changing geographies of access to medical education in london

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Health & Place 13 (2007) 520–531

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Changing geographies of access to medical education in London

Gavin Brown�, Pamela Garlick

Division of Medical Education, Access to Medicine Project, King’s College London, Room 4.20, Shepherd’s House Guy’s,

London SE1 1UL, UK

Received 16 December 2005; received in revised form 16 June 2006; accepted 4 July 2006

Abstract

This paper highlights the need for health geographers to consider the social and cultural geographies of who gets to train

as a doctor. The paper presents a case study of a scheme intended to widen access to medical education for working class

students from inner London. This work examines the role of local education markets and cultures of education in shaping

the aspirations and achievements of potential future doctors. It employs ethnographic data to consider how ‘non-

traditional’ learners acclimatise to medical school. Our findings indicate that the students who succeed best are those who

can see themselves as belonging within the education system, regardless of their social and cultural background.

r 2006 Elsevier Ltd. All rights reserved.

Keywords: Medical education; Medical students; Widening participation; Education markets; Geographies of education

Introduction

Over the decades, medical geographers haveproduced a considerable body of work that demon-strates the spatial differences in the incidence ofdisease, and inequalities in access to healthcare andhealth outcomes (Gatrell, 2002; Parr, 2004). Morerecently, geographers of health have theorised therelationship between the local environment, loca-lised health beliefs and people’s experience of illnessand well-being (Mitchell et al., 2000; Parr et al.,2004). There has been very little, if any, workpublished on the geographies of where futuredoctors come from and the spatial inequalities ofwho has access to the appropriate training.

This is perhaps not surprising, because humangeographers have not, until recently, invested much

e front matter r 2006 Elsevier Ltd. All rights reserved

althplace.2006.07.001

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8 6760.

ess: [email protected] (G. Brown).

intellectual energy into the study of geographies ofeducation (Johnston et al., 2005; Taylor, 2001,2002). Indeed, at the risk of being accused ofpolicing disciplinary boundaries, much of the mostsophisticated work on education that has beenpublished in geographical journals over recent yearshas come from scholars who have spent most of theircareers outside Geography departments (Butler andRobson, 2003).

In response to on-going criticism and concern,both from within and outside the profession(McManus, 1998), about the continuing over-representation of students from professional socialclasses and particular ethnicities amongst thestudent body in UK medical schools, the Councilof Heads of Medical schools (CHMS) has com-mitted itself to a statement of principles, thatincludes the following:

The purpose of a medical education is tograduate individuals well-fitted to meet the

.

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ARTICLE IN PRESSG. Brown, P. Garlick / Health & Place 13 (2007) 520–531 521

present and future needs of society for medicalcare [y] The social, cultural and ethnic back-grounds of medical graduates should reflectbroadly the diversity of those they are calledupon to serve (Council of Heads of MedicalSchools, 1998).

Between 1997 and 2004 the number of medicalschool places increased by over 50% (over 2000 newplaces). Four new medical schools were created inDevon and Cornwall, Yorkshire and Humberside,East Anglia, and Sussex (Department of Health,2004). Most UK medical schools are engaged inwidening participation outreach work with stateschools in their locality, but the volume andintensity of these initiatives vary considerably.King’s College London and the University ofSouthampton have led the way in offering 6-yearmedical degree programmes to young people fromnon-traditional backgrounds. The University ofSheffield and St George’s, University of Londonhave also been engaged in innovative outreach workover many years (Universities UK and SCOP, 2002,2005).

The authors of this paper have, since 2001, beeninvolved in the development and delivery of aninnovative widening participation project, basedin the King’s College London School of Medicinethat aims to encourage and enable studentsattending state schools in 10 inner London bor-oughs to train as doctors. By virtue of thedemographics of the boroughs concerned, thestudents that have been recruited over this periodhave a class profile that is significantly differentfrom that of most student doctors and come from adiverse range of ethnicities that are more represen-tative of their age group in inner London comparedto the students that the school has traditionallyrecruited.

The aim of this paper is not so much to highlightour achievements to date—that paper is destined toappear elsewhere—but to explore themes that webelieve are of importance if we are to understand thechanges in policy development that are needed toreverse the inequalities in access to medical trainingin the UK. Although the questions we pose areparticularly relevant to the field of medical educa-tion, they have a wider application to the geo-graphic study of local education markets, wideningparticipation to higher education more generally(including to Geography departments) and broaderissues of class (re)production and social mobility,

particularly as they pertain to the intersections ofclass and ethnicity.

