Symbolic Access: Medical students’ awareness of institutional culture and its influence on learning, a phenomenographic study.

doi:10.21203/rs.3.rs-2863611/v1

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Symbolic Access: Medical students’ awareness of institutional culture and its influence on learning, a phenomenographic study.

https://doi.org/10.21203/rs.3.rs-2863611/v1

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published 04 Jan, 2024

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Background: The discussion of access in medical education has its focus largely on physical and epistemological access, leaving a qualitative gap regarding sociocultural factors which enable access in this context. This study introduces and defines symbolic access, a concept with a specific lens on sociocultural enculturation, and the influence it has on student learning within the South African medical education landscape.

Methods: A phenomenographic design was used to explore students’ conceptions of symbolic access and its impact on learning. One-on-one exploratory interviews were conducted with fifteen final year medical students at the University of Witwatersrand in Johannesburg. Interviews were analysed using Sjöström and Dahlgren‘s seven-step phenomenography model.

Results: Four categories of description were induced, which described students’ understanding of symbolic access, these were rejection, disregard, invalidation and actualization. Five dimensions of variation were discovered, these dimensions expressed the different ways the categories were experienced. These dimensions were; interactions with educators, peer relationships, educational environment, race and hierarchy. Categories of description and dimensions of variation formed the Outcome Space, a visual representation of the student experience of symbolic access. The outcome space had a double narrative related to symbolic access; exclusion (major) and actualization (minor). Medical student’s chief experience within the medical community was exclusion, however experiences of peer-relationships, clinical skills lessons and participation within the clinical setting facilitated community inclusion, enculturation, and impacted learning.

Conclusion: Despite deeply exclusionary experiences throughout their programme, medical students articulated attaining symbolic access into the community, which is predominantly influenced by clinical experiences during the pre-clinical and clinical years of study. Furthermore descriptions of valuable learning experiences were connected to clinical events and the involvement with patient care. This study suggests that the actualization of symbolic access and description of meaningful learning experiences are linked. Medical educationalists should design undergraduate curricula with early clinical immersion at the fore and explore symbolic concepts pertaining to access, as they are linked to transformative learning experiences for the medical student.

access

symbolic

undergraduate student

institutional culture

phenomenography

learning

medical community

Over the past fifty years there has been an intentional widening of access in higher education, this expansion focused primarily on physical and epistemological access with limited attention on access through the symbolic lens [1,2]. The symbolic lens of higher education constitutes its culture, traditions and implicit communal codes which shape an institution as a community. This symbolic space is bound by intangible yet present borders that define some people and groups as included while excluding others [3]. The discussion of access in higher education, therefore, goes beyond formal admission into physical spaces or the availability of knowledge, to include the symbolic entry into the community or institution; that is symbolic access.

Symbolic access is an emerging concept; hence the discussion around it and its definition are developing, currently its definition is conceptualized from multiple sources [4,5,6], for the purpose of this study it will be defined as, when an individual or group, are given opportunity to gain community culture and identity by gatekeepers within the community (Figure 1). In teaching and learning it can be claimed that gaining symbolic access is an intangible event, however the attainment of it can be recognised by the way the individual changes their expression both within and outside the community. Further it is suggested that symbolic access is facilitated through relationship development and socialization of ‘outsiders’ (students) by community members, into the cultural systems of the institution [4,7,8].

Insert Figure 1: Visual Representation of Symbolic Access

Medical Education, Symbolic Access, and Situated Learning Theory

The medical community has deep rooted cultures, and students admitted into medicine come eager to learn what is necessary to be part of the community, fostering hopes of developing their identity as a junior doctor. Over the years the medical community has been encouraged to not only supply students with programme admission and course-based content; but to be cognisant that through professional relationships and socialization they facilitate symbolic access for the medical student [9].

According to educational theorists Lave and Wenger [7,8]relationships and socialization are integral for student learning. In their Situated Learning Theory, they postulate that learning is a social process, shaped by the development of relationships and socialization between newcomers (students) and old timers (educators/established community members) in a Community of Practice (CoP). Asserting that learning has happened when a newcomer changes their participation within the community.In higher education both symbolic access and learning require relationship development and socialization in order to be realized, the study of symbolic access in higher education therefore is also an exploration of factors that influence student learning.

