Personality traits and types predict medical school stress: a six-year longitudinal and nationwide study

OBJECTIVES: Personality types (combinations of traits) that take into account the interplay between traits give a more detailed picture of an individual's character than do single traits. This study examines whether both personality types and traits predict stress during medical school training. METHODS: We surveyed Norwegian medical students (n = 421) 1 month after they began medical school (T1), at the mid-point of undergraduate Year 3 (T2), and at the end of undergraduate Year 6 (T3). A total of 236 medical students (56%) responded at all time-points. They were categorised according to Torgersen's personality typology by their combination of high and low scores on the 'Big Three' personality traits of extroversion, neuroticism and conscientiousness. We studied the effects of both personality types (spectator, insecure, sceptic, brooder, hedonist, impulsive, entrepreneur and complicated) and traits on stress during medical school. RESULTS: There was a higher level of stress among female students. The traits of neuroticism (P = 0.002) and conscientiousness (P = 0.03) were independent predictors of stress, whereas female gender was absorbed by neuroticism in the multivariate model. When controlled for age and gender, 'brooders' (low extroversion, high neuroticism, high conscientiousness) were at risk of experiencing more stress (P = 0.02), whereas 'hedonists' (high extroversion, low neuroticism, low conscientiousness) were more protected against stress (P = 0.001). CONCLUSIONS: This is the first study to show that a specific combination of personality traits can predict medical school stress. The combination of high neuroticism and high conscientiousness is considered to be particularly high risk.     

Students' perceptions of race, ethnicity and culture at two UK medical schools: a qualitative study

CONTEXT: Globalisation has profoundly affected health care by increasing the diversity of clinicians and their patients. Worldwide, medical schools highlight the need for students to understand and show respect for patients and peers of different ethnicities. Yet a sound theoretical approach and robust methods for learning about cultural awareness are lacking. The reasons for this are unclear. OBJECTIVE: To explore Year 2 medical students' understanding of the concepts of race, ethnicity and culture. METHODS: This study was set in 2 universities in the north of England. The student population of each was of a similar ethnic mix but the universities differed in terms of local demography (a wide patient ethnic mix versus a predominantly White patient population with experience of social deprivation) and curricula (a curriculum involving problem-based learning and paper-based cases versus a curriculum involving early contact with patients). Participants comprised 49 Year 2 medical students (mean age 20.8 years), 40% of whom came from ethnic minority groups. Seven focus groups were held across the 2 universities to explore students' understanding of cultural awareness. Students were asked to discuss the terms 'race', 'ethnicity', 'culture' and 'cultural diversity'. Interviews were transcribed and analysed qualitatively using grounded theory. Themes were identified and validated by an independent researcher. RESULTS: Four overarching themes emerged: 'White fears' at discussing race-related issues; ethnic minority discomfort at being viewed as 'different'; difficulties in relating to professional boundaries, and barriers against talking about race beyond legitimate disease-related discourse. CONCLUSIONS: For students, discussion of race beyond the confines of medical discourse was problematic. If students are to develop professional holistic values towards patient care, they need more support in understanding their own personal values and uncertainties.     

Pre-registration house officers' views on studying under a reformed medical curriculum in the UK

In 1996 the University of Liverpool introduced a new curriculum based on the recommendations published in Tomorrow's Doctors. This work examines how graduates of that course view their undergraduate curriculum and whether they consider it prepared them well for the pre-registration year. Five focus groups were arranged with a selection of graduates from the first cohort to graduate from the reformed curriculum in order to ascertain their views on the course and how it had prepared them to work as pre-registration house officers (PRHOs). The focus groups were tape-recorded, transcribed and analysed. The PRHOs felt they had been well prepared for the PRHO year, citing the clinical experience of the final year, communication skills classes and the Clinical Skills Resource Centre as having been particularly beneficial. There were concerns about their basic science knowledge base although this had not affected their ability to work as PRHOs. They had criticisms of the way part of their course had been structured but overall they were happy with the content of the course. A reformed medical curriculum in the UK can prepare graduates well to work as junior doctors and can take away some of the anxiety associated with graduation; therefore, to that extent curriculum reform has worked. However, anxiety about undertaking the role of junior doctor seems to have been replaced by anxiety about knowledge base, despite having adequate knowledge to work as PRHOs. Students undertaking a reformed curriculum are wary about being the first people to use their training in the workplace. This factor may need to be considered when further reforms are introduced.     