We will explore three themes that we believe areof potential importance to this emerging researchagenda. First, there is the study of local educationmarkets and localised cultures of education, exam-ining how these markets are differentiated by classand ethnicity. Secondly, there is a consideration ofthe limits of choice for young people and theirparents in relation to the education market andfinally we consider the spatialities of learneridentities. How do students mediate their identityas students with other aspects of their lives? And, towhat extent are these performances site-specific?

Before examining these issues in some detail, wewill briefly review ethnicity, class and gender as theypertain both to medical education in the UK and,more specifically, medical education at King’sCollege.

Medical education in the UK (1990–2005)

There is a growing body of evidence that theintake to medical schools around the country israrely representative of their local populations, orthe UK’s population as a whole (Bedi & Gilthorpe,2000a, b). Although the medical profession has beenmost sensitive about accusations of institutionalracism (McManus, 1998; Bowler, 2004), thecurrent body of doctors and medical students isunrepresentative on many levels. While there aresystematic differences between ethnic groups, thevariation within each group is far greater, and socialclass and gender are stronger determinants ofacademic success than ethnicity (Gillborn & Gipps,1996; Rasekoala, 1997a, b; Sammons, 1995),although the effects of these characteristics aredifficult to disentangle (Ball et al., 2001; Demacket al., 2000; Gillborn and Mirza, 2000; Tomlinson,1987).

The CHMS statement quoted above illustratesthat, while other academic disciplines have oftenpursued a widening participation policy out of asense of social justice, the medical establishment hasjustified its hope for a more socially inclusiveprofession in more instrumental terms. It is believedthat by widening access to medical training, theprofession can make itself representative of thepopulation it serves so that it can provide moreculturally competent health services in the future.There is some evidence that medical students frommore socio-economically deprived backgrounds are

ARTICLE IN PRESSG. Brown, P. Garlick / Health & Place 13 (2007) 520–531522

more likely to work in socio-economically disad-vantaged areas (Magnus & Mick, 2000). Although,as widening participation practitioners working inthis field, we would hope that the students we recruitand train do not find their career options limited towork in such areas.

The debate about racial discrimination in medicalschool admission in the UK is difficult to under-stand without an appreciation of the history ofethnic minority applicants to medicine. Ethnicminorities have always been over-represented inmedicine when compared to the proportion in thegeneral population (Modood and Acland, 1998).However, the racial mix of the applicants to medicalschools is almost exclusively made up of applicantswho classify themselves as Indians. Applicants whoclassify themselves as Bangladeshi, Pakistani andBlack Caribbean are under-represented when com-pared to the proportion in the general population(Esmail et al., 1995).

In attempting to make the medical professionmore representative of the population it serves, ithas been (and will continue to be) necessary toexpand both the ethnic and the socio-economicdiversity of the population of medical students.These two factors interact in complex ways. Forexample, Bedi and Gilthorpe (2000b) found thatapplications to medical school from Black African,Indian and White British students come dispropor-tionately from the higher socio-economic groups.In contrast, they suggest that, applications fromBangladeshi, Chinese and Pakistani students aredistributed evenly across the socio-economic range.This highlights that apart from these observabledifferences between particular ethnic groups orbroad socio-economic classes, it is also necessaryto be aware of the differences within these socialgroups.

Diversifying the medical profession cannot beachieved simply by changing the selection processesor criteria for entry into medical education. Manysuitable applicants never consider medicine as arealistic possibility (even if they aspire to a medicalcareer). Many others make subject choices in theirmid-teens that make entry to a medical degree muchmore difficult. Part of the problem has been that,traditionally, admissions procedures seek to select

from within the existing applicant pool rather thanseeking to recruit a more diverse set of applicants. Ifthe students who choose to apply to medical schoolare not representative of the population as a whole,then it is very difficult to select a representative

student body purely by adjusting existing selectionmethods.

The work of many contemporary sociologists ofeducation (Archer et al., 2001; Ball et al., 2002;Reay et al., 2001) concerning recruitment andretention in higher education explains students’choices (and failures) primarily in terms of theirpersonal identity, social capital, and the cultural‘frames’ within which they consider their options.The work of Greenhalgh and her co-authors (2004)is one of the few extant examples of such conceptsbeing applied specifically to the study of medicaleducation (c.f. Seyan et al., 2004). In their study ofthe perceptions and attitudes to medical trainingheld by able state school students, Greenhalgh’steam found consistent differences between pupilsfrom different ethnic groups and socio-economicclasses, but relatively few differences between theviews held by young men and women. Thedifferentially classed perceptions of a medical careerfound in this study are particularly significant:

Pupils from higher socioeconomic groups viewedmedicine as having high intrinsic rewards such aspersonal fulfilment and achievement, and saw itas one option in a menu of other high statuscareer paths y Pupils from lower socioeconomicgroups, especially boys, talked more about theextrinsic (financial) rewards of medicine andabout the ‘blood and guts’ of the job. (Green-halgh et al., 2004, p. 1542).

