Articulating the canon: The sociology of medical education from 1980 to 2000

Introduction

The study of medical training and medical work has been a staple of medical sociology in the United States, often overlapping with similar concerns as research in the sociology of professions. The Golden Age of research activity in these areas occurred in the mid-20th century, when the doctor-patient relationship was the most salient social relationship in healthcare, medical sociologists were trained within medical schools, and when medical sociology had a stronger professional alliance with clinical fields like psychiatry (Bloom, 2002). During these years, teams of medical sociologists produced major studies of medical training: Boys in White, by Becker et al. (2007 [1961]), and The Student Physician, by Merton and Kendall (1957). Still today, these studies are considered canonical. However, some 60 years after their publication, these works remain the touchstone works for sociologists of medical education, and little work in the intervening years has reached their prominence. In the scholarly conversation the Golden Age lives on, despite massive changes in the U.S. medical profession as it has been transformed from a provider-driven, professionally coherent enterprise to one of several stakeholders in a buyer-driven medical system (Light, 1988).

More recently, the subfield of sociology that examines medical training has undergone a rejuvenation, coalescing into a distinct scholarly conversation for the first time in several decades (Jenkins et al., 2021). This raises the question of what happened in these intervening years, a question which this narrative review will explore. It appears, at first glance, that the field lay dormant. However, it is not the case that all sociological research on medical knowledge, medical work or even medical training disappeared. Indeed, the study of medical education as a process of gaining expert knowledge and professional presentation of self has persisted, but no distinct theory-building program emerged from this collection of studies (Brosnan and Turner, 2009; Hafferty, 2000).

In what follows, I focus on articulating the place of well-known sociological work in the canon of sociology of medical education. This task is not completely novel; periodically, scholars have traced the development of the field and have put forth compelling explanations for the recession of sociology of medical education from its central place in medical sociology (for excellent discussions I recommend Bloom, 2002; Fox, 1989; Hafferty, 2000). However, making these updates is a worthy project because there are ongoing changes in medical training as well as in sociological approaches to studying medical training. In this spirit, I put forth the current account.

In the first section I synthesize the accounts past chroniclers like Bloom and Hafferty give and add additional explanations. In the second section, I describe work that took place during 1980–2000, highlighting five of the most significant advances of the field during this time. As I show, articulating the middle years of this canon makes it possible to understand how the recent increase of work in this field is carrying on the legacy of classic conversations from the mid-20th century, while adapting them to attend to the vastly different environment of healthcare today. Indeed, the third section of the paper takes up this task, as I articulate three through-lines in the sociology of medical education that point to enduring concerns of the field. In this section I also acknowledge the interdisciplinary nature of studying medical education. Although the review centers on sociological research in light of shifting disciplinary concerns within sociology, studying medical education has been and continues to be interdisciplinary, with its closest relationships being to anthropology, history, and science and technology studies (for a discussion see also Fox, 1988 [1979]).

This narrative review serves as a conceptual trace, joining together complementary explanations for why the study of medical training faded within medical sociology, focusing on the period from 1980 to 2000. This is a largely US-centric scholarly conversation; however, important developments during this time period occurred in the United Kingdom, and current developments are taking place in Australia, Mexico, Canada, and many other countries. This review reflects the centers of gravity where these historical developments took place, but happily, more and more diverse work is becoming acknowledged in the scholarly conversation. This is important because professional training poses common dilemmas for both trainees and those responsible for training them, but research from different cultural contexts demonstrates how the particular character and history of the training program’s context can shape how these common dilemmas play out.

In this review, I focus primarily on studies of physician education in order to show continuity and change from the original conversations in US medical sociology. However, it is important to emphasize that this field has expanded into a broader examination of professional training and work in multiple health professions fields, such that future examinations of this field and descriptions of this discipline will increasingly use the descriptor Sociology of Health Professions Education (for a discussion, see Jenkins et al., 2021).