Literature Review

Considerable educational research is driven by the question: “What factors influence student learning in higher education?” [10,11,12,13]. Commonly documented influences include student learning approaches, teaching strategies, demographic background, and the learning environment [14,15,16,17,18]. While these factors have been explored extensively there is need to focus on sociocultural factors as they relate to student learning. Sociocultural factors include the relationships, culture, traditions and values of a community or institution[19]. Leibowitz et al [20] explain that in order for learning to successfully occur, continual consideration and reflection needs to be placed on the social, cultural, and community factors that promote or constrain learning. Therefore an inquiry into how students recognize, and access institutional culture is warranted.

Symbolic Access and the Hidden Curriculum

Raso et al [21] state that educator-student socialization, relationship development and enculturation occursin the hidden curriculum, an informal yet influential curriculum in medical education. The attainment of symbolic access is therefore situated within the hidden curriculum. Over the last two decades medical education has produced growing literature on the hidden curriculum, however Bandini et al [22] highlight that there has been a lack of specificity in this research.There are multiple ways the hidden curriculum presents itself; it is not just a blanketed singular curriculum. Lawrence et al [23] encourage researchers to make explicit the details and nuances of the hidden curriculum, as being detailed will allow policymakers and curriculum developers to better identify literature related to their own needs and initiatives. The exploration of symbolic access in medical education constitutes a nuance of the hidden curriculum.

Further two thirds of current literature on the hidden curriculum is limited to North America. As a result the production of more contextualized studies from areas such as Africa has been strongly encouraged to adequately represent hidden curricula in the African medical school context [23]. Therefore the study of symbolic access within a South African context yields contextualized perspectives on the hidden curriculum.

South African Higher Education and Symbolic Access

The South African higher education setting is uniquely framed for the exploration of symbolic access. South Africa has a devastating socio-political history, which created distinctly separatist higher education settings and cultures under the apartheid regime [24]. A distinguishing feature of the apartheid higher education regime was the unequal access to academic, structural, cultural, and social resources in the education of different racial groups. As a result of these disparities one of the main priorities of the 1994 democratically elected government was to redress the inequalities within the higher education sector, by adopting policies that would widen access to higher education for all South Africans [25,26].

While significant achievements regarding access policies were realized, the higher education mandate of the new government focused primarily on physical and epistemological access in higher education, neglecting to envision steps for symbolic access in tertiary institutions [26,27,28]. Reddy[29] explains that transformation in South African higher education focused on issues of student intake and throughput, as well as the over-representation of white faculty at the expense of issues such as institutional culture and the implications thereof.The journey of how students would adopt institutional culture and the process were not deeply considered.Therefore the movement in South Africa towards granting entry into higher education did not necessarily equate to student learning success, as this physical provision of access did not address inclusion beyond university admission [29,30,31].

Some twenty years into democracy, the South African government was confronted with this symbolic oversight, in what Jansen et al [32] describe as the most intense and violent student protests in a century of higher education, the #RhodesMustFall and #FeesMustFall movements. Two factors attributed to the 2015-2016 country-wide student protests: the alienating cultures of historically white universities, known as #RhodesMustFall; and the discriminatory cost of higher education known as #FeesMustFall movement. The #RhodesMustFall movement brought to light the ills of cultural exclusion experienced post 1994 by the black scholar and black academic[33].One year later, in 2017, an event which highlighted the narrative of cultural exclusion presented itself at University of the Witwatersrand (Wits), when medical student protestors displayed a banner during a class photo stating ‘Wits Med School is Racist’ [34].

Symbolic access to institutional culture appears to be a persistent stumbling block in the South African higher education space. If left unexplored students will continue to struggle navigating the academic space; and will be forced to exist on the periphery of the university community. In medical education this may translate into student alienation and isolation from the medical community. It is increasingly important for educators in higher education to be cognisant of institutional culture and the phenomena pertaining to it, such awareness empowers educators to thoughtfully engage students and take responsibility for the role they play in student learning [35].