More than this, their study found that theworking class boys in their sample held stronganti-school values and low self-confidence despitetheir high academic ability. This extended to a deepcynicism towards enrichment and aspiration-raisinginitiatives. As the researchers suggest (Greenhalghet al., 2004) this represents a combination ofattitudes that may account for the continuing failureof UK medical schools to recruit pupils from lowersocioeconomic groups (particularly from white andBlack Caribbean backgrounds). On this basis theymake a number of recommendations for the futureof medically related widening participation work,suggesting that

[it] must go beyond the knowledge deficit modeland address the root causes of low motivationand cultural disaffection in non-traditional stu-dents

and


address the close link between self-esteem,personal identity, and particular aspects ofworking class culture that run counter to tradi-tional academic values and aspirations (Green-halgh et al., 2004, p. 1544).

The King’s College London Access to Medicineinitiative has, since 2001, been promoting many ofthe specific activities that Greenhalgh and herassociates recommend, including extensive use ofmentoring by medical student role-models fromnon-traditional backgrounds and the targeted de-livery of its work in socially deprived areas. Never-theless, after 5 years of work, we have yet to make asignificant impact in the recruitment of young whiteand Black Caribbean working class men. In otherways, though, we have succeeded in recruiting acohort of students that are more representative oftheir peer group in the boroughs in which weoperate. This highlights the long-term nature ofmeaningful widening participation work—a pointthat is often missed in the targets attached to theGovernment’s short-term funding regimes for thiswork. It also brings into focus the differentialattitudes towards education and aspirations forsocial mobility amongst inner London’s diversepopulations. It is these differences that we willattempt to sketch out in the rest of this paper, as ameans of posing a research agenda for the futuregeographic study of local education markets,widening participation and enrolment in medicaleducation.

Access to medicine at King’s college (2001–2005)

The King’s College London Access to Medicineproject was formed in May 2001, after a longincubation period and several false starts. Itscreation was prompted more by the New Labourgovernment’s drive to recruit and train moredoctors, than its policy of increasing the numberof 18–30 year olds gaining some experience ofhigher education. Senior managers in the medicalschool were acutely aware that very few studentswere traditionally recruited from the boroughs inwhich the medical school operated and that thosewho did make it from the local area had mostlystudied at prestigious private schools in London.So, when offered additional student numbers by theHigher Education Funding Council for England tomeet government priorities for more doctors, theydecided to ring-fence the places for local state

school students, rather than recruiting ‘more of thesame’.

Initially, the project operated in five boroughs incentral, east and south-east London, but it wasexpanded to 10 boroughs in 2003. There are twostrands to the project’s work: an extensive pro-gramme of enrichment activities for local schoolsand colleges; and a 6-year, extended medical degreethat recruits students with the aspirations andpotential to train as doctors, even if they have notyet achieved the high examination grades normallyrequired for entry to medical school. The projectworks with young people who live and attend stateschools in the boroughs where it operates. Beyondthese simple conditions, no further socio-economicor ethnic criteria are applied to filter participants inthe scheme. To date, over 5000 young people haveparticipated in some aspect of the project’s outreachand enrichment work, and 144 students have beenrecruited to the extended medical degree pro-gramme. The extended degree started with an intakeof nine students and grew incrementally (by 10students a year) over a 5-year period. In order to beeligible for the extended degree the applicants needto live and study at a state school or college in oneof the 10 target boroughs. There are no suchrestrictions on applications to the standard 5-yeardegree. Normally, successful applicants to theextended degree are given offers conditional onachieving CCC or above in their A2 exams. Thiscontrasts with a standard offer of AAB for the 5-year degree.

Although the project’s catchment area includesmany of the most deprived urban areas in Britain,some of the boroughs also contain significantpockets of gentrified housing (as well as some moreestablished middle class neighbourhoods). As aconsequence, the project has recruited a number ofmore middle class students, alongside a largenumber of young people from low-income, workingclass families. Nevertheless, the socio-economicprofile of the students on the extended medicaldegree is significantly different from their peers onthe conventional 5-year medical degree. For exam-ple, just 7% (n ¼ 6) of the extended degree students(recruited in 2002–04) come from Higher Manage-rial and Professional families, compared to 41%(n ¼ 449) recruited to the 5-year degree in the sameperiod. At the other end of the scale, 17% (n ¼ 14)of the extended degree students have parents work-ing in semi-routine jobs, compared to 5% (n ¼ 58)of students on the 5-year programme.