The review proceeds in three sections. First, I present complementary explanations for the disappearance of sociology of medical education. Second, I engage in a “recovery” of research that took place during 1980–2000, briefly reviewing this work and its place in the discipline. Finally, I examine contemporary work in this field, tracing the influence of past work on current research in medical sociology, medical anthropology, and science and technology studies (STS). With the middle 20 years of this canon in place, it becomes possible to trace enduring scholarly concerns as they have evolved over the past 70 years.

Disappearance

What historical factors help us understand the seeming disappearance of studies of medical training within medical sociology between 1980 and 2000? In this section I describe first the reasons given by other scholars, particularly Samuel Bloom and Fred Hafferty, for why studies of medical training receded from their formerly prominent role in US medical sociology. I follow this discussion with additional explanations: these decades also saw shifts in the locus of medical sociology toward studying major structural changes in the organization of the medical profession, changes in how the sociology of the professions approached the study of professional work, and the rise of the field of medical education as a center for interdisciplinary social science and applied clinical science during these same decades.

Drawing on Merton (1977), in his work Bloom (2002) describes two orientations to writing the history of a field as emphasizing its cognitive identity and social identity. Bloom takes up the latter orientation, focusing on the successes and failures of various initiatives to institutionalize medical sociology as a collaborative project between the medical and sociological professions. I take up the former orientation, drawing on the work of scholars like Brosnan and Turner (2009), Cockerham (2009), Gorman and Sandefur (2011), and Hafferty (2000). These scholars have examined the shifting cognitive identity of sociology, which includes tracking changes in theoretical foci in the subdisciplines of medical sociology and sociology of professions.

Bloom (2002) charts the major trends that help us understand what happened within American medical sociology from 1980 to 2000. Many of the preconditions for these trends were set much earlier, and indeed his history of medical sociology also begins several decades earlier. In his account of the events from 1980 to 2000 Bloom notes three specific factors that led to the failure of medical sociology to become institutionalized in medical schools and the medical profession. First, he describes that medical sociology largely reflects the broader trend of social sciences after World War II, where unlike the physical and biological sciences, they failed to gain secure funding and valued places as policymakers and advisers. Nevertheless, sociology’s standing was still tied to government favor, and in the 1980s as the dismantling of the New Deal state continued, sociology’s association with progressive political concerns became detrimental. By turns, sociology was both irrelevant and too influential, leading to its broader marginalization in funding discussions and budget appropriations. Second, Bloom discusses sociology’s relationship with medicine, characterizing sociology as having an insider-outsider status, such that to do regular sociology could easily be seen as overly critical and iconoclastic. As Bloom explains, this was particularly the case in the field of psychiatry, as some early ethnographies like Goffman’s (1961) Asylums exposed terrible conditions in institutions and other treatment settings. Moreover, medical sociologists were beholden to medical schools for access to their research subjects, as Cockerham (2009) and Hafferty (2000) describe in the case of both Merton’s and Becker’s teams. Third, by the 1980s the United States was struggling with spiraling medical costs and the emphasis of social science research in medicine shifted to favor health services research in order to understand how to control healthcare spending. The period from 1980 to 2000 also saw the rise of managed care as a solution to this problem, fundamentally reorganizing medical work, and with it the physician-patient relationship that had been at the heart of early medical sociology and sociology of medical education.

In addition to these arguments about the various failures and successes over time of medical sociology to institutionalize itself within medicine, other arguments can be assembled that contribute to explaining why the sociology of medical education receded from the scholarly conversations within the field of medical sociology. These reasons attend to the cognitive identity of medical sociology, to draw once again on Merton’s framework. Here I seek to link changes in the cognitive identity of medical sociology to its shifting institutional conditions. To Bloom’s account, I add the following three reasons, which I briefly preview here: the first reason is that as medical sociologists followed the major structural changes in the organization of the medical profession in the late 20th century, this research agenda did not include an analysis of corresponding changes in medical education. This has resulted in a relative lack of longitudinal and broad-scope studies of medical education that build on Merton et al. (1957) and Becker et al. (2007 [1961]) (for a discussion, see Brosnan and Turner, 2009; Cockerham, 2009; exceptions like Atkinson, 1981; Sinclair, 1997 will be discussed below). Additionally, the sociology of the professions, which was a primary subdiscipline that supported study of the medical profession, began to dissolve during the latter half of the 20th century (Gorman and Sandefur, 2011). Finally, the field of medical education research, which is comprised of educational research on medical training, has risen as a locus of interdisciplinary social science and applied clinical science during these same decades (Kuper et al., 2010).

