Pierre Bourdieu and medical education

Pierre Bourdieu e formação médica

ESSAY

Pierre Bourdieu and medical education

Pierre Bourdieu e formação médica

Andréia Patrícia Gomes^I; Sergio Rego^II

^IUniversidade Federal de Viçosa, Viçosa, RJ, Brasil

^IIFundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil

^{Correspondence}

ABSTRACT

The contemporary discussion about the transformation of the training of health professionals has focused primarily on the change in method. This article discusses this issue in the light of Pierre Bourdieu's theoretical contributions - habitus, field, symbolic capital, symbolic violence and reproduction. The conclusion is drawn that pedagogical change alone is not enough to change the profile of medical graduates.

Keywords: Medical Education; Staff Teaching; Teaching.

RESUMO

A discussão contemporânea sobre a transformação da formação de profissionais de saúde tem dado grande ênfase à mudança de método como sua questão principal. Este artigo discute tal questão à luz das contribuições teóricas - habitus, campo, capital simbólico, violência simbólica e reprodução - de Pierre Bourdieu. Conclui-se que isoladamente a mudança pedagógica não é suficiente para mudar o perfil do egresso.

Palavras-chave: Educação Médica; Formação de Recursos Humanos; Ensino.

INTRODUCTION

The paradigm shift in the training of medical professionals has been discussed in Brazil and the world for some decades now. The literature is increasingly discouraging adoption of the hegemonic model, which focuses on specialized scientific training and individual knowledge, rather than technical competence and ethics focused on the integration of multiple determinants of the health-disease process. The process culminated, therefore, in an alliance between the Ministry of Health and Ministry of Education and the publication of the National Curriculum Guidelines (DCN) of the Undergraduate Medicine Course¹, which recommends the following profile of the graduate-professional:

The undergraduate course in medicine has a graduate/professional physician profile of a generalist, humanist, critical and reflective background, able to work based on ethical principles in the health-disease process at different levels of care, with the promotion, prevention, recovery and rehabilitation of health from the perspective of comprehensive care, with a sense of social responsibility and commitment to citizenship, as a promoter of total human health¹.

General guidelines for the targeting of training in Brazil require core competencies to be achieved during the development of undergraduate studies, as seen in the DCN, Article 5, sole paragraph, which states that "the training of physicians should include the current health system in the country, provide comprehensive care in a regionalized system of health and hierarchical referral, counter-referral and teamwork"¹. The strategies therefore focus on the role of the student as an active learner, relying on the teacher as facilitator and mediator of the process. Thus, the process of change in medical schools should be supported by objective imaging of the profile recommended in the DCN, and reinforced by the Incentive Program for Curricular Changes in Medicine Courses - PROMED (2002)², and the National Health Training Reorientation Program - PRO-SAÚDE (2005)³, with emphasis on

comprehensive medicine, emphasizing the concept of health instead of disease, the development of active teaching and learning methods, the enhancement of humanized care with the formation of a solid ethical basis, encouraging future doctors to work in primary care activities, giving priority to the Family Health Program, and to work in new teaching-learning settings that are not exclusively teaching hospitals².

These multiple actions and interventions are aimed at an objective profile of medical, critical, reflective and social commitment.

The changes implemented, however, as verified by Oliveira and colleagues in 2008⁴ in an analysis of the institutions which performed with the aid of PROMED changes, have been concentrated in specific areas, especially curricular and pedagogical changes, to the detriment of other actions:

Although there is a growing number of medical courses that have been discussing changes, only a minority of these courses has deployed disciplines and/or undergraduate research programs, and promoted community/public involvement; two issues of paramount importance for medical training in the current context of the health system.⁴

Focusing on curriculum change in terms of changes in teaching method - i.e., going from traditional curricula to active teaching and learning methods, or more specifically, from traditional teaching to Problem-Based Learning (PBL) - will medical school prepare professionals of a new profile? Several studies have attempted to answer this question. However, far from promising findings have pervaded the literature since on the subject since 1993, according to Albanese and Mitchell.⁵

It is indisputable, therefore, that the response to the preparation of a new professional will not be achieved by only making methodological changes - either changes to the teaching-learning process, or cognitive changes - which are necessary but insufficient. The question that remains is why results are not achieved when we focus on such changes in an isolated manner?

The aim of this paper is to discuss methodological change and the reasons for its inefficiency from a theoretical perspective, using Pierre Bourdieu's concepts of habitus, field, symbolic capital, symbolic violence and reproduction.

PIERRE BOURDIEU'S FUNDAMENTAL CONCEPTS FOR THE DISCUSSION

Pierre Bourdieu was born in 1930. Trained as a philosopher and a sociologist by trade, he developed extensive academic works always drawing connections between theory and practice. He developed concepts which he applied to investigations into analyze society, and was considered one of the greatest exponents of cultural reproduction⁶. According to Catani, 2001⁷, his first texts arrived in Brazil in 1968 and reading of his work increased in the 1970s with the translation of the first edition of Reproduction⁸. Characteristically, his thinking and works are based on multiple theoretical perspectives, combining them to produce concepts⁹.