A comparison of the ethnic make up of theintakes to the two medical degree programmes overthe same period reveals similarly significant differ-ences:

�
36% of students on the 6-year extended degree(n ¼ 31) identify as Black African compared to3% of 5-year degree students (n ¼ 37); � 16% of students on the 6-year extended degree
(n ¼ 14) identify as Bangladeshi compared to 2%of 5-year degree students (n ¼ 26);
� 5% of students on the 6-year extended degree
identify (n ¼ 4) as White British compared to37% of 5-year degree students (n ¼ 402);
� 5% of students on the 6-year extended degree
identify (n ¼ 5) as Indian compared to 18% of 5-year degree students (n ¼ 191).

A more detailed analysis of these headline figures,including the gaps they hide, is included in thesection that follows. However, we include them hereas an indicator of the project’s successes to date inrecruiting a different group of students and one thatis (largely) more representative of their age group inthe areas of London from which they come.

Local education markets and cultures of education

The bald statistics presented in the previoussection are a useful indicator that the Access toMedicine project is producing some change in thepatterns of medical student recruitment, but revealvery little about the complexities of inner London’seducation market(s). Butler and Robson (2003)have demonstrated the importance of local educa-tion markets (alongside the employment and hous-ing markets) in the differential forms of white,middle class gentrification to be found across innerLondon. However, little geographical work has yetbeen undertaken to examine how non-white groupsacross the class spectrum (as well as more aspirantsections of the white working classes) make the mostof the state education sector in the capital. There isan urgent need for such work to be undertaken. AsReay (1998) has argued, there is a ‘pervasivetendency’ to consider middle class experiences (ineducation and elsewhere) as normative, with theresult that the extent to which social processes aredifferentiated by class is ignored and the workingclass attitudes to education are depicted as deficient.

In order to gain a deeper understanding of theways in which inner London’s education markets

are mediated by class and ethnicity, it is importantto move beyond crude class and ethnic categorisa-tions in order to develop more subtle analyses whichacknowledge the increasing horizontal and verticaldifferentiation within class and ethnic fractions.

A closer analysis of the intersections of classand ethnicity in the case of the extended medicaldegree students reveals some interesting trends.For example, half of the white British studentscome from lower professional and managerialfamilies. This highlights the limits (to date) ofthe Access to Medicine initiative’s work, as it hasyet to make a significant impact on the aspirationsof white working class students. It also reinforcesthe findings of previous studies (Archer et al., 2001)in that the few white working class young men whosee any value in higher education participation doso on the basis of achieving practical (usuallyfinancial) and short-term ends. This makes themunlikely to see any point in the long-term studiesrequired to become a doctor, despite the obviousfinancial rewards to be claimed at the end of theprocess.

With very few exceptions, the Bangladeshistudents come from families concentrated in thelower socio-economic groups and live in TowerHamlets. They include a large number of studentsfrom families where neither parent is economicallyactive. The numbers of students from other SouthAsian backgrounds are too small to identify clearclass fractions. However, there are clear spatialpatterns to their residence, with the Indian andPakistani students mostly living in Newham and theTamil students (whether their families are originallyfrom Southern India or Sri Lanka) predominantlyliving in Lewisham. Although the number of NorthAfrican and Arab students is quite small, a clearmajority is from professional families and residentin Westminster or Kensington and Chelsea.

Students from professional families were morelikely to travel out of their home borough forschooling. White British, West African and NorthAfrican students were most likely to travel out ofborough for their pre-16 education. The Bangladeshistudents were most likely to stay in their homeborough. For sixth form, nearly two-thirds (64%)of students travelled out of their home boroughfor their education, compared to 42% travelling fortheir GCSEs. Again this trend was most pro-nounced amongst White British and West Africanstudents. Although a slightly greater number ofBangladeshi students travelled for their A levels than


for their GCSEs, the majority still remained rootedin Tower Hamlets for their studies.