Medical students are exposed to established institutional culture during their extensive medical programme. In South Africa these students have publicly expressed their experience of alienation and discrimination in relation to this institutional culture over the years. The medical students’ experience of access to institutional culture and the impact it has on learning has not been formally researched or reported in this context. This body of research introduces symbolic access in medical education, with emphasis on exploring students’ awareness and experience of symbolic access in the medical community in the South African context. Further it explores what influence symbolic access may have on student learning.

This study was rooted in an interpretivist paradigm and used phenomenography, a common qualitative methodology within the social and health sciences [36, 37]. Phenomenography aims to answer specific questions about thinking and learning and helps describe the variation of ways that people understand the same phenomenon [38, 39]. This study explored various ways medical students’ recognised and experienced symbolic access within their community and how it influenced their learning.

Study Setting

A unit for undergraduate medical education at a research-intensive university in Johannesburg, South Africa was chosen as the study setting. When selecting a study setting it is important that it provides the researcher access to study participants who can give insight and relevant information on the topic being studied. Further it is important for the researcher to elaborate on the social context of the study setting as it adds historical and current insight to the investigation [40]. The medical school, where this study was conducted, is a historically White Anglo-Saxon influenced university, which has its roots in cultures of educational exclusion based on race, gender, class, and religion. Over the years there has been intentional diversification of the medical school community in this institution; the institution now consists of a community which is demographically representative of the South African population at large.

At the selected university the medical degree (MBBCh) is 6-years long. There are two entry points into the programme: as a secondary school leaver into the first year of the programme or as a graduate into the third year as part of a Graduate Entry Medical Programme (GEMP). First to fourth year students spend ninety percent of their almanac in didactic teaching, while fifth- and sixth-year students spend ninety five percent of their academic calendar in the clinical setting as they rotate between three academic teaching hospitals in Johannesburg and Soweto.

Study Participants and Sampling

Participant selection for phenomenographic studies requires the researchers to make strategic and purposeful efforts to maximise diversity of participants selected, this ensures inclusive representation of participant experiences [41]. This study was conducted in 2020, and due to the COVID-19 pandemic subsequent academic disruption, and the abrupt closure of on campus activity, convenience sampling, instead of purposeful sampling, was conducted. Participants were selected based on their availability of time, access, and willingness, resulting in a realized sample. The realized sample (depicted in Table 1) had an acceptable degree of diversity in race, age, gender, academic performance, country of origin and programme entry point to fulfil variation requirements and provide insight into the study population. The sample size of this study was 15 participants, phenomenographic studies typically suggest a sample of 10–15 participants as sufficient to capture variation and reach saturation[41]. There is no recommended upper limit currently, however sampling should ensure that the resulting amount of data remains manageable [41, 42, 43].

Table 1

Study Population and Realized Sample Demographics
Realized Sample (n = 15)			Study Population (n = 321)
Race	African	N = 8 (53%)	N = 122 (38%)
	Asian	N/A	N = 4 (1.2%)
	Coloured	N = 1 (6.7%)	N = 15 (4.7%)
	Indian	N = 1 (6.7%)	N = 69 (21.5%)
	White	N = 5 (33.3%)	N = 111 (34.6%)
Age Range	20–22 years	N/A	N = 13 (4.1%)
	23–24 years	N = 10 (66.7%)	N = 201 (62.6%)
	25–26 years	N = 2 (13.3%)	N = 51 (15.9%)
	27–28 years	N = 2 (13.3%)	N = 46 (14.3%)
	> 30 years	N = 1 (6.7%)	N = 10 (3.1%)
Academic Performance	Top Performing	N = 4 (26.7%)	N = 53 (16.5%)
	Middle Performing	N = 9 (60%)	N = 156 (48.6%)
	Lower Performing	N = 2 (13.3%)	N = 112 (34.9%)
Gender	Female	N = 9 (60%)	N = 179 (60.7%)
Gender	Male	N = 6 (40%)	N = 126 (39.3%)
Entry to Medicine	School Leaver	N = 12 (80%)	N = 204 (63.6%)
Entry to Medicine	Graduate	N = 3 (20%)	N = 117 (36.4%)
Student Country of Origin	Local (South African)	N = 12 (80%)	N = 309 (96.3%)
Student Country of Origin	International	N = 3 (20%)	N = 12 (3.7%)

Following an invitation email sent to the entire class, 19 final year students showed interest in being participants, the first 15 participants who were readily available were interviewed and became the realized sample.

