I first started teaching medical students in 1975, having just taken up a part-time lecturing post at Charing Cross HMS. Much has changed in London over the period since, not least the mergers of most HMSs into four large multi-faculty institutions (leaving St George’s HMS as an outlier). Sociology teaching has changed too. In this brief blog, a contribution to discussions on twitter, I will precis my personal views on teaching sociology to medical students.
When the GMC announced its decision that sociology should be incorporated into the undergraduate medical curriculum its rationale was clear. The health of the populations doctors were being trained to serve was rooted in people’s experiences of day-to-day living, in their circumstances as well as their behaviours. Health and longevity were far from being functions of access to doctors or to health care in general. Moreover people’s behaviours were clearly ‘shaped’ – I would now say ‘structured’ but not ‘structurally determined’ – by social relations like class, status, gender, ethnicity, age and so on. This applied of course to doctors and allied health professionals as well as to patients. So it was to be sociology’s task to reveal by means of theories generated and tested by research just how this structuring worked. Topics typically included: definitions of health, illness and disease, changing causes of death and longevity by time and place, the social aetiology and courses of diseases, risk and help-seeking behaviours, doctor-patient interaction, coping and the management of long-term and disabling conditions, the ramifications of stigma and deviance, issues around dying and bereavement, evaluations of health care interventions, and the nature and effectiveness of primary, secondary and tertiary prevention and of health care systems as a whole. Sociological perspectives moved back and forth from macro- to micro-.
These foci have probably not changed too much over time, although theories and studies have evolved. But why is all this relevant to an apprentice doctor learning to detect, diagnose and manage or treat disease in an individual patient? The answer is obvious to a sociologist who sees social processes at work in the very structuring of (bio-)medicine and its preoccupation with the individual. But medical students have always asked, reasonably enough: ‘how does all this affect what I say or do when a patient comes to the surgery or clinic?’ Well a few ‘evidence-based’ tips might be forthcoming: listen to why your patient has come, join a dialogue of equals, explain any advice clearly, and so on. But much of sociology seems far removed from these individualistic encounters. This distinguishes it from most psychology, and epidemiology too deals in aggregates of individuals rather than social structures, relations and processes.
It seems to me crucial to recognise that sociology feeds less directly into clinical practice than perhaps any other discipline that students will sample in medical school. Its thrust is educational. It invites semi-detachment from personal practice and calls for a healthy dose of reflexivity. I have yet to encounter a colleague who aspires to make sociologists of medical students or doctors. The common goal is to imbue them with a sense of the context in which they will practice and of the parameters of the possible. What doctors can accomplish across the medical specialities is immense but circumscribed; and reflexivity about this is extrinsically as well as intrinsically worthwhile: it can serve as an effective ego-defence for example.
One criticism of sociological teaching is that it somehow promotes ‘left-wing’ views. My own experience is that sociologists are extremely careful to distinguish, Weber-like, between theory and data about how things are and why and moral and political stances. There are of course ready theories about why people like medical students, recruited disproportionately from the privately educated offspring of parents in well-paid professional and managerial jobs, might misdefine a sociological account of medical recruitment or class or gender-related health inequities as committed propaganda. So be it, is my response; and if they complain about bias, we fight our corner. Sociology in medical schools often educates against the grain. Extremely positive evaluations of sociology teaching could even be worrying! Talking of evaluations, I recently sought to encourage a younger colleague with three of my own, and after the same mini-series of lectures: ‘he was awesome’, ‘he was a waste of space’, ‘he never turned up’.
Sociology teaching to medical students has got more difficult in my view. It was hard to get our courses established and taken seriously in the early days. By the beginning of the 1980s, however, new textbooks like ‘Sociology as Applied to Medicine’ were available, many HMSs were providing resources for small-group teaching, and summative assessment was often by written examination and essays. There may be more choice of textbooks now, but small-group teaching has become impractical and the testing of student knowledge and understanding is typically by MCQs or SBAs, ludicrous modes of judging a critical and reflexive grasp of the social structuring of the contemporary life-course. Weberian ‘rationalisation’ has grown apace, as has the size of student intakes and the premium on space.
As for the students themselves, as American sociologists Howard Becker and co put it half a century ago, they were, and remain, intent on survival, rather like members of the French resistance during the 2nd world war. It is not easy training for medicine; and the lot of the medical student can be very unlike the university education other students experience. For many of them sociology is understandably seen as but one peripheral hurdle to be overcome, and that in the most felicitous manner possible. It is our task to make our mark as they rush past us. Fortunately we have an ally or three among our clinical and public health colleagues who typically see our students at a later stage.