At least half of the students resident in theboroughs of Hackney, Southwark and Westminstertravelled for their education, whereas no studentstravelled from Tower Hamlets or Greenwich fortheir secondary schooling. Complex issues wouldappear to be at work here, as there was only a veryweak inverse correlation between a borough’saverage GCSE pass rate (at grades A*–C) and theproportion of students travelling out of their homeborough for their education. Similarly, there ap-peared to be no correlation between the social classof a student’s family and the quality of the schoolthey studied in. However, the fact that the studentsattending the highest achieving schools were fromfamilies in the intermediate social class is suggestiveof some level of aspiration for upward socialmobility amongst this fraction. Not surprisingly,the schools that attracted students from the furthestdistances for their GCSEs were mostly those withthe highest GCSE pass rates, and there was a directcorrelation between the distance travelled to schooland the school’s GCSE pass rate. It should be notedthat students came from a wide variety of schoolsfrom across the spectrum of academic achievementand not from a small, select group.

This provisional analysis suggests that localeducation markets in inner London operate atseveral scales (from the neighbourhood to the sub-regional) and that these are shaped by the intersec-tions of class, ethnicity and potentially verylocalised cultures and structures of feeling. Itremains to be seen what long-term social andpsychological consequences there will be for thosestudents who did not travel for their schooling andfound themselves relegated to receiving their educa-tion in low-achieving schools. Although, it is hopedthat their success in gaining entry to medical schoolwill reduce the ‘destiny effects’ (Bourdieu, 1990) ofattendance at often stigmatized schools, we cannotyet predict whether these students carry with them apathologized sense of their own self-worth and howthis will impact on their subsequent academicperformance and career choices.

(The limits to) student choice

The fact that some students travelled out of theirhome borough for their secondary education, andthat even greater numbers travelled for their sixthform studies, indicates that these students and their

parents were making active choices about theirschooling. It seems likely that these choices tookplace within a complex web of social factors,including social class, ethnicity and religion. Similarfactors come into play when students choose if andwhere to apply for higher education (Ball et al.,2002; Reay et al., 2001).

Ball et al. (2002, p. 54) have suggested that, whenmaking choices about progression into highereducation, students actively consider their place inrelation to the ‘relative status and social exclusivityof the universities they are considering’. That is tosay that students do not simply consider how likelythey are to meet the entrance requirements for theirpreferred degree, but also think about how well theywill ‘fit in’. In doing so, the students draw on theirsocial and cultural capital, as well as taking intoaccount material constraints (the cost of travel,accommodation and, now, differential tuition feesand varying levels of student support). ‘Choice’ is asmuch about self-exclusion from some institutions asit is about an affinity to others. This processgenerates and reproduces patterns of social distinc-tion and differentiation across the UK highereducation sector. As Bourdieu (1984, p. 471)argued, objective limits become transformed into apractical anticipation of those limits, such thatindividuals develop a sense of their place withinsocial hierarchies which leads them to activelyexclude themselves from those places from whichthey expect to be (or feel) excluded.

Greenhalgh et al. (2004), building upon the workof Ball et al. (2002) characterise two types of highereducation choosers—those who make contingentchoices and those for whom choice is firmlyembedded in their cultural script. ‘Contingentchoosers’, it is said, tend to come from lowersocio-economic groups and have no family traditionof higher education. Their choice is a short-term oneand weakly linked to a sense of where their life willgo. While their mothers may offer practical supportwith the process of applying to university, they areunable to draw on much parental support, and canrarely rely on the broader support of socialnetworks, for information and guidance. They tendto gravitate towards local universities, havingnarrowly defined social and spatial horizons. Forthem, the ethnic mix of a university is an importantfactor to consider and can be a positive attribute.

In contrast, ‘embedded choosers’ are mostly fromhigher socio-economic groups. Their choice of whatand where to study in higher education is embedded


in a ‘deep grammar of aspiration’ that presentshigher education as part of the normal and expectedlife course. It fits into a coherent plan for theircareer and personal life. Their parents play a strongpart in framing their expectations and an active rolein their choice of university. They are able tomobilise extensive social capital to shape theirchoice and prepare for university. On one level,their social horizons are broad and they areprepared to travel nationally for their education.However, this is broadly about fitting in on a classlevel, and (at least for the white, middle classembedded chooser) the ethnic mix of a university isquite marginal to their decision-making process.

It seems likely that the group of students enroledon the King’s College extended medical degreeprogramme represent a mix of contingent andembedded choosers. Informal conversations withthe students, alongside more rigorous focus groupinterviews over the years, suggest that most wouldhave progressed to higher education in some form ifthey had not been admitted to medical schoolthrough this scheme. By virtue of the fact that theyare relatively high-achieving students (at least incomparison with their peers at school) and have themotivation to undertake a 6-year degree that leadsto a career that requires considerable postgraduatetraining, they are quite different to the stereotype ofa ‘widening participation’ student.