Data Collection

All interviews were conducted as exploratory in-depth interviews, in keeping with phenomenographic guidance [41, 44]. Due to the COVID pandemic regulations all interviews were held online via the Microsoft Teams (MS Teams) application, which was freely available to all students in the university. DRL conducted all interviews, which ranged from 30-60min in length. Data was collected from April to September of 2020. Two exploratory questions were created which helped the researchers learn more about the topic leading to a discovery-oriented approach. Two prompt interview questions were formulated to solicit further detail and depth from participants[45, 46]. All four questions were assessed and revised in collaboration by both researchers prior to data collection, additionally the research question, aims and objectives were referred to when creating the questions in order to make sure they would satisfy the study. During and after each interview DRL took notes of how best to conduct future interviews, discussing previous interviews with SM. DRL utilized the notes in subsequent interviews. As per phenomenographic methodology all 15 interviews were recorded and transcribed verbatim for subsequent analysis [41].

Data Analysis

Interviews were analysed using Sjöström and Dahlgren‘s seven-steps for phenomenographic data analysis[47]; this method was chosen as it is easy to understand for the novice researcher and did not conflict with the other available phenomenographic processes [48, 49]. Steps in the data analysis process is depicted in Table 2. The aim of this iterative step-by-step process is to produce an Outcome Space, this space represents the qualitatively different ways which participants understood the phenomenon and shows the experiences which facilitated their understanding [50, 51]. The first steps of phenomenographic analysis result is the development of Categories of Description- how participants understood the phenomenon; further steps reveal the Dimensions of Variation- the ways categories of description were experienced (Fig. 2). Both of these components eventually populate the Outcome Space.

Insert Fig. 2: Interaction between Categories of Description and Dimensions of Variation

Table 2

Steps in Data Analysis Sjöström and Dahlgren⁴⁸
Sjöström and Dahlgren‘s Seven-steps	DRL Process of Analysis
Step 1 Familiarization	The researcher printed and read all transcripts repeatedly while simultaneously listening to the audio recordings, in order to familiarize herself with the data. Notes and sections of each interview were manually highlighted. The researcher immersed herself in the data to ensure in-depth understanding of the text and to get accuracy of context.
Step 2 Condensation	Relevant recurring feelings, words, and experiences participants used were identified, grouped together and recorded as patterns. This was done in order to uncover repeated patterns or similarities in the data.
Step 3 Comparison	Researcher studied and discussed patterns with supervisors in order to identify similarities and differences in the patterns.
Step 4 Grouping	Patterns were sorted into initial Categories of Description according to the similarities of their essence and how the categories described the participant’s experience of the phenomenon - symbolic access.
Step 5 Articulating	Categories were read and discussed between researcher and supervisors to identify the essence of each category. The main aim of this step is to set up boundaries among the categories.
Step 6 Labelling	After confirming the categories, the next step was to distinguish features between them, these become the Dimensions of Variation, and label them accordingly.
Step 7 Contrasting	Discussion and reviewing of categories of descriptions were held between the researcher and supervisor. Categories were contrasted and thoroughly defined in order to be clearly distinguished and arrive at the four categories in this study. The process of articulation, labelling and contrasting (step 5–7) was iterative, which is true to the nature of phenomenographic data analysis. The end goal was to define categories which best represented the qualitative variations of the phenomenon from the participants’ responses.

All interview recordings were printed and manually analysed by the principal researcher (DRL) who induced categories and variations. After initial development the principal researcher discussed categories and findings with the senior researcher (SM) during weekly meetings over the course of one year. The final categories were established through an iterative process between both researchers. This collaborative discussion is fundamental in the phenomenographic data analysis process as it helps to avoid researcher bias and preconceived notions [50].

Four categories of description were induced, Rejection, Disregard, Alienation and Actualization.

Categories capture the collectives experience of the phenomenon. In phenomenography it is impossible for one quotation to illustrate all aspects of the category described, but one appropriate quote can be selected which emphasizes the differences between categories, more than their commonalities [52].