The author brought to the discussion ideas such as field, habitus, symbolic capital, symbolic violence and the education system as reproduction. An intellectual who believed in the changing power of ideas in society, he was very active both academically and in his practices and positions in the world. He applied his concepts to reality, discussing several issues, considering man as more than an exclusive product of the environment, and focusing on the role he has in production and ideas that man himself inherits, leading him to think and act in specific ways in his relationship with other men; know-how that forms the daily operation of relations or habitus. The habitus is, therefore, a generating principle of different practices, classification, views and likes¹⁰, he is a "matrix, determined by the individual's social position that allows him to think, see and act in different situations"¹¹. The concept of habitus covers action and styles, which seems to be an innate gift for determination, but is socially constructed and engages the collective in the individual, through a standard way of living. Thus, the perception of an individual that interacts with the social reality is retrieved, without losing sight of the fact that the same social reality interacts with the individual; this structurual and structuring principle consists of a durable and transferable arrangement of perceptions, thoughts, of appreciation and action and characterizes the group to which the individual belongs¹². it is the habitus, therefore; a predictive model of our behaviors in the world, our response to certain circumstances, an operator of rationality within the limits of their structures¹³. It is not the simple internalization of social rules, rather it is a dynamic interaction between individuals, social agents and social structure in order to enable acting in the world. Thus, actions do not occur mechanically¹⁴, they are guidelines inherited from socialization¹⁵; they are strategies, which as more compatible with that particular group, living in that particular situation, become an integral part of that whole. The "process is triggered at birth" and "lasts until death"¹⁶.

What about the field? What does this concept refer to? The field is a microcosm within the macrocosm formed by the global social space¹⁷; a structured space of social positions and actions. The field, as stated by Corcuff¹⁸ is "a sphere of social life which was gradually gained autonomy over the course of history around social relations, contents and own resources, unlike those of the other fields". Sometimes as an arena for social interaction, each and every field is the setting for measuring (and mediating) forces, forming a force field; equally it is a battle field where social agents meet and confront each other to maintain, transform, lose or gain such forces, competing within the rules established or the acquired habitus specific to each field¹⁹. Fields work and are regulated therefore based on their own social laws and not external social laws; each field is a story, a monopoly of categories of appreciation and of modes of operation. The fields of science, art, haute couture, economics, literature and so on are fields with different modes of functioning within this existing peculiarity of them all, and therefore possess specific space and capital, as well as their own habitus, which allows them to act under the same script. So the field is like a big game, where the participating agents, owners and knowers of the rules dispute positions of specific dominance and profits²⁰.

As regards specific capital in Bourdieu, we must emphasize that we are not talking about economic capital, or economic strength. Besides economic capital - directly linked to the possessions of individuals and groups - Bourdieu brings to the discussion other forms of capital: social capital, that is,

the aggregate of the actual or potential resources which are linked to possession of a durable network of more or less institutionalized relationships of mutual acquaintance or recognition - or in other words, to membership in a group - which provides each of its members with the backing of the collectivity-owned capital, a 'credential' which entitles them to credit ... and are united by lasting and useful connections²¹

The contextualization around cultural capital is also noted, which can exist in three forms: the state in which the individual is embedded, i.e., an integral part of the person and constitutes the habitus, cultural capital in its objectified state, which consists of cultural goods such as books, paintings, and finally cultural capital in its institutionalized state, with (school) certification as its main characteristic²². Thus, from different possible capitals, a new capital is presented in Bourdieu: symbolic capital. This is commonly called prestige, reputation, fame and is the form perceived and acknowledged as legitimate of the various forms of capital²³. This symbolic capital, defended in a non-violent manner by individuals and groups in society or within a specific field, leads to a situation of power, on the grounds that this is culture, thus validating it as superior to the others. The possessor of symbolic capital is also endowed with symbolic power, perceived as natural. One more concept then emerges - that of symbolic violence.

Symbolic violence is the process in which the dominant culture is legitimized and accepted by all as superior and legitimate, with the inclusion and adherence of the dominated¹⁷. There is a hoarding of symbolic capital, legitimate for those who dominate and legitimized by those who are dominated - like the Hegelian master-slave dialectic - that certifies the taste of its possessor¹². It is therefore a disguised violence with powers and effect afforded by the fact that it is legitimate, as it supposes ignorance of the actual violence²⁴; whereby it gains its strength and reproduction.

And finally, we come to the important concept of reproduction, one of the great ideas in the author's works, where several other concepts intersect in order to explain relations in the social field. Using symbolic capital and symbolic violence as value-instillers and modes in society, creating specific habitus of social agents and groups, Bourdieu discusses the power of reproduction of these same habitus through the school by considering a cultural arbitrariness which it does not produce and concealing the domination exercised by those who possess symbolic capital. The education system helps one see the dominant ideas as natural, through the educational action practiced by individuals endowed with authority⁸. It's certainly a smooth way of perpetuating the status quo, contributing to the maintenance of symbolic power in the fields and in society.

With these theoretical foundations in mind, we can now establish dialogues and cross-overs between the author's ideas and medical training.