In a recent focus group interview, a number of the2004 intake explained that they had consideredapplying for medicine at a range of other medicalschools. For one white working class young man,these were exclusively based in London. But for ayoung man of West African heritage and a youngBlack Caribbean male, these included Oxbridgecolleges and prestigious research-led universitiesoutside the capital.

These students are clearly not the white, middleclass students that Ball and his colleagues had inmind when they coined the phrase ‘embeddedchoosers’. So, how then did they frame their choicesand what resources did they draw on? The parents ofa minority of the students had university degrees,frequently obtained overseas. For most then, experi-ence of the UK higher education system came fromolder siblings, cousins or more distant relatives. Ahandful of students had mothers who were currentlyundertaking degrees as mature students. Althoughfor these students there is close family experience ofhigher education, this hardly seems to qualify as thetradition of higher education that Ball et al. (2002)

associate with the families of those making em-bedded choices about their education.

What seems more important in the choices madeby some students was that they had family membersworking in medically-related occupations; for ex-ample, uncles who were dentists, aunts working aspharmacy assistants and mothers who were medicalsecretaries or healthcare assistants and nurses. Thefather of one refugee student had practised medicinein his home country, but had never registered topractise in the UK. This suggests that even if there isno embedded culture of higher education withinthese students’ immediate families, there is anawareness and understanding of the culture of theNHS and the habitus of different professionalgroups in the NHS, which can be mobilised toassist the student with their studies and preparationfor university. These are also families wherescientific issues are understood and appreciated:

My dad, he’s like a walking dictionary for mebecause he was a doctor in [two countries] and hecan tell me about things I don’t understand.(Student 1: Arab male).I think as a young child I used to sort of thinkabout [studying medicine] because my father wasa very scientific person. I remember one timewhen he brought in this stethoscope set and Iused to play around with it on my dolls and mymum always used to say, oh, you are going to bea doctor and I sort of grew up with medicine atthe back of my mind (Student 2: West Africanfemale).

All of the students who participated in recentfocus group interviews reported that the decision tostudy medicine had been their own, but some saidthat their parents had harboured the ambition thatone of their children would be doctor.

It was always in my family, I remember when Iwas young, it was like my mum used to say, oh,[student’s name] is going to be a doctor, and itwas just like that when I was growing up, oh[student’s name] is going to be a doctor but it waswhat I wanted (Student 3: West African female).

However, for some students, familial support wasless straightforward. One Bangladeshi student whocompleted her first year in 2005 explained that herfamily had mixed opinions about her studies. Herfather had studied in higher education in Bangla-desh and was keen for her to study medicine. Incontrast, her mother discouraged her application


because she felt it would be too difficult and taketoo long. For others, domestic and familial respon-sibilities and expectations place limits on theirchoice of university and can act as obstacles totheir success in higher education. Many of ourstudents share bedrooms with younger siblings andhave no quiet space at home in which they canstudy, and yet they cannot afford to move out ofhome in order to create that space. Financially,many of these students find themselves in a doublebind—it is not simply that their families cannotafford to offer them any financial support for theirstudies, very often the families are themselves relianton financial contributions that the students makefrom any part-time work they undertake alongsidetheir studies. For these students, their choice of if,what and where to study is shaped by more than justaccess to social and cultural capital—their educa-tional choices and subsequent performance is‘‘socially constituted in a nexus of effort, motiva-tions and distractions’’ (Ball et al, 2002, p. 53).

For one student, from a refugee family, themotivation to study medicine in the UK was moredeeply embroiled with his life history:

I feel like I owe this country a lot of debt. Theyhave given me, people have given me so much,and pay back time will come, so I have to payback, hopefully put more in than I have beengiven because I am so grateful in a way. I don’tplan to go back to my country as yet (Student 4:Somali male).

The experiences of this student, and indeed themajority of those quoted in this section, shouldserve as a reminder that the identities of people fromminority ethnic groups are not static but are fluidand continually being (re)negotiated in the contextof changing social, cultural and economic factors.The generation to which our students belong is‘‘extremely mobile in linguistic, religious andcultural terms’’ (Basit, 1997, p. 437) and drawswidely on the range of cultural traditions andresources that are available to them. Their aim isto shape their lives on their own terms. For somestudents this process can satisfy their parents’ambitions for them; for others, the choices theymake may be more unexpected and bewildering,even to the point of generating inter-generationalconflict. What seems likely, however, is that whetherthey have parental support and encouragement ornot, the students who succeed best are thosewho can see themselves as belonging within the

education system. These students (and their fa-milies) hold both a sense of entitlement to a ‘decent’education and the ability to negotiate their waythrough the educational system (Reay and Lucey,2003). Although the work of widening participationprojects such as our own can contribute to raisingstudent’s aspirations, and provide their parents withinformation on how best to support their childrenthrough their education, it seems realistic toacknowledge that we play a very marginal part ina larger process. This still begs the question as towhich ‘outsiders’ can see themselves as (potential)‘insiders’ within the educational system?