Category of Description 1: Rejection

Rejection was the experience of students feeling unwanted in the community. It was most prominent during the pre-clinical years and carried into the clinical years in varying intensities. Students expressed conversations and experiences with educators which elicited feelings of rejection in the community.

The one doctor said she never signed an agreement to teach students. And she said that blatantly in our face, and we’re like, were you never once a student?

Participant GECG15

Category of Description 2: Disregard

Disregard was the feeling of not being recognized by the community. It was experienced due to various events, from poor teaching efforts during the pre-clinical years to a complete lack of acknowledgement from clinical educators during the clinical years.

“Many times, a consultant would come do the ward round with everyone there, no hello to us or anything, then once the round is over, they leave, without even recognizing we [students] are there. And that’s it”.

Participant SBB14

Category of Description 3: Alienation

Alienation was the experience of separation and isolation from the community. It was most pronounced during the pre-clinical years and continued in various incidences in the clinical years.

“For me to be honest, Medical School is just not welcoming or friendly. During the pre-clinical years, you’re basically sitting in lecture theatres all day, then the clinical years are two years of feeling unwanted”.

Participant SWG1

Category of Description 4: Actualization

This category expressed the collectives’ realization of symbolic access; three broad events contributed to this realization: 1. Relationships with peers, 2. Clinical skills teachings during the pre-clinical years (3rd and 4th year), 3. Clinical immersion and participation during the clinical years (5th and 6th year).

Relationships with Peers

… I always said that going to lectures and listening to a lecturer with your classmates is sort of like thinking, hey guys, we’re in this together.

Participant SBB14

Clinical Skills Lessons

I only spoke to the doctors during Clinical Skills and stuff. That was the only time I interacted with doctors. I felt like most of them were very helpful and I really learned a lot from them.

Participant SBB7

Clinical Immersion

It was invaluable being in the hospitals, to actually manage the patients, see the conditions that you’ve heard the theory about.

Participant SBB7

Clinical Participation

In the actual hospitals I had some good experiences, Like in Obstetrics, I had a doctor – he was so nurturing…Even in the ward round, he made us a part of the team.

Participant GECG15

Dimensions of Variation

In phenomenography categories of description are experienced through dimensions of variation, dimensions are a collective of similar events found in the data. The five dimensions of variation that were discovered were: 1. Interactions with Educators, 2. Relationships with Peers, 3. The Educational Environment, 4. Race and 5. Hierarchy. The interaction of these nine descriptors expressed how students experienced symbolic access in the medical community and was depicted in the Outcome Space.

The Outcome Space

The Outcome Space is the integration of the categories and dimensions, it gives a visual representation of how the phenomenon was experienced at a collective level [50, 53]. It can be represented as a diagram, table, or figure, three types of recommended outcome spaces exist: hierarchal inclusive, with categories presented in taxonomy format, climatic, in which categories are arranged according to the level of the explanatory power, and chronological, which represents the development of the participants’ experience of the phenomenon [49, 53]. This study presents its outcome space in two ways, first using a chronological figure (Fig. 3), this method shows the development of how participants experienced symbolic access throughout the programme. Initially, participants expressed limited experience of symbolic access but as they developed relationships with peers, attend clinical skills lessons and progressed to the clinical years, there is growing perception of the phenomenon. The second outcome space representation is in a table format (depicted in Table 3), it is a more detailed representation of the outcome space. A discussion of the outcome space will be elaborated in the discussion section.

Insert Fig. 3: Chronological Outcome Space

Insert Table 3: Tabular Outcome Space

This discussion is divided into three parts; Part I: The Outcome Space: what the data means, Part II: Students’ awareness of Symbolic Access: Do you feel like you’re part of the team? and Part III: Does symbolic access impact learning? These separate sections discuss what was found in the outcome space, linking it to the research questions, aims, objectives and the literature.

Part I

The Outcome Space, what the data means.

Two experience narratives were described in the outcome space, the first major narrative was of exclusion, it was experienced as rejection, disregard, and alienation through interactions with educators, the educational environment and racism. Which is elaborated on in the following paragraphs.