A central reason why medical education faded from the concern of medical sociologists was the increasing emphasis on the structural aspects of the medical profession (see also Hafferty, 2000: 239 for a discussion of Eliot Freidson’s role in this shift). This is distinct from Merton et al. (1957) and Becker et al. (2007 [1961]), who despite their differences, primarily investigated how medical students took up the physician’s mantle. On a structural level, the medical profession strategically gained control over medical work in the 19th and early 20th centuries, a process that included regulating through educational and licensure standards who could practice medicine (Starr, 1982). In the early 20th century, educational standards were formalized and unified following the Flexner (1910) Report. Physicians also fought via the American Medical Association to control the implementation of policies that might harm the status physicians had accumulated, as in multiple cases of opposing health care reforms (Quadagno, 2004). Over the course of the 20th century, the medical profession’s control began to weaken, due to diverging goals with the private insurance industry (Quadagno, 2004). The profession lost crucial policy battles and was accused of violating its social contract through opportunism and profit orientation following the influx of funding guaranteed by the passage of Medicare/Medicaid legislation in 1965. The profession was also subject to the effects of broader changes in American culture, such as the rise of individualism, the increasing importance of choice as part of neoliberal ideology, and citizens’ loss of trust in institutions of authority during the 1960s and 1970s (Cockerham, 2009). These cultural changes further weakened the medical profession’s control over medical practice. The era of managed care was formally ushered in by the Clinton administration, but was prefigured by Nixon’s 1969 declaration of a “crisis in healthcare” (Ehrenreich and Ehrenreich, 1970), and by the increasing emphasis on outcomes measures and cost control during the Reagan presidency (Bloom, 2002). In short, managed care seeks to control medical cost by controlling medical work (Cockerham, 2009; Hafferty and Light, 1995), a radical departure from the provider-driven system physicians had spent the previous century crafting.

Also during this time, medical sociology developed a more critical relationship to medicine. As Bloom discusses, medical sociology had worked out an alliance with medicine, particularly psychiatry, in the middle of the 20th century. Aspects of this alliance were dependent on medical sociologists investigating research questions of interest to the medical specialties they were embedded in, what has come to be known as sociology in medicine. This arrangement posed consequences for more critical approaches to medical sociology. However, as the medical profession’s stature began to crumble at the end of the Golden Age and medical sociology shifted to being done in departments of sociology, medical sociology increasingly adopted a critical perspective. Major architects of this critical perspective were Howard Waitzkin and Vincente Navarro, whose development of Marxist theory in the context of healthcare and social relations allowed for critiques of capitalism, including of the role of the state in healthcare (Navarro, 1989) and of social control in the doctor-patient relationship (Waitzkin, 1989). Another important theoretical advance in medical sociology was the development of the theory of countervailing powers (Hartley, 2002; Light, 1991). This theory accounts for the rise of other powerful stakeholders in healthcare and how they put pressure on the medical profession. This is not a theory of managed care per se, but it was developed as sociologists shifted their attention to the consequences of the structural reorganization of medical work and its implications for individual professionals.

The second reason why studies of medical education have become less prominent in the discipline is that the sociology of the professions, which contributed to the prominence of studies of medical education in the mid-20th century, has slowly dissolved as a formal field (Gorman and Sandefur, 2011). As Gorman and Sandefur describe, the sociology of professions at mid-century was primarily occupied with delineating the features of professions and using taxonomies to classify occupations as professions, professionalizing, or not professions. The sociology of professions was transformed by Abbott’s (1988) social ecology approach, which reoriented the study of professions to issues of jurisdictional conflict and control of everyday work tasks. His approach was also novel because it was explicitly comparative; the majority of other studies of professions favored (and continue to favor) case studies. Although Gorman and Sandefur (2011) argue that the sociology of professions has since dissolved as an organized enterprise, they trace ways in which the study of professions lives on. The authors identify classic concerns of studies of professions as they appear in more recent work: expert knowledge, technical autonomy, normative orientation to the service of others, high social status, income, and other rewards (pp. 278–279).