An investigation of medical student reactions to feedback: a randomised controlled trial

BACKGROUND: Medical educators have indicated that feedback is one of the main catalysts required for performance improvement. However, medical students appear to be persistently dissatisfied with the feedback that they receive. The purpose of this study was to evaluate learning outcomes and perceptions in students who received feedback compared to those who received general compliments. METHODS: All subjects received identical instruction on two-handed surgical knot-tying. Group 1 received specific, constructive feedback on how to improve their knot-tying skill. Group 2 received only general compliments. Performance was videotaped before and after instruction and after feedback. Subjects completed the study by indicating their global level of satisfaction. Three faculty evaluators observed and scored blinded videotapes of each performance. Intra-observer agreement among expert ratings of performance was calculated using 2-way random effects intraclass correlation (ICC) methods. Satisfaction scores and performance scores were compared using paired samples t-tests and independent samples t-tests. RESULTS: Performance data from 33 subjects were analysed. Inter-rater reliability exceeded 0.8 for ratings of pre-test, pre-intervention and post-intervention performances. The average performance of students who received specific feedback improved (21.98 versus 15.87, P<0.001), whereas there was no significant change in the performance score in the group who received only compliments (17.00 versus 15.39, P=0.181) The average satisfaction rating in the group that received compliments was significantly higher than the group that received feedback (6.00 versus 5.00, P=0.005). DISCUSSION: Student satisfaction is not an accurate measure of the quality of feedback. It appears that satisfaction ratings respond to praise more than feedback, while learning is more a function of feedback.     

Self-report of quality of medical student health care

OBJECTIVES: To summarise survey results for the quality of medical students' personal health care, characterise the results according to the demographics and career orientations of the students, and evaluate the relationship between the perceived quality of health care received and the degree of emphasis on prevention in the health care provided. METHODS: We carried out a cross-sectional study with 2316 medical students in the class of 2003 from 16 medical schools, surveyed at 3 points during their training. We used a self-administered questionnaire designed to assess personal health care and related variables in medical students. RESULTS: The majority (92%) reported receiving health care that was at least good, but only a minority (23%) said they received excellent health care. Half had a regular doctor. Health care quality was rated more highly at Year 1 orientation than at later timepoints by students who had a regular personal doctor, and especially by those with personal doctors who emphasised prevention. CONCLUSIONS: The majority of medical students perceived that they had received health care that was good or better, but most did not believe it was excellent. As the provision of preventive care is important to students, increasing the amount of preventive care provided to students may both increase their personal satisfaction with their health care and model good clinical preventive practices for them.     

Approaches to medical student remediation after a comprehensive clinical skills examination

OBJECTIVE: Most US medical schools conduct comprehensive clinical skills assessments during Years 3 and 4. This study explores strategies used to identify and remediate students who perform poorly on these assessments. METHODS: In the academic year 2005-06, we conducted 33 semi-structured interviews with individuals responsible for standard setting in and remediation after their schools' comprehensive clinical skills assessments. We coded interviews to identify major themes. RESULTS: Prior to remediation, some schools employed a 'verification' step to ensure the accuracy of the failing score or need for remediation. Participants described a remediation process that included some or all of 3 steps. Firstly, students' specific learning deficits were diagnosed. Next, students participated in remedial activities such as performance review sessions or practice with standardised or actual patients. Lastly, students were re-tested, usually with a shorter, more formative examination. All participants reported using a diagnostic step, most offered or required remedial activities and many re-tested, although schools varied in the emphasis placed on each step. Many participants cited the individualised attention students received from remediation faculty staff as a strength of their approach, although they raised concerns about the substantial time demands placed on remediation faculty. Most respondents reported some dissatisfaction with their school's remediation process, particularly uncertainty about efficacy or rigour. CONCLUSIONS: Schools vary in the intensity and scope of remediation offered to students who perform poorly on clinical skills assessments. Although many schools invest significant resources in remediation, the effect of these efforts on students' subsequent clinical performance is unknown.     

Altruism revisited: a comparison of medical, law and business students' altruistic attitudes

OBJECTIVE: Although the concept of altruism in medicine has a long tradition in Western thought, little empirical research has been carried out recently in this area. This study compares the altruistic attitudes of medical, legal and business students. METHODS: We used a cross-sectional survey to compare the altruistic attitudes of 3 types of contemporary 'professional' students, those in medicine, law and business. RESULTS: The results suggest that medical students report more altruistic attitudes than legal students, but not than business students. Overall, female students reported stronger attitudes consistent with altruism compared with males; African-American and Hispanic students reported more altruistic attitudes compared with White students. CONCLUSIONS: Our results suggest that the recent trend in recruiting more women and under-represented minority group members into medicine may have a positive impact on altruism in the profession, if we can assume that attitudes correlate with behaviours.     

