Discourses of student orientation to medical education programs

Abstract

Background: Although medical students' initial orientation is an important point of transition in medical education, there is a paucity of literature on the subject and major variations in the ways that different institutions orient incoming medical students to their programs.

Methods: We conducted a discourse analysis of medical education orientation in the literature and on data from a survey of peer institutions' approaches to orientation.

Results: These two discourses of orientation had clear similarities, in particular, the critical role of ceremony and symbols, and the focus on developing professionalism and physician identities. There were also differences between them, in particular, in the way that the discourse in the literature focused on the symbolic and professional aspects of orientation; something we have called 'cultural orientation'. Meanwhile, those who were responsible for orientation in their own institutions tended to focus on the practical and social dimensions.

Conclusion: By examining how orientation has been described and discussed, we identify three domains of orientation: cultural, social, and practical. These domains are relatively distinct in terms of the activities associated with them, and in terms of who is involved in organizing and running these activities. We also describe orientation as a liminal activity system on the threshold of medical school where incoming students initially cross into the profession. Interestingly, this state of ambiguity also extends to the scholarship of orientation with only some of its aspects attracting formal enquiry, even though there is a growing interest in transitions in medical education as a whole. We hope, therefore, that this study can help to legitimize enquiry into orientation in all its forms and that it can begin to situate the role of orientation more firmly within the firmament of medical education practice and research.

RESEARCH ARTICLE

Discourses of student orientation to medical education programs

Rachel H. Ellaway1*, Gerry Cooper1,2, Tracy Al-Idrissi1,3, Tim Dubé1 and Lisa Graves1,4

1Undergraduate Medical Education, Northern Ontario School of Medicine, Greater Sudbury, ON, Canada; 2Schulich School of Medicine & Dentistry - Windsor Program, Western University, Windsor, ON, Canada; 3Office of the Registrar, Trent University, Peterborough, ON, Canada; 4Department of Family and Community Medicine, St. Michael's Hospital, Toronto, ON, Canada

Abstract

Background : Although medical students' initial orientation is an important point of transition in medical education, there is a paucity of literature on the subject and major variations in the ways that different institutions orient incoming medical students to their programs.

Methods : We conducted a discourse analysis of medical education orientation in the literature and on data from a survey of peer institutions' approaches to orientation.

Results : These two discourses of orientation had clear similarities, in particular, the critical role of ceremony and symbols, and the focus on developing professionalism and physician identities. There were also differences between them, in particular, in the way that the discourse in the literature focused on the symbolic and professional aspects of orientation; something we have called 'cultural orientation'. Meanwhile, those who were responsible for orientation in their own institutions tended to focus on the practical and social dimensions.

Conclusion : By examining how orientation has been described and discussed, we identify three domains of orientation: cultural, social, and practical. These domains are relatively distinct in terms of the activities associated with them, and in terms of who is involved in organizing and running these activities. We also describe orientation as a liminal activity system on the threshold of medical school where incoming students initially cross into the profession. Interestingly, this state of ambiguity also extends to the scholarship of orientation with only some of its aspects attracting formal enquiry, even though there is a growing interest in transitions in medical education as a whole. We hope, therefore, that this study can help to legitimize enquiry into orientation in all its forms and that it can begin to situate the role of orientation more firmly within the firmament of medical education practice and research.

Keywords: medical student orientation; white coat ceremony; professionalism; medical culture; transition; identity development

*Correspondence to: Rachel H. Ellaway, Undergraduate Medical Education, Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada. Email: [email protected]

Received: 30 December 2013; Revised: 18 February 2014; Accepted: 21 February 2014; Published: 14 March 2014

Medical Education Online 2014. © 2014 Rachel H. Ellaway et al. This is an Open Access article distributed under the terms of the Creative Commons CC-BY 4.0 License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

Citation: Med Educ Online 2014, 19: 23714 - http://dx.doi.org/10.3402/meo.v19.23714

Introduction

Medical education research is a maturing discipline with an ever-growing evidence base for its many activities, processes, and systems. Transitions between pre-clerkship and clerkship have received a fair amount of attention (1, 2), as have transitions from MD training to residency (3). However the current literature reflects an apparent limited research interest in the design, practice, or experience of orientation activities for incoming medical students beyond the archetypal 'white coat ceremony' (4). This would seem to reflect a sense that orientation is neither fully within nor entirely outside of medical education and as such, enquiry into this time of transition faces questions of legitimacy in medical education scholarship. Nevertheless, for some institutions at least, orientation is valued as a significant part of the student experience and is an important part of the academic calendar. For these institutions, including the authors' own schools, the question is not whether orientation is worthy of research but rather how should research be pursued in and around orientation practices and experiences.

This paper reports on a formative study that explored the potential research context of medical school orientation by comparing and contrasting existing discourses from the literature and from peer medical schools to develop a descriptive framework of key issues in medical school orientation thinking and practice. In doing so, we sought to take a critical stance on how orientation to medical school is understood, and the role of scholarship in shaping orientation and linking it to medical education as a whole.