The third factor in the declining emphasis on studies of medical education within medical sociology is the emergence of medical education research as a field in its own right. This is a field composed mainly of active medical educators, but medical sociologists and anthropologists also cross-publish in these journals. However, the intellectual developments and trends in medical education research have little cross-pollination with disciplinary sociology, despite the participation of sociologists in this field (for a discussion of more recent trends, see Albert et al., 2020). Nevertheless, journals such as Academic Medicine and Medical Education have been the main venues for in-house studies of medical education and a reliable cross-publishing venue for sociologists and anthropologists of medical education. As I will describe below, sociologists like Fred Hafferty continued sociological conversations and spurred important theoretical developments in the field of medical education research.

Recovery

I have charted several reasons why studies of medical education and training faded from prominence in medical sociology in the late 20th century. However, work on medical education continued in the period from 1980 to 2000. In this section, I “recover” these missing years, placing them into the broader narrative of sociology of medical education. As I will show, several important theoretical advances took place during these decades, and I argue that these advances are crucial for understanding the relationship between contemporary sociology of medical education and classic studies in the field. In this section I will briefly highlight five of the most significant advances in the period from 1980 to 2000.

One critique of the sociology of medical education is that it has failed to coalesce into a comprehensive theory-building program, partially because of the lack of longitudinal and broad-scope ethnographies of medical education (Brosnan and Turner, 2009). During these intervening decades, two important ethnographies of medical education were produced in the United Kingdom: Atkinson’s (1981) The Clinical Experience: The Construction and Reconstruction of Medical Reality and Sinclair’s (1997) Making Doctors: An Institutional Apprenticeship. Sinclair’s ethnography was an important development of Bourdieu’s theory within professional socialization in medical education, while Atkinson’s focus on the everyday work of the trainee resonated with the interactionist concerns that have been present in the field since Boys in White.

Another major advance within sociology of medical education during this time was the first substantive critique of Fox’s (1957) work on training for uncertainty. Over a period of a few years, Atkinson (1984), Haas and Shaffir (1977, 1982a, 1982b), Katz (1984), and Light (1979) both elaborated and critiqued Fox’s finding that medical training is a process of learning to manage uncertainty. Central findings advancing this discussion showed how medical students are trained to project certainty and competence to both their professors and patients alike.

Moments where sociology of medical education held the attention of mainstream medical sociology were sparse, but in 1988 the Journal of Health and Social Behavior, the American Sociological Association’s medical sociology journal, published a special issue on “Continuities in the Sociology of Medical Education.” This journal featured papers by the most prominent sociologists of medical education, and some of these papers, particularly Fred Hafferty’s paper on cadaver stories, have become the “new classics” in sociology of medical education. Other papers from Don Light, Samuel Bloom, and Patricia Kendall and George Reader examined the state of medical training and the sociologist’s role. One further paper, “Notes on the Sociology of Medical Discourse: The Language of Case Presentation,” by Renee Anspach (1988), formed a key linkage between studies of doctor-patient communication and the sociology of medical education.

Indeed, studies of doctor-patient communication and medical discourse, shared by sociology, ethnomethodology, and sociolinguistics, underwent major developments during this time, with key works such as Mishler’s (1984) The Discourse of Medicine, Candace West (1993) and Aaron Cicourel’s (1993) contributions to The Social Organization of Doctor-Patient Communication (Todd and Fisher, 1993), and Drew and Heritage’s (1992) Talk in Institutions. Studies of professional language, as demonstrated by Waitzkin (1989) and carried forth by these scholars, have animated an ongoing investigation of how medical trainees learn to use professional language and manage the doctor-patient relationship, and how this process is shaped by the ongoing social transformation of the medical profession (Timmermans, 2020; Vinson, 2016).