Optimal sequencing of bedside teaching and computer-based learning: a randomised trial

Objectives  We aimed to establish the most effective order in which to deliver teaching to medical students when using both bedside teaching (BT) and computer-based learning (CBL) and to ascertain the students' preferred method and order of delivery.
Methods  A sample of 28 medical students were randomly divided into two equal groups during their orthopaedic knee examination teaching session. Group 1 received standard BT and group 2 undertook a CBL package. Each group then undertook an objective structured clinical examination (OSCE). The groups then received the other method of teaching followed by another OSCE. A questionnaire was administered to all students to assess their views on, and preferences for, the various teaching methods.
Results  Mean scores on the first OSCE were 12.19 for group 1 (BT then CBL) and 11.96 for group 2 (CBL then BT) ( P  = 0.692). Mean scores on the second OSCE were 11.81 for group 1 compared with 12.79 for group 2 ( P  = 0.038). Statistical analysis showed a significantly better score improvement for group 2 (CBL then BT) over group 1 (BT then CBL). Of the 26 students who returned questionnaires, 24 (92%) expressed their preference for traditional BT over CBL only, and 23 (88%) were in favour of undertaking CBL prior to traditional BT.
Conclusions  The CBL package is a useful tool and is most effective if used before BT. Students prefer BT alone over CBL alone, but, if offered both, prefer to undertake CBL first.     

Perceptions of and attitudes towards medical errors among medical trainees

OBJECTIVES: The purpose of this study was to develop a better understanding of how medical trainees define medical errors and what factors influence medical trainees' perceptions of medical errors. METHODS: We surveyed 423 medical students and house staff at an urban academic medical centre to learn about how they defined medical errors, their experiences with medical errors, their beliefs about when a patient should be informed of an error, and their attitudes towards medical errors with differing severity of outcomes. RESULTS: Trainees stated that an event could be considered an error regardless of outcome, negligence, intention or consent. Definitions did not vary according to gender or level of training. Trainees had increasing feelings of guilt and fear as the outcomes related to errors worsened. Respondents were more likely to feel guilty and angry at themselves, and be afraid of accusations of malpractice, losing their licence, damaging their reputation, or losing confidence when errors were made while working individually versus in a team setting. Female trainees were more likely than male trainees to feel guilty and angry at themselves, and were afraid of losing confidence if they made an error. CONCLUSIONS: Trainees' perceptions and attitudes towards errors vary depending on whether they are in their clinical years, the severity of outcome, and whether the error is attributable to an individual or a team. These factors will have to be explored in greater depth if we are adequately to prepare young doctors for the errors they will inevitably make.     

A comparison between senior medical students' and pharmacy pre-registrants' knowledge and perceptions of generic medicines

OBJECTIVE: To ascertain any differences in knowledge and perceptions of generic medicines between senior (final year) medical students and pharmacy pre-registrants in Australia. METHODS: National web-based surveys containing 16 common questions were administered to each group. Responses were compared using Mann-Whitney U-test. RESULTS: Responses were received from 400 medical students (response rate 26.7%) and 289 pharmacy pre-registrants (response rate 30.5%). Both groups scored poorly on the allowable bioequivalence limits when comparing a brand-name medicine with a generic medicine, with pharmacy pre-registrants scoring better (P < 0.001). Pharmacy pre-registrants were more likely (P < 0.001) to report having been introduced to bioequivalence during their courses, and less likely (P < 0.001) to desire more information on bioequivalence testing. Both groups correctly agreed that generic medicines are bioequivalent to corresponding brand-name medicines but not necessarily to each other, and that generic medicines are cheaper. Pharmacy pre-registrants were more aware that generic medicines must be in the same dosage form (P < 0.001) and contain the same dose (P < 0.001) as the comparator brand-name medicine. Both groups incorrectly believed that generic medicines are required to meet higher safety standards, are inferior in quality, are less effective and produce more side-effects. Both groups agreed that it is easier to recognise a drug's therapeutic class from its generic name and that they needed more information about the safety and efficacy of generic medicines, with medical students feeling more strongly about this (P < 0.001). CONCLUSIONS: Although there were some differences in responses, both groups had knowledge deficits about the quality, safety and effectiveness of generic medicines, which need to be addressed by educators in order to increase the future use of generic medicines in Australia.     