Exclusion

During the first four years of the programme educators and students engaged in a ‘transactional relationship’. This relationship consisted of educators delivering knowledge to the students, who in turn transacted this knowledge back to the lecturers in exams, no concrete effort was made by educators to socialize students into the medical community or to develop community relationships with them. Although students had the title of medical student, it did not translate to their lived experience and instead of developing community identity and belonging, students identified as general university students. The early medical years were cocoon-like, where students existed apart from the community and had very limited opportunities to bond with their educators.

In the clinical years student interactions with clinical educators was dependent on the most senior doctors personality, as a result relationship development was erratic and inconsistent. Experiences of rejection and alienation were interspersed with some recognition and inclusion. Stark [54] explains that the fragmented student-educator relationship found in the clinical setting is common, there are examples of high quality and inspirational interactions alongside deep humiliation and being made to feel unvalued. Students struggled to concretize relationships with senior educators, as interactions rarely went beyond scheduled one hour bedside tutorials. Instead a significant amount of the students’ time was spent with less senior community members i.e., medical officers, or interns whose main objective was service delivery not teaching or intentional community socialization.

Alienation from the community was experienced across two educational environments, the physical environment, and the educational climate [55, 56]. Students’ expression of the physical environment mirrored their relational experience with educators, disconnected and neglected. During the pre-clinical years a significant amount of time was spent in didactic teaching lessons, which were mass delivered in the same lecture venue for an entire year. The educational climate of the clinical years was isolated and anxiety provoking. The complexity of managing a new learning environment and the clinical workload, coupled with poor support from clinical educators left students feeling alone and vulnerable. Alienation was uniquely experienced by Students of Colour (SoC) at two levels.

SoC’s experienced general isolation of being a medical student in the volatile community and specific alienation of being a student of colour in the medical community. Discrimination based on race uniquely shaped the SoC’s time in medical school, and narratives of race-based community exclusion were frequently repeated by SoC’s. Social and academic alienation from community were described, as well as feelings of disconnect from the community culture. White participants did not discuss experiences based on race. Literature highlights that most medical school culture caters largely for the White student, who more easily assimilates into its community and way of being [57, 58, 59]. Despite its importance, there has been a noticeable lack of attention on how institutional racism is perpetuated by medical schools and communities. Racist experiences are brushed off, culture remains and the profile of faculty members, particularly at senior levels, remains dominated by white staff, particularly men [60].

Unfortunately exclusionary experiences in medical education are not uncommon and are documented globally [61, 62, 63], this exclusivist culture is ingrained in medical education, with recurring student stories of neglect and estrangement from the medical community.

Inclusion

The second minor narrative from the outcome space was of inclusion and the realization of symbolic access, which this study defines as actualization. Actualization was developed from peer relationships, clinical skills lessons, meaningful clinical immersion and participation, and hierarchy. Peer relationships between junior and senior students were the first ‘welcome’ students received into the community. These informal relationships were a consistent source of affirmation for the medical student, as senior students shared strategies of how to become successful academically and socially in the community. Through these relationships junior students developed confidence and a sense of legitimacy in their new community. Clinical skills teaching sessions were profoundly inclusionary experiences for the students. During these low simulation teaching lessons students had positive community socialization with their clinical educators, learnt and participated in important community traditions like wearing scrubs, using medical equipment, and performing clinical examinations. The nature of clinical skills teaching lends itself to relationship development; small groups, interactive sessions, and continued guidance create a favourable climate for positive educator-student relationships [64]. Stark [54] explains that medical students view clinical skills teaching as non-threatening and optimum, a time of strong affirmation from community educators. Clinical skills sessions were a distinct foundation for symbolic access, through this process the students’ awareness of their medical identity began to take shape.

Clinical immersion and meaningful participation in the clinical setting, both of which occurred during the final two years of the programme, were chief actualization events. Being in the hospital, being entrusted to manage patients from admission to discharge, recognition during community events and acknowledgement as junior colleagues from senior educators boosted student confidence and a sense of community belonging.

Hierarchy as Actualization?