A final major development during this time period was the introduction of sociological concepts to the emerging field of medical education research, and their subsequent development into major independent conversations outside of disciplinary sociology. The chief example of this trend is Fred Hafferty’s introduction of the concept of the “hidden curriculum,” originally developed in the sociology of education. As Kendall and Reader (1988) describe, many curricular reforms in the 1970s and 1980s focused on making sure that medical students learned professional values and attitudes as part of their training. These reforms can be interpreted as a response to the crisis of confidence in the medical profession that resulted from a general reduction of trust in powerful institutions, as well as more directly as a response to major bioethics breaches discovered in the 1960s and 1970s (Rothman, 1991). In 1994, Hafferty & Franks published “The hidden curriculum, ethics teaching and the structure of medical education,” and Hafferty followed this paper with a 1998 publication, “Beyond curriculum reform: confronting medicine’s hidden curriculum.” Both of these papers can be read as addressing some of the concerns highlighted by Bloom’s contribution to the 1988 Journal of Health and Social Behavior special issue, which examined why medical education seemed to be in a state of constant reform but with no substantive change. The introduction of the hidden curriculum concept into medical education research spurred much scholarship that developed the concept, identifying it in empirical settings and assessing its value as a theoretical framework (Hafferty and Castellani, 2009; Martimianakis et al., 2015). The prominence of this work as well as Hafferty’s role in the field mean that he has acted as an important source of continuity for research in the sociology of medical education in these decades.

These five advances between 1980 and 2000 moved the early work in sociology of medical education forward in substantial and important ways, often crossing paths with other disciplines and attending to significant contemporary social and political concerns. If we add this “missing” work back into the conversation, it becomes possible to clearly trace the roots of the current renaissance in sociology of medical education and sociology of health professions education. The following section builds on these “recovered” works to show the evolution of classic sociology of medical education concerns and how they are taken up today.

Linking the past and present

Instead of organizing this section chronologically, I organize it thematically to show how scholarship published between 1980 and 2000 carries forward conversations from the mid-20th century. My goal is to provide a broad overview of the state of the field, in light of a significant renaissance of activity in the sociology of medical education and health professions education (for an in-depth review of research in the sociology of medical education from 2000 to 2020, please see Jenkins et al., 2021). Specifically, in this section I will attend to a rising focus on practice, affect and embodiment; a sustained focus on knowledge and professional subjectivity; and an increasing attention to the structure of curriculum and role of faculty. Perhaps more than ever, sociological interest in these phenomena has brought the discipline into conversation with related bodies of work, particularly in anthropology and science and technology studies (STS), although Fox (1988 [1979]) stands as an early example of the legacy of interdisciplinarity in studies of medical training.

A dominant thread that runs through recent work in sociology of medical education is a focus on practices, which is consonant with a larger turn towards practice in sociology and STS (Schatzki et al., 2001). Working from a Bourdieusian perspective, Sinclair’s (1997) comprehensive ethnography gave an overview of the different dispositions that make up the medical habitus and their acquisition during medical education. Drawing on Sinclair’s work, Rice (2010) examined the role of the stethoscope in physician identity, linking the specific uses of the stethoscope in a clinical encounter to the medical habitus. Another important and classic theme in sociology of medical education is learning the feeling and display rules (Hochschild, 2012 [1983]) that make up the physician’s demeanor (Lief and Fox, 1963). This was a focus of work in the 1980s, especially in the context of professional socialization in the anatomy lab (Hafferty, 1988; Smith and Kleinman, 1989). Recently, Underman (2015, 2020) has studied the affective aspects of the professional socialization and medical practice, as learned through simulated patient encounters with gynecological teaching associates. This work has contributed to a renewed emphasis on the emotional aspects of medical training (Underman and Hirshfield, 2016), uniting them with a focus on practices (Vinson and Underman, 2020).