Overview of accreditation of undergraduate medical education programmes worldwide

Context  There is significant variation in the structure and quality of undergraduate medical education around the world. Accreditation processes can encourage institutional improvement and help promote high-quality education experiences.
Methods  To investigate the overseeing of medical education from an international perspective, the Foundation for Advancement of International Medical Education and Research (FAIMER^®) has developed, and continues to update, the Directory of Organizations that Recognize/Accredit Medical Schools (DORA). The directory includes information on the presence of national accrediting bodies and related data. Medical education accreditation information was pooled by World Health Organization (WHO) regions.
Results  Although over half of all countries with medical schools indicate that they have a national process for accrediting medical education programmes, the nature of the various authorities and levels of enforcement vary considerably.
Discussion  Despite global trends indicating an increasing focus on the quality of education programmes, data linking accreditation processes to the production of more highly skilled doctors and, ultimately, better patient care are lacking. Investigating current accreditation practices is a necessary step for further research. To this end, we will continue to gather data on medical education around the world and will explore opportunities for relating these processes to outcomes.     

The relationship between reciprocity and burnout in Dutch medical residents

Objective  This study examined reciprocity in medical residents' relationships with supervisors, fellow residents, nurses and patients, and associations between reciprocity and burnout. Furthermore, we considered if a discrepancy between the perceived and preferred levels of reciprocity influenced the level of burnout complaints.
Methods  In 2003, self-report questionnaires were sent to the homes of all 292 medical residents at the University Medical Centre Groningen (UMCG), Groningen, the Netherlands. Reciprocity was measured with a single-item reciprocity scale based on the Hatfield Global Measure of Equity Scale. The Utrecht Burn-Out Scale (UBOS/MBI-HHS) was used to measure burnout.
Results  A total of 158 residents participated in the study. Those who reported under-benefiting in the relationship with supervisors perceived significantly more emotional exhaustion and depersonalisation than those who perceived a reciprocal relationship. Residents who indicated that they over-benefited in the relationship with nurses reported more emotional exhaustion than residents who perceived a reciprocal relationship and less personal accomplishment than residents who perceived a reciprocal relationship or under-benefit. No differences on the burnout subscales were found between residents who perceived their relationships with patients and fellow residents to be reciprocal and those who considered they under- or over-benefited. The greater the discrepancy between perceived and preferred reciprocity in the relationship with the supervisor, the more emotional exhaustion residents reported.
Conclusions  Perceptions of reciprocity in relationships with supervisors and nurses had particular influence on the level of burnout complaints among residents. The discrepancy between the impacts of perceived and preferred reciprocity on burnout was negligible and the only significant relationship to emerge concerned that with emotional exhaustion.     

Teaching undergraduate psychiatry in primary care: the impact on student learning and attitudes

OBJECTIVE: To explore the impact of undergraduate psychiatry placements in primary care settings on students' learning and attitudes to mental illness. DESIGN: Questionnaire survey and qualitative in-depth interviews. SETTING: A primary care-based psychiatry undergraduate teaching programme at Royal Free and University College Medical School, London. PARTICIPANTS: A total of 145/183 (79.2%) students attending the primary care-based programme over 2 academic years completed a questionnaire survey. In-depth interviews were conducted with 14 students, 12 general practitioner (GP) tutors and 20 patients participating in the course. RESULTS: In the questionnaire survey, 121/144 (84.0%) students valued the primary care-based teaching highly. In total, 87/139 (62.6%) students felt their attitudes to mental illness had changed as a result of the course. In-depth interviews demonstrated 4 key benefits of the teaching programme: increasing breadth of experience, understanding the patients' experience, learning about mental illness from a GP's perspective and changing students' attitudes towards mental illness. The students' attitudinal shift comprised 2 main dimensions; 'normalisation' of mental illness and increased empathy. CONCLUSIONS: Learning psychiatry in primary care settings offers students a broader experience of a range of patients than in hospital settings and encourages a 'person-centred' approach, which in turn can have a positive impact on their attitudes to mental illness, reducing stereotyping and increasing empathy.     