In the final section of this paper, we continue toexplore these issues through a consideration of themechanism by which widening participation stu-dents learn to be medical students and adapt to themedical school habitus. We also examine the extentto which our students come to feel alienated fromtheir original friends and family as a result of thisprocess of enculturation.

The spatialities of learner identities: ‘becoming’ a

medical student

Research from the USA suggests that one of themost important predictors of persistence in medicaleducation is the extent to which students becomeintegrated into the institutions at which they study(Tinto, 1998). This social integration operatesacross a number of scales, including the extent towhich students feel they ‘belong’ to the institution(Cabrera et al., 1999), and the extent to which theycan develop more proximal affiliations in terms ofbelonging to smaller social networks within theinstitution (Hurtado and Carter, 1997).

When asked about their time at medical school,students on the extended degree were positive abouttheir relationships with the majority of students onthe conventional course. However, they suggestedthat there was a feeling that there was a class divideand an element of snobbery between the two studentgroups.

Some [five-year] students really look down on us.They’re busy organising their horse riding andgoing away for the summer and assume we won’tbe going away for our summer holidays, asthough we are second class citizens (Student 5:mixed race female).


[They are] quite middle class. A lot went to publicschool and they do lots of sports like rugby(Student 6: mixed race female).

Several extended degree students have made theeffort to join student societies but, with theexception of those involved in the African Carib-bean Society, few play an active part, seeminglyfinding it difficult to fit in. Nevertheless, theextended degree students, as their numbers grow,are making more of an effort to integrate them-selves. They are now fully represented on theinfluential Student Medical Education Committeeand some have stood in student union elections. Forsome students their marginalisation from the sociallife of the university was not a problem:

We are here to get a medical degree, not tosocialise (Student 1: Arab male).

But, for those students who have failed tointegrate with their peers on the extended degree,let alone the broader student body, the culture ofthe medical school can be very alienating anddisheartening.

In some ways, I feel that I’ve lost confidence inmyself y When I was at college I could talk topeople about it but you get to meet people herethat you wouldn’t normally meet and it can behard sometimes to meet people who you wouldsocialise with on this course, because they’re notlike the kind of people like where I come fromand I sometimes feel I haven’t got much incommon with them. I find it quite lonely actually(Student 3: West African female).

Those students who were most confident in theirplace at medical school, tended to question theprofessionalism of students on the 5-year coursewho made derogatory comments about them.

[In our first] year there was a boy on the normalcourse and one of the tutors came in and said,there’s a twilight lecture and it’s for accessstudents and anyone else who wants to come.And it was basically on something we’d alreadycovered and this student, he says, ‘yeah theretards’, like that. We could all hear him and Ijust thought, it’s people like that, and you justthink, how can they ever do medicine with anattitude like that? (Student 2: West Africanfemale).

In a similar vein, a white working-class studentspoke about an incident in a medical sociologyseminar in which stereotypes were discussed. Thestudents were asked to write something aboutthemselves to enable someone to form an impres-sion of them.

I put down that I was from a council estate and Ididn’t think anyone would think anything of it.Well, virtually everyone had an opinion on it.I said, would you expect that I live in a high riseblock of flats and the windows are broken andthe lifts don’t work, they smell disgusting, thereare, like, single mothers on every floor and theysaid, ‘yeah’, just like that, ‘yeah’. And then onegirl said, she said to me, well done for gettinghere. I couldn’t believe it. I mean I’ve spoken toher since and she’s all right but she doesn’t evenrealise what she said. I’m not bothered but youdo get people like that, there’s no getting awayfrom that.[The tutor] also said, what do you feel you’ve gotto gain from having said that on your little bit ofpaper and I said, well, you know, I can talk topeople on different levels but, like, that girl shehas no idea, so that’s where I see this [extendeddegree] as a good thing, because I want to meetmore people like me if I went to the GP or if Iwent to a hospital (Student 6: White Britishfemale).