Studies of medical education today are also marked by an ongoing focus on knowledge and the development of professional subjectivity. A 2011 special issue of the journal Culture, Medicine & Psychiatry, “Anthropologies of Clinical Training in the 21st Century,” featured several articles about the process by which students acquire the practices and worldview of the medical profession. Among these papers were guest commentaries about the importance of studying the process of acquiring a physician’s subjectivity (DelVecchio Good, 2011), the history of medical education studies within medical anthropology (Holmes et al., 2011), and fashioning an orientation towards patients and others as being a “culturally competent” physician (Shaw and Armin, 2011: 106). These papers move from a framework of professional socialization, which involves “instilling [in the student] the norms, values and behaviors that are accepted by the profession” (Holmes et al., 2011:106), to an emphasis on subjectivation—both the external medical gaze discussed by Foucault (1994) and the process of self-fashioning, which the authors refer to as the “inward gaze” (p. 108). In a similar vein, Jaye et al. (2006) show how medical school curricula function as normalizing technologies of self that shape how students develop physician subjectivity.

Medical knowledge underpins and anchors professional subjectivity. As discussed above, much has been written about how medical students learn to deal with ambiguities in medical knowledge (Atkinson, 1984; Fox, 1957; Haas & Shaffir, 1977, 1982a, 1982b; Katz, 1984; Light, 1979). In the intervening years, the production of medical knowledge has increased with breathtaking speed. This abundance of knowledge raises pertinent questions, chiefly among them how medical students decide what is important to learn. Knopes (2020a, 2020b) has investigated the management of ignorance and knowledge in medical professional socialization. She developed the notion of “sufficient knowledge” to describe “the process of emphasizing information with the greatest perceived utility for a particular condition of training or situation of medical practice, while deliberately deemphasizing or ignoring information that is not deemed necessary in context” (p. 447). Her findings echo a classic finding from Boys in White (1961), namely that medical students work together via peer cultures to direct their effort.

In addition to the management of knowledge itself, there has been substantial research about the effects of formal, informal, and hidden curricula in medical education (Hafferty and Franks, 1994; Hafferty and Castellani, 2009). These various curricula structure what becomes regarded as knowledge, valued in terms of formal or informal assessment, and what knowledge remains unspoken. Understanding the hidden curriculum in conversation with ongoing work in the management of knowledge and ignorance is crucial for fully understanding the development of professional subjectivity. Generally, research on the hidden curriculum has more to say about how medical students sense contradictions in institutional priorities and what this might tell us about the development of unprofessional behavior. However, the hidden curriculum concept can also tell us about the nature of medical knowledge at a given point in time. For example, Murphy (2016) examined sexuality education in medical school and found that there was a hidden curriculum of heteronormativity in medical education. She argued that understanding teaching about sexuality in medical education was important because whatever students learn or do not learn shapes their existing notions of sexuality and becomes the understanding of sexuality they carry with them as they do their medical work. Murphy relates this to a broader process by which heterosexuality is rendered normal and obvious and non-heterosexual identities are construed as less intelligible, less obvious, and even invisible—thereby reproducing sexual stigma as part of medical knowledge. Writing within medical anthropology on a similar topic, Robertson (2017) also identified a lack of training on queer health issues in the medical school curriculum, and identified ways that queer students struggle to reconcile their own queer identity and developing professional identity in a professional culture marked by heteronormativity and the desire for neutral and “objective” medical knowledge that is unrelated to one’s self or personal experience.

The bodily dispositions of the habitus, on one hand, and the subjective experience of practicing medicine as a professional, on the other, are united in the work of Prentice (2007, 2012), who showed that the technical lessons students learn from surgeons in the operating room are embodied and carry with them corresponding social lessons about responsibility and clinical judgment. In so doing, she draws together disparate traditions that emphasize “doing medicine” and “being a physician” that evoke—and serve as a foundation for—current work in sociology of medical education.

