Anna Harvey is currently between her final year of medical school at King’s College London and an Academic Foundation post in the Northern Deanery. Her areas of interest in clinical education research are mainly around identity development and she hopes to be able to investigate this further during her academic time. Outside of medicine she aspires to adequacy in her other identities: daughter, sister, auntie, partner and friend.
“To laugh often and much; to win the respect of intelligent people and the affection of children. To earn the appreciation of honest critics and endure the betrayal of false friends, to appreciate beauty, to find the best in others. To leave the world a bit better, whether by a healthy child, a garden patch, or a redeemed social condition. To know even one life has breathed easier because you have lived: this is to have succeeded.”
This passage, generally attributed to Ralph Waldo Emerson, is one that I first read during my second year of medical school, and is one I frequently return to. As I have come to the end of my journey at medical school and reflect on the learning and growing I have done during my time as a student it is one that continues to speak to me for its nuance and gentle good humour. Notably, it doesn’t mention much in the way of ambition, career progression or wealth – though all of those things may too be considered markers of success.
Having been lucky enough to have had the opportunity to do lots of interesting things during my time at medical school, including spending a year working at The BMJ as editorial scholar, I am often asked to speak, both to large audiences and in one on one informal sessions, about my personal success, and how I achieved this. It’s always flattering to be asked, but I often struggle to communicate the nuances of my personal philosophy on success.
This all ties in with a project I completed as a student selected module in medical education. I had been interested in widening access and participation (WA/WP) to medical school for a number of years, and whilst doing some preliminary reading in preparation for the project found a number of interesting papers about differential attainment and the barriers to progression for students from marginalised and minoritized backgrounds. I also see repeated debates on Twitter about the merits of the measures used to allocate junior doctor jobs and training numbers, with many of the opinion that the current points system used isn’t the best way to assign value to potential trainees.
A well-known concept in widening access to higher education is the “aspiration gap” – children and young people from certain backgrounds are less likely to apply to courses like medicine as they cannot see themselves in the profession . Attracting more working class medical students has been presented as a solution for recruitment and retention to less-filled specialties like general practice and psychiatry, and less desirable areas of the UK – things sometimes unkindly viewed by the rest of the profession as “unsuccessful.”
So – the question I asked myself was: is there a role for conceptions of success to have an impact on WA students’ progression and eventual career path? And, more broadly: how do we, as a profession and an academic field, even measure success in the first place?
To answer these questions, I conducted a number of informal conversations with students at my university who described themselves as WP/WA. Their conceptions of success were broad; often perceived as being “above average” in their written and practical exams; and generally linked to their performance allowing them to better serve their patients in the future.
Alongside this primary interviewing, I performed a non-systematic literature reviews of attainment literature and educational guidance to build up a picture of how the clinical education academic field measures success. Almost all the attainment literature took a linear, hierarchical view of progression, assigning meaning to speed of progression through training, number of papers published, and exam results. The below quote, from McManus et al, 2003, sums up succinctly the attitude of the clinical education literature to measuring attainment:
‘medical careers are hierarchical. Speed of progression and of attaining postgraduate qualifications therefore indicate success. Although exceptions occur, doctors who take longer to reach the top realise their potential less.’ (2)
In some ways this project made me ask more questions than it answered. There are so many facets that I was unable to explore: what is the interface between the measures of success used in academia and how students form their conceptions of success? What about the measures used to benchmark junior doctors for training posts – does knowledge of this shift perceptions? For widening access students – how does their perception of their own and others’ success evolve as they become more integrated in the profession? And how do their ideas compare to those who come from professional, or even medical, backgrounds?
There is enormous scope for continuing to investigate these attitudes through qualitative research, specifically with focus on widening access and impact on medical students’ and doctors’ wellbeing.
What is clear is that as we strive to diversify the medical profession the measures we use to assign and measure success must too become more holistic, flexible and individual. Without this shift, we do a disservice to those who, for any reason, do not follow the traditional linear career pathway. Success looks like many things, and medicine as a field must begin to reflect this.