The tutor’s challenge to this student illustrates theextent to which medical education is shaped bytutors’ formal and informal constructions of an‘ideal client’ (Gillborn, 1990, p. 26), incorporatingclassed, gendered, and raced notions of appropriatebehaviour and knowledge. Although, in this in-stance it was a white working class female studentwho fell foul of these prejudices, they have the mostprofound implications for non-white students, andperhaps young men in particular, whose sub-cultural affiliations are already marginalised withinthe mainstream school system (Youdell 2003). Theattitudes of both the tutor and the ‘conventional’medical student in this incident reinforce Reay’sobservation that across the British education system‘‘all the authority remains vested in the middleclasses’’ (2001, p. 334) with the consequence thatworking class cultural capital seldom gets valorised.

Some students spoke of the difficulty of main-taining friendships with old friends who had notgone on to university and were either working orhad already started a family. For these students,


university represented some kind of threat to theirlinks with the communities and social networks inwhich they had previously circulated. Conversely,for one student, the medical school represented arefuge from the pressures of her life at home:

Yeah, it was like I was having to deal with, like,home situations and it was difficult and I came inhere to get away from the stuff I was having todeal with and get a bit of normality and a bit oftime to forget, like, my home situations (Student3: West African female).

Others were more aware of the process of changethey were going through. Indeed, they felt it as adeeply embodied experience:

I have become more disciplined because I was,like, not focused and I have changed. Before Iwas this little young playful kind of guy and nowI am more serious internally (Student 7: WestAfrican male).

The majority of these students are learning (somepainfully, some less so) that the reality of fitting intothe middle class habitus of the medical professionentails learning to be ‘different people in differentplaces’ and that the process of becoming a medicalstudent requires them to give up something of theirformer selves (Ball et al., 2002, p. 69). For somestudents, perhaps Black students more than others(Youdell, 2003), this requires either giving up ormasking the sub-cultural identities that play asignificant role in the maintenance of their self-esteem and potentially their very sense of self. Thereis broad scope for further research in this area.

Conclusions

Our primary aim in this paper has been tohighlight the need for health geographers to beginto consider the social and cultural geographies ofwho gets to be trained as a doctor. We see this aspart of a broader imperative for geographers toengage more fully with local and regional cultures ofeducation and local education markets. In order toillustrate some of the issues concerning the recruit-ment and training of future doctors that we feelhold the potential for further geographical analysis,we have presented a preliminary analysis of localeducation markets in inner London, as they impactupon the life chances of a diverse groups of aspiringdoctors. We have also offered a brief examination ofhow these students from working class and minority

ethnic communities learn to adapt their identities inorder to perform ‘being a medical student’ in thepredominantly middle class spaces of medicaleducation.

Our preliminary analysis suggests that localeducation markets in inner London operate acrossseveral scales and that these are shaped by theintersections of class, ethnicity and potentially verylocalised cultures of education. Our findings alsoindicate that the students who succeed best are thosewho can see themselves as belonging within theeducation system. Regardless of their social andcultural background, these students and theirparents hold a sense of entitlement to a high qualityeducation and demonstrate an ability to negotiatetheir way through the British educational system.Further research will be needed to fully understandthe means by which recently arrived immigrantfamilies acquire the social capital to negotiate andmanipulate the state education system to their ownadvantage. In terms of their eventual acclimatisa-tion to life at medical school, we found that studentsfrom widening participation backgrounds encountersome class prejudice from both staff and students,but most demonstrate a remarkable resilience inlearning to perform within the bounds of theexpected behaviour of a student doctor. Never-theless, for some students there is clearly a costattached to these performances and they perceivemedical school as being quite socially and spatiallyseparate from their quotidian lives.

We intend to pursue many of these themes furtherin the future, but we would be keen to see otherresearchers engage with related issues. There is aclear need for further analysis of local educationmarkets and cultures of education, particularly asthey are differentiated by class and ethnicity, as wellas other social identities. In particular, we wish tosee geographers engage critically with the ‘pervasivetendency’ (Reay, 1998) to consider middle classexperiences in education as normative, and tofurther examine working class attitudes to educa-tion without framing them as necessarily deficient.Given our interest in medical education, we see aneed for greater analysis of who applies for medicalschool (or training in other health professions), whois offered a place and who ends up studying where.But, there is scope for work on access to highereducation more generally. Such work should alsoanalyse the spatial distribution and impact ofwidening participation initiatives. Amongst the on-going debates about policy relevance in human


geography, little attention seems to have been paidto the potential for shaping access and social justicein the very institutions that employ us.

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