year female at School B, and Law graduate, was a leading student advocate for human rights and climate action. She held policy makers and funders of health-related systems ultimately responsible for distributive inequalities. A Final Year male at School A with high status parents, spoke of his mothers’ prosocial work, table talk of social justice issues, and habit of keeping informed of sociopolitical events. Notwithstanding the family’s high status, it was anathema to be thought uncaring of others’ misfortunes. Few insiders referred to close professional experiences of the social adversities patients faced. Another School A international and Final Year male watched a video of a woman having pseudo-seizures and felt contempt for her ‘faking’ a ‘medical’ illness. He later realised the error of applying biomedical criteria to a functional mental illness. Yet he was surprised by interview Question 5. comparing impacts of medicine and sociopolitical health advances. [‘In the U.S. since 1950, only 3 out of seven years of improved life expectancy can be attributed to improvements in medicine.’ What does this statistic suggest to you?]
b. Outsider participants referred to family experiences of social adversity as refugees and migrants to Australia that informed singular perceptions of social injustice. Many had intersectional equity identities and were ambitious to restore their families’ capital status. Two School A Final Year females with refugee parents had extended their learning of global social inequalities in a Baccalaureate course. Two School A, First Year Australian females of South-East Asian background arranged a visit to a remote Indigenous school and became informed of students’ social and educational disadvantages. A Final Year female at School A defended social justice as a religious tenet of the Catholic church that prohibits pregnancy termination, but was not informed of the moral complexities of decision-making faced by vulnerable pregnant women. An intersectional female in the same Year group had a service- learning experience in a homeless women’s shelter which informed her of ‘levels of capacity’ or empowerment among homeless women resorting to paid sex work for survival. A Final Year School B female, immigrant from eastern Europe, narrated a formative service- learning experience in the Solomon Islands. She recognised the need to educate Islander mothers with low health literacy to rehydrate their sick children; an expectation she had taken for granted. These examples of reality-based experiences brought participants closer to a sociological understanding of how context modifies health care needs.
c. Participants from rural and remote areas of Australia, in closer proximity to Indigenous groups, voiced awareness as recognition  of the historical nature of unmet Indigenous health needs. Two International School B First Year males considered Australia’s health system mismatched to Indigenous health needs and recommended Chinese medicine an alternative. A School B Final Year male participant witnessed physician racism toward an Indigenous patient; while others found the same sexism, homophobia, and racism exists in medical culture as in Australian society.
d. Examples of transformative learning of equity concepts were uncommon. A Final Year female at School A, of African-Australian identity, went to Africa for service-learning and found corruption in the health system, and poor rural people with low critical consciousness and health literacy. However, street theatre as a means of health education of HIV-AIDS risks provided an example of social accountability fitting the community context. In another example of service design for health equity, a Final Year School B male training in a remote Australian Indigenous community reported a practice he found ’strange’; implying liminal understanding of the threshold concept of health equity. Diabetes was prevalent, turnout at diabetes clinics was poor, and limb amputations common. The hospital provided cold room storage of limbs in respect for the Indigenous spiritual obligation to be buried whole once a diabetic patient dies. This strategy could improve clinic attendance, diabetic management, and reduce need of amputations. Recognition of this social fact was key to problem solving equitable access to diabetic health care.
In overview, the partial knowing of diverse patient needs participants reported can incrementally transform their ontology or ‘becoming to know’ as a physician. Student experiences of “engaging, exploring, experiencing, emerging, enabling, and evolving”  provide an ‘ecosystem view of knowledge’ that more closely aligns with the dynamic and uncertain nature of health production in contemporary global societies. Critical reflexivity on holistic or multi-system needs of Indigenous peoples was voiced by outsiders with direct experiences in rural communities. A ‘becoming to know’ framework was complemented by the critical gazes of intersectional participants on practices unfairly distributing health care based on outmoded and stigmatising colonial gazes. Yet, by Final Year some intersectional participants held a stance that placed unrealistic expectations on patients for specialised knowledge and capabilities, such as health statistics and complex self-care. This represented an ellipsis of habitus  to a perspective that ignores patient context as a value in clinical reasoning. The participant was a School B Final Year outsider male who was conscious of his age, the need to repay student loans, and attain financial security. Core values of social justice expected from a disadvantaged background had been supplanted by secondary values of self-concern.
Theme 3. The medical practice of social accountability
Differences in participants’ prosocial agency; how integration of medical and social accountability practices was conceptualised, is collated in Figure 3. For many Final Year participants, ‘doing both’ (health care and social accountability) was unthinkable in the overloaded hospital settings where they trained. A female Final Year, School A, insider commented on the number of patients arriving at hospital in a low SES community. “Some of us ask where does it [sic] come from?” This comment exposed a preliminal understanding of the societal error : the preferential funding of specialised hospital-based care over community-based improvements in social, commercial, and cultural health determinants . In contrast, First Year (PA1) understood the societal error from her own experiences in disadvantaged Singapore communities. She met women that assumed breast screening services were only for women with breast cancer; and others that refused necessary medical treatment if attending a clinic deprived their families of subsistence income.