Background

Our approach to this study should be understood in the context of our affiliation with the Northern Ontario School of Medicine. Our charter class students created a commemorative yearbook for their graduation that contained many comments and photographs harking back to their orientation program 4 years earlier. Knowing the depth and breadth of educational experiences the students had had since orientation, we were quite surprised that their orientation experiences remained such a positive point of reference for these soon-to-be residents. In our efforts to better understand and enhance our own orientation program, we began to analyze the original assumptions that defined the orientation model we used, which led us to explore how orientation was perceived and practiced in other medical schools.

We approached medical school orientation as one of the 'sentinel events and experiences that accelerate the attachment of professional identity' (5), not least because professional identity formation has been shown to be significantly impacted by students' earliest experiences (6).

We conducted a longitudinal mixed methods study to document, appraise, and explore the nature of orientation activities for students entering our own institution, a key part of this study was a review of what orientation meant to others both in the literature and at peer institutions. This paper reports on this latter contextual component of the study.

Our questions for the component of the study reported in this paper were:

1. What constitutes current practice in medical school orientation and how are they represented?

2. What does a research space for exploring orientation in a meaningful and productive way look like?

We operationalized these questions by comparing and contrasting existing discourses from the literature and from peer medical schools to develop a descriptive framework of key issues in medical school orientation thinking and practice. In doing so, we sought to take a critical stance on how orientation to medical school is understood, and the role of scholarship in shaping orientation and linking it to medical education as a whole.

Methods

There were two data components to this review:

1. A literature search was conducted in 2011 using CINAHL and PubMed looking at the published literature from January 1, 2000, to December 31, 2010, using the terms '(medical OR health) AND student AND orientation'. The bibliographies of the 18 most relevant papers were used to identify other sources for the review. The material we identified contained a high proportion of opinion and argumentation and very little empirical data. We decided to use Gee's model of discourse analysis as the basis of a thematic synthesis both of what was discussed and how it was discussed (7, 8). This involved iteratively identifying and coding discursive themes in the texts around concepts of significance, practices, identities, relationships, politics, connections, and sign systems. The analysis was primarily conducted by one of the research teams (RHE) using standard coding techniques to develop a candidate model of the discourses in the literature around orientation to medical school. The other members of the team then reviewed this model, and consensus was iteratively built to create the final model we report in the results section of this paper.

2. A survey-based review of orientation activities in Canadian medical schools was undertaken. All 17 medical schools in Canada were approached to participate in this study. A pro forma survey was sent by email to the leads of student affairs department of each medical school in August 2011 - see Table 1. Reminder email messages were sent later in August and again in December 2011. Gee's model of discourse analysis was also applied to this data set.

[Table omitted -see PDF.]

Discussion

We have structured our discussion of our findings around our two research questions:

Current practice in medical school orientation

Orientation to medical school would seem to vary between institutions although it does seem to involve many common component activities and philosophies. This was reflected in the similarities between the two discourses of orientation that we analyzed, in particular the critical role of ceremony and symbols and the focus on professionalism and physician identity development. There were also differences in the way that the discourse in the literature remained focused on the symbolic and professional aspects of orientation, something we have called 'cultural orientation'. The survey identified two other forms of orientation practice: 'social orientation' intended to bind individual students together as a coherent and supportive class, and 'practical orientation' briefing students on the basic facts needed to function in the program and to process various administrative tasks.

Orientation was typically defined as a series of highly situated events that took place shortly before, at, or shortly after a class of medical students started their studies. These events involved aspects of social, practical, and cultural orientation to what it is to be a medical student in a particular place at a particular time. The focus on the class, rather than the individual, would seem to be a deliberate, if a less than clearly articulated, mechanism that takes a group of individuals and socializes them so as to unify them as a class.

A key difference between the two discourses was that, while student involvement in designing and leading orientation activities was identified by a number of survey respondents, it was largely absent from the literature. The primary reason for this would seem to be linked to senior students' focus on the social rather than the professional dimensions of orientation. Furthermore, although some of the survey respondents discussed the involvement of their local communities in their orientation activities, we were unable to find equivalent references to such practices within the literature, despite a growing focus on social accountability in medical education as a whole (33).

The variety of institutional views on the legitimacy and significance of orientation was reflected in the levels and forms of funding for orientation, and in the shifting balance between student and institutional responsibility for orientation. It would seem that, in an age where professionals are expected to be ever more abstemious and accountable for their actions, the acceptability of alcohol and hazing in orientation has diminished and risk management has become an increasing part of orientation planning for medical schools. As a result, orientation has become more of an institutional responsibility over time and would seem to be likely to continue in this direction for some time to come.

Developing a research space for exploring medical school orientation

Our work has identified several dimensions of potential research in and around medical school orientation:

1. Medical school orientation may be the subject of research in and of itself as a social and logistical phenomenon. The three dimensions of cultural orientation, social orientation, and practical orientation we identified in the current study can form a single theoretical framework of orientation practices - see Fig. 1. This could serve as a program theory for future enquiry into this as-yet under-researched aspect of medical education. Other areas of potential inquiry include economics, stakeholder representation, discourses within the conduct of orientation, and participant outcomes.