A final area of focus is on medical curriculum and the role of faculty in professional socialization. Focusing on organizational and institutional structure through the actions of curricula and faculty can set us up to link developments in medical education with developments in the social organization of the profession, and by extension, changes in broader social contexts (Vinson, 2015). The mechanisms by which these processes unfold are related to curricular standards and who the faculty are. Specifically, medical schools continually reevaluate their programs in light of professional needs (even if these reforms do not always lead to change, as discussed by Bloom, 1988; Christakis, 1995; Reagan-Smith, 1998). Moreover, medical schools rely on practicing physicians to carry out much of the education on the practice of medicine (Olsen, 2019), which includes the doctor-patient relationship and conduct in the clinical encounter. Medical school faculty and organizational culture are important to examine for the way they contribute to the reproduction of institutional status and status separation within specialties (Jenkins, 2020) and professional culture and professionals’ roles (Vinson, 2016).

Recent work has brought increased attention to organizational and institutional structures of medical education, particularly in residency training. Within this area, Jenkins (2015) and Szymczak and Bosk (2012) have investigated how organizational constraints affect resident physicians. This is a departure from earlier studies of residents that focused on their moral development (Bosk, 2003 [1979]), how they distance themselves from patients as a stress response (Mizrahi, 1984), or sideline learning humanistic skills in a hospital sub-culture that emphasized coping with stress by developing a “get rid of patients” mentality (Mizrahi, 1985). In her study of patient autonomy and end-of-life care, Jenkins (2015) found that residents face different constraints than senior physicians and that conflicts between institutional, professional and moral constraints can lead residents to overlook patients’ preferences in end-of-life decision-making. Szymczak & Bosk (2012) studied how residents used their time, and how time constraints shaped the development of their professional identity. They found that efficiency was a norm in medical practice, but that it was also a strategy that residents used to manage their overwhelming workload and accomplish their labor in a complex health care system.

Kellogg (2011a, 2011b) also focused on residents, but she turned her eye not to the stable institutional constraints that affect medical practice, but rather toward efforts to change these constraints. She investigated work hour reform in surgical residency programs, a movement that was catalyzed by medical error—an exhausted resident delayed responding to a page, which led to the death of a young patient. Kellogg (2011a) developed the concept of political toolkits that accomplish the actions implied in cultural toolkits (Swidler, 1986). Political toolkits contain tools like “accountability systems, staffing systems, and evaluation systems that depend on the formal authority of more powerful organization members for their introduction into particular organizations” (2011a, p. 483). Kellogg’s work dovetails with Becker’s (1995) work on institutional inertia and provides an account of the conditions under which members of organizations are able to effect organizational change.

These studies examine the education and socialization of residents, providing much needed updates that allow us to link the subjective experience of trainees to the constraints of the organization they are embedded in. However, residents have already completed their initial medical training and are engaged in full-time practice. It is also important to investigate what students in their first years of medical education are learning about healthcare and their professional role as a physician. This is where the initial parameters of students’ professional subjectivity are set—at the time when they are most aspirational and least experienced (Vinson, 2015). Over a decade ago, Brosnan (2009) noted that, in addition to few analyses of structural features of medical schools, there had been little emphasis on faculty members’ perspectives on medical education. To this I will add that there had been very little attention overall to theorizing the role of faculty as agents of socialization. In the past ten years, research in this area has expanded greatly, continuing to revisit longstanding concerns of sociology of medical education in contemporary contexts.

For example, Brosnan (2011) described scientific knowledge as a form of distinction between medical schools and between individual students. In a comparative study of two medical schools in the United Kingdom, Brosnan investigated the place of science in the curriculum. She examined how the place of science was shifted by faculty efforts to produce more humanistic physicians by incorporating early clinical experience and problem-based learning into medical training and what is at stake in discussions about science in the curriculum. Likewise, Anderson’s (2008) discussion of teaching race at medical school detailed the resistance he encountered in leading a discussion of the social construction of race with medical students. Anderson’s account of leading small discussion groups and interacting with his colleagues from anthropology and history and the course faculty in the medical school exposed the difficulty of changing institutionalized ways of thinking, even when the organizational structure of the medical school was ostensibly open to incorporating teachers with different intellectual perspectives. Olsen (2019) moved beyond Anderson’s single case study, interviewing medical educators and students from 37 U.S. medical schools about how the schools responded to Liaison Committee on Medical Education (LCME) standards to teach about race in the medical school curriculum. She found that most teaching about social inequalities occurred during small group Practice of Medicine courses, and that faculty facilitators rely on students in the small group to complete the curriculum by sharing their own personal experiences of race and racism, what Olsen calls the “conscripted curriculum.” Similar to Murphy’s (2016) study of sexuality education, Olsen finds that the devolution of instruction to the small group level and the reliance on students’ personal experience results in non-standardized teaching about racial inequalities, thereby representing knowledge about social inequalities as less important than other forms of knowledge. This body of research on medical school and residency training emphasizes the structures and professional culture that shapes the medical curriculum and training context, thereby responding to calls from Light (1988) to transcend social psychological research and increase the focus on structure in sociology of medical education.