The influence of gender on student willingness to engage in peer physical examination: the practical implications of feminist theory of body image

CONTEXT: Previous research has consistently found a relationship between students' attitudes towards peer physical examination (PPE) and their gender. Male students are more comfortable with PPE than females and students are more comfortable with same- rather than mixed-gender PPE. Despite these findings, previous research has not discussed the gender-attitude relationship in any meaningful depth. OBJECTIVES: This discussion paper examines why a relationship exists between student attitudes towards PPE and student gender using insights from feminist body image theory. DISCUSSION: According to the feminist theory of objectified body consciousness, females experience their bodies differently from males. Females may be less comfortable with PPE because they have higher levels of body shame and body surveillance than males. They may also be more likely than males to fear critical and teasing comments and sexual objectification by the opposite sex. CONCLUSIONS: Capitalizing on what we already know about psychoeducational and activism approaches to the prevention and change of negative body image, I recommend that body image issues are discussed as part of students' PPE and professionalism programmes. Further research is needed to examine medical students' body image alongside their attitudes towards PPE.     

The effect of gender on medical students' aspirations: a qualitative study

Objective  This study aimed to explore the effect of gender on medical students' aspirations.
Methods  The study design included purposive sampling and interim data interpretation to guide recruitment of medical students with a wide spectrum of opinions. Data were collected through audio-recorded, semi-structured, in-depth exploratory interviews, which were transcribed verbatim. Qualitative analysis was carried out by a female medical student researcher. Her evolving interpretation was constantly compared against the original data by male (doctor) and female (pharmacist) staff researchers in a systematic search for internal corroboration or disconfirmation. Causal associations consistently present in the data are reported.
Results  Six male and six female medical students in Years 3 and 4 shared a wish to achieve a work−life balance that allowed them to devote time to bringing up children while contributing usefully to society as doctors. However, women were readier to compromise professional attainment within their personal work−life balances. Their readiness derived from gendered stereotypes of women's social and professional roles, a lack of female professional role models, womens' greater awareness of the tensions between career and family, various other informal social influences, and a lack of positive career advice to counterbalance these influences.
Conclusions  Better career advice and more flexible work opportunities are needed if the two-thirds of medical students who are women are to contribute specialist as well as generalist expertise to the medical workforce.     

Sexual harassment during clinical clerkships in Dutch medical schools

Context  Sexual harassment of medical students has been the focus of many international studies. Prevalence rates from 18% to over 60% have been reported. However, a Dutch study at Nijmegen Medical School found the prevalence rate to be lower (13.3% in the total group; 20% among female students only).
Objectives  We aimed to identify whether Nijmegen constitutes a positive sample of Dutch medical schools or whether incidents of sexual harassment are less prevalent in the Netherlands than elsewhere, and to establish if and how these experiences impact the professional lives of students.
Methods  Students received a semi-structured questionnaire containing questions about their experiences of sexual harassment during clerkships. The questions referred to students' reactions to any incidents, the possible consequences for their wellbeing or professional functioning and the way cases of sexual harassment were handled.
Results  The prevalence of sexual harassment was significantly higher in Utrecht than in Nijmegen. In both studies rates were relatively low compared with international data. Nevertheless, 1 in 3–5 Dutch female medical students had experienced unwelcome sexual attention from patients, colleagues or supervisors. Three of 10 students who had experienced such an incident stated that it had a negative impact on their functioning afterwards.
Conclusions  Prevalence rates of sexual harassment in medical schools in the Netherlands are low compared with international rates. However, the number of women students who experience sexual harassment is still 1 in 3–5. The occurrence of and ways to deal with these incidents should be important topics in the training of medical students and supervisors.     

Understanding student concerns about peer physical examination using an activity theory framework

Context Peer physical examination (PPE) has been employed for several decades as part of the formal curriculum for learning clinical skills. Most of the existing studies exploring students’ attitudes towards PPE are single‐site and use quantitative methods. Currently, there is a lack of theoretical underpinning to PPE as a learning method. Methods Using an adaptation of the Examining Fellow Students questionnaire, we captured qualitative data from Year 1 medical students about their views and concerns around learning using PPE. The study was set in six schools across five countries (the UK, Australia, New Zealand, Japan and Hong Kong). Students provided free text comments that were later transcribed and analysed using framework analysis. Results A total of 617 students provided comments for analysis. This paper focuses on several related themes about the complexities of students’ relationships within the context of PPE and their reflections on peer examination in comparison with genuine patient examination. Students drew parallels and differences between the peer examiner–examinee relationship and the doctor–patient relationship. They explained how these two types of relationship differed in nature and in terms of their levels of interaction. Discussion Our findings illuminate the interactional and complex nature of PPE, drawing out concerns and ambiguities around relationships, community and rules. We discuss our results in light of Engeström’s model of activity theory (AT) and provide recommendations for educational practice and further research based on the principles of AT.     