Several participants construed social accountability simply as ‘helping people’.
“I think that’s the entire reason that a lot of people go into medicine, because we want to help people and I think that’s our responsibility to try to do that even when someone doesn’t want to change.” (School B First Year female)
This comment recognised the social facts for many patients, living lives unconscious of the unfairness of oppressions limiting their freedom, capabilities, and health . Physicians’ equity actions can uncover hidden assumptions in order to correct them; assist patients to navigate the health system; and empower their interrogation of social burdens on their lives. This can be effected as a communicative action or ‘dialogic praxis’; mutual learning between patient and physician to help each understand the causes of distress, meaning of emotions in relation to lifeworld, and to motivate engagement in social change .
The theme of ‘ways of seeing and knowing’ drew on participants’ moral understandings of the intention of A Physician’s Charter of medical professionalism. Critical ‘awareness’ means more than perception of social inequity; it commits professionals to moral actions of justice and care. The concept of a knowledge management system (KMS), as delineated by Sveiby & Skuthorpe (2006), explains knowledge as ‘a capacity to act’ ; converting an intangible value into tangible outcomes. “I guess at the end of the day, students will be seeing a lot of social disadvantages in society …and I think the important thing there, is not treating the symptoms but treating the actual problem. It could be stress causing all those issues.” [School B intersectional First Year female)
The starting point was acknowledgement of difference.
“Once you listen to someone who might be very different to you, you can start to understand, what? I don’t know… just a lot of different things, I guess.” (Final Year male, School B).
“You don’t have to be an activist, but even in your encounters with Indigenous people within a medicine context; then, just being respectful or be more culturally aware, things like that can have a positive impact” (First Year female, School A).
The alternative stance, doing nothing and still being paid, was posed ironically by a Final Year male at School B. Money was responsibilized for negative impacts on the profession’s reputation, and in reflexive comments on physician complicity in social inequalities.
“Because I’m white, middle-class, living in Australia, in a developed country, I have access to a lot of things… particularly a lot of privilege and you know, I buy a lot of products by people who are not paid enough money, and that is a huge source of inequality that I contribute to” (First Year female, School B).
Drug prescription and drug company influence on professionalism was also problematised.
“It’s very much taught, this is how you treat, and it’s a medication. It’s also easier to give someone a drug or... just kind of, let people be the way they are, because it’s hard to change it.” (Final Year male, School A)
Yet, there was a tendency to presentism in some participant responses; defined as “the analytic neglect of historical forces shaping”  the professional discourse. One implied that social accountability was a specialised skill; and another, the responsibility of social workers. Lack of continuity with patients meant that students did not learn from the course of their illnesses. Past atrocities of medical intervention, lacking proper accountability to the human context, were mentioned by just one insider male, School B participant.
“There’s so little time for doctors and students to reflect on these things, there’s so many other pressures… the amount of patients you have to get in, get out…no beds, no time for anything.” (Final Year female, School A)
Few participants were reflexive of the macro influences of policy and power structures on these downstream processes; nor the hegemony of science and hospital-based practice on students’ collective imagination of ‘health’ . Critical reflexivity on the social gradient of health inequalities  was often prompted by service-learning or community-based experiences in underserved settings. Following clinical placement in the Northern Territory, a School B Final Year insider male wondered at his initial perception of Indigenous health being a single entity. A whole world appeared.
“What do you mean they’re Indigenous? Are they Pitjanjatjara, or are they like, Larrakia? Or… ? You can’t just paint them (different language groups) with one stroke!”
Behavioural education of individual patients to modify ‘lifestyle’ was viewed as social accountability by participants responding to a ‘proximal risk’ paradigm of illness. Diet and exercise prescription reflected the health preoccupations of young middle-class women influenced by social media. Yet no account was taken of patients’ social distinctions, their emotional and cognitive states, or contextual lifeworld stressors. Advocacy of further education for disadvantaged mothers was suggested by two School A, First Year outsider females, in recognition of this social determinant of health.
A final theme in participant data referred, in two main ways, to a sustainability paradigm of health care. One participant recognised the problem of high staff turnover in remote clinics, and how this disadvantaged continuity of care for Indigenous people. Another understood sustainability as providing multi-disciplinary health services for both illness prevention and health care actions.
D. Social accountability reasoning
A general finding was a low capability for problematizing the patient’s social context in medical problem-solving; to ‘take account of’ how inequities in societal conditions of living distribute health and alter the physicians’ ethical responsibility.