2. Orientation may also be researched as the first of many stages in medical students' training. For instance, a class is the organizational unit with which researchers typically work, yet its origins are rarely if ever considered. Understanding how a class forms in orientation could be expected to provide important insights on how the individual and collective identities of the class may subsequently respond to different educational interventions.

3. Orientation may be researched as a construct within a broader educational ecology. For instance, although orientation has no explicit assessment, there is an implicit assessment as individual student's ability to benefit from orientation may well impact their ability to succeed later in their studies. Research may also consider more theoretical constructs, such as the hidden curricula of orientation, the impact of orientation on learner identities, or orientation to their medical school's communities of academic and clinical practice. The need for further research in this latter area was implied by the ways that our findings echo Wenger's models of 'communities of practice' (34), such as the roles of novitiates and those that induct them into a community of practice, the role of shared symbols and boundaries for a community of practice, and the ways in which these boundaries can be legitimately crossed.

4. Orientation sits at the threshold of medicine and could be researched as a liminal time when students are neither in nor out of the medical school or medical profession, and where they start to set aside aspects of their previous lives as they begin their journey to become physicians. This observation parallels Turner's work on rituals (35, 36), which he describes as liminal socially complex activities required for individuals to cross social thresholds. Although the discourse on orientation in medical education often uses the term 'ceremony', a small but significant part of orientation activity involves ritual, at least in following Turner's observation that while 'ceremony indicates, ritual transforms' (35, p. 80).

5. Orientation may also provide a valuable professional development opportunity for existing students by providing opportunities for them to plan, manage, and lead orientation activities, and to mentor incoming students. The potential for participation in orientation to develop leadership, organizational, and mentorship skills raises the possibility of researching it as an educational intervention for these students. independently or in tandem with its impact on incoming students.

Fig 1

Fig. 1. Essential activities of orientation organized according to their involvement of social, cultural, or practical dimensions of orientation.

Orientation is, as yet, an under-investigated aspect of medical education practice, and there are many ways in which research in and around orientation could be developed and conducted. Our own lines of inquiry include aspects of the hidden curriculum and identity formation in our own institution's orientation. We hope to learn from others' explorations in to different aspects of orientation at their own institutions.

Limitations

We acknowledge a number of limitations to this study. First, we have addressed a very large (and somewhat under-explored) area of medical school practice and in doing so, we have chosen to review how orientation is discussed rather than directly observing orientation activities, sampling participant experiences, or describing or measuring the outcomes of such activities.

This was not an in-depth study as the literature search and survey were both limited in scope and rigor in the way they were planned and executed as we focused on developing a broad understanding of the concepts of orientation as a precursor to, and as a way of informing other parts of, our study into orientation at our own institution. This study is formative and question-generating rather more than it is question-answering a clear precursor, at least provisionally, for defining a research space.

On a more practical note, we acknowledge the limitation of only conducting the survey and literature search in English and only at Canadian schools. A more thorough review might have considered a wider range of different cultures (both social and geographical). However, as previously stated, this study was about defining a research space rather than fully occupying it, and as such the limited range of contexts we examined aligned with our own institution's setting.

The two discourses we decided to analyze were somewhat discontinuous. One pre-existed the study and was dominated by debate around a particular ceremonial set of practices and associated ideologies. The other was generated by the project with its format and focus predetermined and to some extent directing of the responses we entered into our analysis. Treating both as discourses allowed them to be synthesized but in doing so we acknowledge that there are limitations to the comprehensiveness of the findings we present.

We also acknowledge that our use of discourse analysis was relatively cursory compared to its use to analyze single texts in depth. This was a deliberate methodological choice as we used discourse analysis as a way of analyzing and synthesizing multiple academic papers and survey results in a single model. Discourse has proved to be a valuable technique to use, particularly where there is so much contention (in the literature at least) and the concept of orientation is so limited, neither fully within or outside legitimate scholarly enquiry. Our work is in itself, an act of exploring the legitimacy of inquiry in and around this topic and as such we acknowledge that it too will contribute to and be held accountable within the discourse of orientation to medical school.

Conclusions

Orientation to medical school is a complex, culturally rich, and to some extent ritualistic undertaking, only part of which has been explored in the literature. This study has attempted to describe orientation to medical school by looking at how it has been described and discussed rather than looking at its practices or outcomes. In doing so, we have found that orientation has three domains, namely cultural, social, and practical, and that these domains are relatively distinct in terms of the activities associated with them, and in terms of who is involved in organizing and running these activities.

We have also been able to identify and describe orientation as a process of professional transition, both as an activity system that sits on the threshold of medical school and as a gateway to the medical profession for individual incoming students. This juxtaposition also extends to scholarship with only some aspects of orientation attracting formal enquiry even though there is a growing interest in transitions in medical education as a whole. We hope, therefore, that this study can help to legitimize enquiry into orientation in all its forms and that it can begin to situate the role of orientation more firmly within the firmament of medical education practice and research.

Conflict of interest and funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

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