While all other ‘actualization experiences’ were quickly understood, hierarchy warranted deeper unpacking. The culture of hierarchy is a well-documented feature of medical communities and much more evident in the clinical training environment [65, 66]. Upon entering the medical community, medical students typically find themselves at the very bottom of a long, steep, and established hierarchy [67]. Students described their experiences of hierarchy as a form of initiation, they believed it was a process all medical students go through in order to be deemed “tough enough to do medicine”. Although it was continually expressed as a negative event; participants described the necessity of hierarchy as a rite of passage into the community, which helped to explain how it contributed to the actualization of symbolic access. Vanstone and Grierson [65, 66] add that hierarchy in medical education has positive effects, explaining that it helps to create a social framework for the student who can establish awareness of ‘their place’ in the community.

Part II: Students’ awareness of Symbolic Access: Do you feel like you’re part of the team?

In light of the outcome space’s double narrative further reflection of the interview data was required, the researchers aimed to discover if students had ultimately attained symbolic access and if they were aware of this attainment. Deeper reflection of the text and findings revealed that despite extremely exclusionary experiences, overall participants described gaining symbolic access within the medical community. This awareness of symbolic access was revealed by the collective’s ability to identify with the community and its culture. In various ways students identified themselves as part of ‘the team’ or explained that they were confident with ‘their role’ in the community. Medical education literature emphasises that the main factors which contribute towards medical students’ sense of community belonging and professional identity include 1. Doing the work of the doctors, 2. Increased patient interaction, 3. Time spent in the hospital, 4. Being treated as healthcare workers, 5. Increased responsibility, and 6. Seeing their role models in action in the workplace [68]. Eberle et al[69] add that within the medical setting the experience of community immersion and participation facilitates the development of community identity and belonging.

The researchers attribute the following inclusion experiences as the main factors which contributed towards the students’ actualization of symbolic access: 1. Peer relationships, 2. Clinical Skills lessons and educator relationships developed during these lessons, 3. Being in the hospital and participating in bedside learning opportunities, 4. Managing their own patients, 5. Performing clinical skills in the hospital setting, 6. Working with future colleagues in the profession and 7.The experience of community hierarchy.

Part III

Does symbolic access impact learning?

During the pre-clinical years teaching was mass delivered didactically to classes of 300 + students, leaving little room for interactive and engaging learning opportunities. This teaching coupled with poor educator-student interactions resulted in student learning being described as isolated, cognitive overload and disconnected from ‘real medicine’. One exception to the negative pre-clinical learning experience was clinical skills teaching and learning. These sessions were valued by the student body, who appreciated small group learning, and described the learning environment as supportive and conducive.

Learning experiences during the clinical years were largely positive. Bedside teaching in smaller clinical groups with real life patients, experiential clinical learning and clinical immersion bridged theory-practice gaps and created meaningful learning experiences for the students. Learning was tangible during the clinical years and contributed towards positive perceptions. Clinical learning is said to be the cornerstone of medical education, as it is in this learning environment that students are able to participate in the medical community and develop both their clinical skills and professional identity. Medical students often perceive the tangible difference between the pre-clinical and clinical curricula; and are able to articulate these changes in their learning due to the vast contrast of experiences [70].

Learning that was valued during the pre-clinical years centred primarily around clinical skills lessons, during the clinical years learning that was valued included bedside teaching, clinical immersion, and meaningful clinical participation. Significant events which resulted in students’ actualization of symbolic access also resulted in students perceptions of meaningful learning experiences. Student learning came to life as students gained symbolic access, symbolic access facilitated the shift from disconnected, isolated, and dead-end learning to applicable, contextual and inspirational learning experiences. This study suggests therefore that attaining symbolic access improves students’ learning experiences.

Symbolic access functions as a ‘key’ which helps to unlock enculturation, identity development and valued learning experiences for the medical student. It is influenced both by positive and negative community encounters and events. Medical educationalists should design undergraduate curricula with intentionality, focusing on promoting educator-student interactions, early community socialization and early clinical immersion, as these factors are linked to the attainment of symbolic access and meaningful learning opportunities.