Interview Question 3, on the difficult physician task of motivating behaviour change, was answered more critically by Final Years with training experiences in underserved rural areas. An example was a rural male participant at School B who compared the ideal patient (“well educated and well informed”) with others; “… from a situation where they have to prioritise a hundred different things, and you’ve just given them another thing to worry about.” Yet, an urban, insider male in Final Year at School A (PA6), regarded social justice “a silly idea” that only led to mixed results, arguing only legal justice mattered. He had learned from a general practice mentor that persistent nagging of patients, to lose weight or quit smoking, was eventually successful. An intersectional School B Final Year female considered dietary education essential for all patients, perhaps reflecting her Hindu dharma (way of life). Yet variation in availability and affordability of fresh foods were neglected in her account.
The theme of awareness revealed the majority perspective of social accountability to this question. Awareness was a metaphor for the physician’s need to be mindful or reflexive of composite causation ; to cast a critical sociological gaze of health inequities in the patient’s lifeworld. The awareness theme also lent support to critical consciousness; in Bourdieu’s terminology, critical ‘recognition’ of differences in power (‘capitals’) between physicians and patients that underpins need for equity reasoning for social accountability. A First Year female at School B argued for mindfulness of patients’ social positioning and how this intersects with illness; “I think it goes hand in hand because a lot of the people doctors deal with are not only sick, but are probably in a group that are marginalised in society or face injustice. I think this [The Charter] is highlighting for, um medical professions, how important it is to keep this in mind.” [School B First Year female and outsider]
This empathic awareness was lacking in PA6’s account of behaviour change as nagging; and the social practice among physicians of labelling patients with low self-efficacy, ‘acopic’. The pseudo-Latin neologism ‘acopia’ is applied to patients who remain in the hospital system after treatment; unable to cope independently at home. A School B Final Year female was confident that due diligence was done to acopic patients’ health care, despite the health team’s resentment for the added workload. Postcode shaming stereotyped patients by the demographics of their suburban address. In both examples, there was misrecognition  of how the patient’s free agency may be immobilised by contextual adversity, structured by social and commercial determinants of health. Equity actions, enabled by physicians’ symbolic social status, require evaluation of the patient’s lifeworld stressors and correction of misperceptions; identification of SDH deficits, social and political advocacy; critical education; and multi-disciplinary action plans.
Interview Question 7, on the apparent paucity of LGBQTI patients in an urban medical practice, also required awareness of how unconscious bias against stigmatised social identities can be co-constructed by patients and physicians. The topic was best answered by participants disclosing LGBQTI status. They reported social anxiety in public; behaviours to avoid the stigmatisation and violence that plagues LGBQTI sexualities; and the stress of self-stigma that primes some to contemplate suicide. Illegality of homosexuality in Singapore society was an additional stressor faced by PA1 and her peers. PA1 narrated exceptional insight to the ways that marginalised social and legal identities were met by prejudicial treatment by physicians in Singapore’s health system; the resulting institutional (or structural) harms further impairing their health. These experiences radicalised PA1 and motivated her entry to medicine.
In their replies to Question 7, a majority proposed hypotheses problematising the physician, the practice, or the LGBQTI community. Against pre-study expectations, two Final Years at School B did not recognise this equity dilemma as an important clinical problem; perhaps habituated to the orthodoxy of demand-led medical practice and the biomedical gaze. A School B Final Year male from Canada declared his millennial generation more accepting of homosexuality than prior generations of physicians. A First Year female at School B referred to a lecture on ‘men who have sex with men’ and regarded a snap association between LGBQTI sexualities and HIV-AIDS the stigmatising factor causing non-attendance at clinic.
In contrast, students that self-identified as LGBQTI remarked how pervasive social anxiety for homophobic violence was unavoidable in their public life. They advised physicians to be aware of how stigma anxiety affected attendance of ‘coming-out’ LGBQTI youth at health services; to be reflexive of unconscious bias in communicating with LGBQTI patients; avoid stereotyping patients by their identity and health risks; and recognise the high prevalence of poor mental health related to social discrimination.
The final interview question drew on participants’ creative imaginations to conceive novel strategies for alleviating common social problems in an Australian rural community. A male from a remote area, in Final Year School B, spoke about youth sports, men’s sheds, and a philosophy club in his town. The concept of ‘health production’ as improving the health of a community was difficult for most participants, a typical response being “Hopefully that’s what we’re already doing [by treating illness].” Implicit to misrecognition of public health was the capture of students’ medical imagination by an individualist paradigm of society.
This discourse, broadcast in both medical education and neoliberal societies, effectively de-politicises and unfairly responsiblizes patients for their poor social situation . First Year participants from backgrounds more proximal to social disadvantage were more likely to responsibilize systemic constraints than individuals. Yet, a Final Year first-in-family outsider at School B clearly held patients self-responsible for their health despite his own family’s hardships. This adaptation to conservative norms of merit or ‘desert’ can happen in a hidden curriculum as students undergo ‘ellipsis of habitus’: distortion of habitual responses to a professional logic unreflexive of contextual social facts. Core values of social justice can then give way to personal concerns, which for this student, was pressing financial debts.