Finally, picking up on the field’s longstanding emphasis on doctor-patient communication, there have been several investigations of how the physician-patient relationship is trained in contemporary contexts. These analyses incorporate the changing conditions of healthcare delivery and advances in educational modalities to examine new constraints and opportunities in medical training. For example, Harter and Kirby (2004) found that because practicing physicians wrote the scripts for standardized and virtual patient interactions, the cases required medical students to carry out a version of medical practice that was influenced by the organizational constraints of managed care. Specifically, students learned to value efficiency because their interactions with standardized patients were timed, and they learned to balance efficiency with a competing priority—the need to value patients as people. The students also learned aspects of biomedical ideology, such as rationally treating symptoms and valuing certainty over uncertainty. Other work in this vein has examined how physicians train medical students to communicate with patients in a healthcare delivery context that is marked by patient consumerism, an emphasis on patient choice, and a cultural mandate to effect a warm demeanor in the clinical encounter (Vinson and Underman, 2020). Doctor-patient communication and the nature of patient involvement in the encounter continues to enliven the field of medical sociology and sociology of medical education (Timmermans, 2020).

In this section I have aimed to demonstrate how current research on medical training in sociology has carried forward the concerns of classic research from the mid-20th century and incorporated insights from sociology of medical education during 1980–2000. The rising focus on practice, affect and embodiment; sustained focus on knowledge and professional subjectivity; and increasing attention to the structure of curriculum and role of faculty reflect are examples of empirical and theoretical development in the sociology of medical education. I have also drawn in selected studies from anthropology and science and technology studies to convey the interdisciplinary interest in medical training, especially as many sociologists of medical education have begun to find these works in the search for novel theoretical resources in their studies of, for example, embodiment and practice. Finally, while the classic dichotomy has long been presented as sociology of medicine versus sociology in medicine, recent work has begun to not only bring sociological knowledge to bear in studies of medical training, but has begun to explicitly articulate medical training as a case for studying questions of general sociological interest (Jenkins et al., 2021).

A revitalized canon

Why is it important to reassemble and articulate the canon in sociology of medical education? This project matters because here the concerns of the sociology of medical education align with those of other medical sociologists—the continued social transformation of American medicine. Indeed, Brosnan and Turner (2009) view medical education as “a crucible in which many of the questions central to sociology come to the foreground, involving as it does the socialization of professional groups, the interaction of institutions such as universities, hospitals, the medical profession and the state, the collaboration of different disciplinary groups, the production of knowledge, and the construction of professional values” (pp. 2–3).

My intended contribution with this review is to reunite sociology of medical education with the stream of medical sociology that focuses on the social transformation of American medicine. In so doing, it is possible not only to use general sociology to interpret findings in studies of medical training, but also to go beyond this—using medical training as a case for generating empirical and theoretical insights that are relevant to general sociology. This aim is consonant with early studies of medical training, which sought to make sense of a dramatic rise of professional work in the United States during the 20th century.

The studies reviewed in this article demonstrate that sociology of medical education has retained many of its enduring concerns, expanding over time to emphasize embodiment, affect, subjectivation, practice, culture, organizational structure, and social institutions. This broad focus, with its corresponding theoretical developments, is especially necessary as we seek to understand how medical education changes in response to changes in the medical profession and what this can tell us about how doctors are prepared to practice medicine in the current professional and cultural climates.