RELATING BOURDIEU'S CONCEPTS TO THE FIELD OF MEDICAL TRAINING

Considering medicine as a socially structured space where social agents, namely physicians and those who intend to gain this title - medical students - meet and follow rules and principles of regulation specific to that occupation, it would appear that this profession, based on paradigm, can function as a well-organized model for Bourdieu's field. Those with more habitus or cultural capital incorporated - particularly to that condition, to that class - acquired through the process of professional socialization, ranging from school-validated knowledge (institutionalized cultural capital or the diploma), objectified cultural capital (assets) and social capital (relationships), will gain the recognition, fame and dignity that will make them bearers of greater or lesser prestige in the field. They are also participants of the battle arenas, which is one property of the field. Such battles, permanently designed in the field, demonstrate the diverse levels of power and positions, thus structuring subordinative relationships of some to others based on a legitimate authority, configured arbitrarily as superiority; hence, symbolic violence perpetuating the structure in force, or reproduction. A clear example of this is the doctor teaching the student, who follows him bearing in mind his clinical experience, the result of years of cultural and, of course accumulated symbolic capital, and thus assimilates the concepts of the field, its rules, its mode of operation habitus, and forms the doctor's habitus. Six years of undergraduate study for that ... But lest we forget, the only ones worthy of such a métier are those who have survived the traditional school system and bear years of incorporated symbolic violence and pedagogical action produced by the school, by the teaching of the habitus of the dominant classes, of which some were members and others were not; but this is a separate discussion.

Therefore, looking at the medical school as a field and considering teachers as representatives justified by study, diplomas, fame and prestige accumulated throughout their academic and professional training, in other words, agents of the dominant ideology, their task of teaching medicine leans towards cultural and social reproduction and this practice. Such practice does not consist only of cognitive scientific theories, but also rules, beliefs, perceptions and lifestyles, political, moral and aesthetic judgments, that is, it is also a means of action in this field, a habitus. Based on the elements considered above, how we can it be thought possible to change training by purely and simply changing the teaching method, within a context of operation and organization that, in effect, intends to perpetuate the existing symbolic capital? Is it supposed that a curriculum change with the creation of new subject modules or an integrated curriculum, for example within a problem-based learning structure, is enough to transform the social agents belonging to that field in such a way that they form a habitus in their students which they, the teachers, do not possess? What will prevail in the field, since it is driven by agents who think and act in various situations, with propositions which have been set for years and years? Is it possible to change the profile of a student without changing the profile of the agents - teachers and professionals - that make up this field?

Considering that education alone does not meet all the demands of a changing society - as it often contributes to the reproduction of the mode of operation of that society and even legitimizes its operation - would it not be extremely naïve to ascribe to the pedagogical changes a vast array of qualities that the doctor needs to acquire and thus meet the said needs of the society? It is certainly not possible to base the training of a critical, pensive, active and committed physician on the isolated foundations of changes to the teaching-learning methods because, in simple terms, in the field of medicine the perpetuated habitus is not that of the critical and pensive doctor, with a sense of social responsibility and commitment to citizenship. How can one be made competent, as states Perrenoud²⁵, having "this capacity to act effectively in a certain type of situation, supported by knowledge, but not limited to it"? How can one be made competent, taking into account the need for cognitive, psychomotor and affective attributes to be changed, to transform the know-how and practical intelligence, engaged in the practice of medicine? How can the training be changed without changing the habitus of that field? Is it the habitus that makes the doctor?

FINAL CONSIDERATIONS

It is not the objective of this study to condemn the change made in medical schools. What we intend to discuss, bringing new theoretical considerations, is the ineffectiveness of such isolated changes, since training medical professionals is much more than merely presenting or guiding the search for knowledge. Nor is the intention here to dictate rules on how such training should be conducted. What is proposed here is the development of a reflective stance on this field. Changing medical training means building a different field with different social agents, it means forming new ways of thinking, new ways of operating, it means changing considering the social structure that perpetuates itself in the action and readjustment of the individuals themselves, who act according to the incorporated models and arrangements, but are also not rigid, mechanical and inflexible, which makes it possible to change. How can this be done? That's another story...

Some new actors, like Paulo Freire, point a new vision of education, in which world changes can be the reality, and humankind works with more generous behaviours, in a model of freedom. This is not seen in our society today and we cannot wait for it to happen in medical education. Therefore, this paper is directed at medical educators, with the aim of bringing to light the real situation, despite the proposed changes.

Recebido em:15/07/2012

Reencaminhado em:05/04/2013

Aprovado em: 23/04/2013

CONFLICT OF INTERESTS: Sergio Rego is editor of the Revista Brasileira de Educação Médica

AUTHORS' CONTRIBUTIONS

Andréia Patrícia Gomes contributed to the original idea, research and composition of the article. Sergio Rego guided all stages of the composition of the article. They both prepared the final version.

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Publication Dates

• Publication in this collection
  19 Aug 2013
• Date of issue
  June 2013

History

• Received
  15 July 2012
• Accepted
  23 Apr 2013
• Reviewed
  05 Apr 2013