This study was conducted in one institution, making the findings contextual and not easily generalized. There was scarcity of prior research on the phenomenon under investigation, symbolic access, which meant there was minimal literature to support or elaborate on the phenomenon but simultaneously warranted the need for such a study. The study methodology chosen was labour and time intensive and the sample size may have had more variation of experiences if it was larger, although it was within acceptable limits for a phenomenographic study. The involvement of researchers meant that data could not be completely without the bias of the researchers, who developed the categories of description. Further the interpretation of participants words, which resulted in the categories of description, was influenced by the philosophies and interests of the researchers. However only interpretations supported by the data were taken. Readers and researchers are therefore open to analyse the categories based on the data given and arrive at a different interpretation [50].

Manohar et al [71] propose that qualitative research is a mutual space, shaped by both researcher and participants, hence both identities have the potential to influence the entire research process. It can also be argued that the collective, which is often described in phenomenographic methodology, includes the researchers as they conceptualise the research, participate and shape the interview and the data [72].

Table 3: Tabular Outcome Space (to be inserted below Figure 2: Chronological Outcome Space)

OUTCOME SPACE
Categories of Description:	Dimensions of Variation
Categories of Description:	Interactions with Educators	Relationship with Peers	Educational Environment	Race	Hierarchy
Rejection	No initiation by educators to develop educator-student relationships.		1^st-4^th year: Students not welcomed by medical community. 5^th&6^th year: Feelings of illegitimacy in the community by students.	Exclusion and poor community identification by SoC.
Disregarded	1^st-4^th year: Students not recognized by community. Clinical Years: Students ignored during significant community events.		1^styear: Students completely ignored by medical community. 2^nd-4^th year: Students on medical campus but not prioritized. 5^th&6^th year: stressful often with little support from educators.	Neglect and othering of SoC based on race.	Clinical setting of medical community extremely hierarchal, medical student always at the end of the queue.
Alienation	Significant isolation during early years of the programme.		1^st- 4^th year: Students separated from the medical community in lecture theatres.	Sense of estrangement from the community.
Actualization	3^rd and 4^th year: Clinical Skills educators source of community acceptance. 5^th&6^th year: Recognition and prioritization close to graduation.	Facilitated a sense of community and identity development. Students ‘seen’ by peers. Source of comfort and guide for students to navigate the academic and clinical space.	3^rd and 4^th year: Clinical Skills lessons opportunity to learn skills to be used in future. Safe environment. 5^th&6^th year: Opportunity to meaningfully participate.	Positive experiences of encouragement by seniors of same race.	Hierarchy a rite of passage into medical community.

Bachelor of Medicine and Bachelor of Surgery Degree MBBCh
Community of Practice CoP
Microsoft Teams MS Teams
Students of Colour (African, Coloured, Indian) SoC
University of the Witwatersrand Wits

Ethics Declaration

The protection of research participants through the application of appropriate ethical principles was applied. Ethical clearance was obtained from the Human Research Ethics Committee (HREC) Medical of the University of the Witwatersrand (Clearance Certificate no. M191042). All study methods were carried out in full accordance with the relevant HREC Medical guidelines and ethics regulations. Participants were provided with written information about the study’s purpose by the researchers, informed and audio recording consent was obtained from all participants. The participants were assured anonymity and confidentiality. Participants were further informed that their participation was voluntary, and that they could withdraw at any time without any prejudice.

Consent for Publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing Interests

The authors declare that they have no competing interests.

Funding

No external fund was received for this study.

Authors' contributions

DRL and SM were student and supervisor respectively in this study, which partially fulfilled the requirements for a master’s degree. DRL conceived the study. DRL and SM agreed on the study methodology. DRL collected and analysed the data. DRL and SM interpreted the data. DRL drafted the first manuscript. SM provided comments and edits on subsequent versions of the manuscript. Both authors approve the final submitted version of this manuscript and agree to be accountable for their contributions.

Acknowledgements

The authors would like to thank Lynne Slonimsky, for the introduction to Bourdieu and symbolism, Hilary Thurling, who contributed greatly to the early stages of this study, Scott Smalley who reviewed versions of this manuscript with an eagle eye, and the participants of the study, without whom none of this work would be possible.

Author Information

C/O Centre for Health Sciences Education, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa

Dina-Ruth Lulua

Centre for Health Sciences Education, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa

Shirra Moch

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No competing interests reported.

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published 04 Jan, 2024

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Symbolic Access: Medical students’ awareness of institutional culture and its influence on learning, a phenomenographic study.

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