Senior medical students' appraisal of CanMEDS competencies

CONTEXT: In 2003 the Dutch Central College of Medical Specialties presented guidelines for the modernisation of all medical specialty training programmes in the Netherlands. These guidelines are based to a large extent on the CanMEDS (Canadian Medical Education Directives for Specialists) 2000 model, which defines 7 roles for medical specialists. This model was adjusted to the Dutch situation. The roles were converted to 7 fields of competency: Medical Performance; Communication; Collaboration; Knowledge and Science; Community Performance; Management, and Professionalism. OBJECTIVE: As changes in postgraduate training will probably be most effective if future trainees recognise their value, we set out to determine how senior medical students rated these fields of competency in terms of their importance. METHODS: We carried out a study at University Medical Centre (UMC) Utrecht, the Netherlands, in which 80 Year 6 medical students answered a questionnaire in which they rated the importance of each of 28 key competencies within the 7 competency fields. RESULTS: Although all key competencies were regarded as important (averages > or = 3.8), Professionalism and Communication scored highest on the student ratings. Management was assessed as least important. CONCLUSIONS: It is interesting that medical students acknowledged the importance of competencies other than those involving medical expertise and performance. It confirms the opinion that educating doctors is currently viewed as much more than providing theoretical and clinical knowledge and skills. The CanMEDS framework is appreciated by Dutch medical students. The fact that all competencies are seen as important adds to their face validity and therefore to their usefulness as a basis for postgraduate training.     

Students' views of reflective learning techniques: an efficacy study at a UK medical school

OBJECTIVE: To describe the effects of a voluntary intervention using reflective learning techniques on students' learning. DESIGN: An interventional study with reflective learning techniques offered to medical students. SETTING: Year 3 of undergraduate medicine at Cardiff University where the curriculum is integrated with early clinical contact. PARTICIPANTS: All 232 Year 3 students were invited to participate. A total of 65 attended an introductory lecture. After the lecture 35 students agreed to take part; 15 of these subsequently dropped out (some before attending tutorial groups, others after taking part for some weeks). INTERVENTIONS: Participants kept learning journals for 2 terms and attended fortnightly, facilitated tutorial groups where they discussed their reflective journal entries. Main outcome measures were qualitative interviews and examination results. RESULTS: Interviews were carried out with 19 full participants, 4 initial participants and 7 non-participants. Participants perceived that they gained a greater ability to identify learning objectives and to integrate learning. The tutorial groups encouraged students to compare progress with their peers. Some students did not take part because they thought that the large factual content of the curriculum would make reflective learning less useful. There were no differences between the groups in examination results. CONCLUSIONS: Students among the small, self-selected group of participants were better able to identify what they needed to learn although there was no improvement in examination results. Students appear unlikely to take up voluntary reflective learning if they do not think it relates to the curriculum and assessments. Student culture exerts a potent effect on willingness to attend extra tutorial groups.     

Why are there so few working‐class applicants to medical schools? Learning from the success stories

Objectives  Students from lower socio-economic circumstances remain under-represented in UK medical schools despite recent shifts in other demographic variables and specific policy emphasis on widening participation (WP). This study aimed to further understanding of the reasons for this.
Methods  Volunteer participants at three English medical schools took part in narrative-style, in-depth interviews examining their pathways into medicine and the relationships between these pathways and participants' socio-cultural, educational and family backgrounds. This analysis uses findings from interviews with 12 mature students from working-class backgrounds. It employs theoretical work from the wider field of education sociology that has investigated the relationship between higher education decision making and class.
Results  This study demonstrates how 'normal working-class biographies', constructed by the majority of students targeted by WP activity, result from the influences of socio-cultural context, as well as familial and institutional habitus. The resultant influence on habitus as identity and, in particular, the disjuncture between working-class perceptions of medicine and individual identities are key to understanding the reasons behind the low number of working-class applicants to medical school.
Conclusions  Interventions that aim to increase participation rates in medicine must address this disjuncture. This might be achieved by re-orienting working-class identities and perceptions of medicine as a profession. However, it should be acknowledged that 'identity conflict' is related to the elite image that medicine maintains within contemporary society and, as such, efforts to re-orient individual working-class identities may have only a limited impact on overall participation rates.