original paper
Clinical students’ initial reports of the educational
climate in a single medical school
Mary A Seabrook
INTRODUCTION The quality of the educational
environment has frequently been identified as crucial
to effective learning. Aspects of the clinical context
differ from those of other higher education envi-
ronments. This study explored the educational cli-
mate (the environment perceived by students) at a
single medical school. The article focuses on the
perceptions of students in the early stages of their
clinical course.
METHODS A longitudinal study of the school was
carried out over a 5-year period from 1995 to 2000,
using ethnographic methods. Data collection meth-
ods included participant observation, in-depth inter-
views, focus groups, and collection of written
documentation. Analysis was conducted using a
grounded theory approach.
RESULTS At the beginning of their clinical course,
students were motivated by the patient contact and
enjoyed clinical teaching. However, they also felt
daunted because the earlier years of the course had
not prepared them in terms of the knowledge or style
of learning required. Aspects of the hospital envi-
ronment were perceived as being unhelpful to
learning, for example, doctors’ frequent late arrival
for, or cancellation of, teaching. Students often per-
ceived that they were
in the way, and that their
individuality was not valued. Maturity, gender and
ethnicity impacted on students’ perceptions and on
their career aspirations and expectations.
DISCUSSION Students’ transition to the hospital
environment was difficult. This may become less of
Department of Medical & Dental Education, Guy’s, King’s & St
Thomas’ School of Medicine, London, UK
Correspondence: Mary Seabrook, Senior Lecturer, Department of Medical
& Dental Education, Guy’s, King’s & St Thomas’ School of Medicine,
Sherman Education Centre, 4th Floor, Thomas Guy House, Guy’s
Hospital, London SE1 5RT, UK. Tel: 00 44 207 ext. 5635; Fax: 00 44 207
955 2766; E-mail: mseabrook@onetel.com
 Blackwell Publishing Ltd MEDICAL EDUCATION 2004; 38: 659–669
an issue as medical curricula become more integra-
ted. Specific strategies to induct students into the
hospital, and increased staff awareness of their needs,
could also help. Ensuring an inclusive atmosphere
may be more difficult, requiring cultural change.
KEYWORDS education, medical, undergradu-
ate ⁄ *methods; hospitals, teaching ⁄ standards ⁄ *meth-
ods; clinical competence ⁄ *standards; attitude of
health personnel; curriculum; data collection; focus
groups ⁄ *methods; longitudinal study.
Medical Education 2004; 38: 659–669
doi:10.1046/j.1365-2929.2004.01823.x
INTRODUCTION
The term
climate refers to how an educational
environment is perceived or experienced, usually by
its students. Genn describes it as
the soul and spirit
of the medical school educational environment and
curriculum.1 The climate has been widely found to
influence student behaviour and contribute to the
prediction of student achievement, satisfaction and
success.1 For example, students’ perceptions of good
quality teaching and appropriate assessment have
been shown to predict a deep approach to learning,
which has been consistently shown to result in better
learning outcomes.2,3 A relationship has also been
demonstrated between students reporting high aspi-
rations (e.g. ambition) and perceiving a supportive
school environment.4 Students’ reports of the learn-
ing climate may, therefore, provide signals as to its
effectiveness.
There have been many attempts to define and
measure the characteristics of effective learning
environments using questionnaires, including some
specifically designed for medical environments.1,5 At
a more anecdotal level, there have been various
659
660 original paper
Key learning points
Entering the hospital-based part of the course
was motivating but daunting, and required
students to adapt to a different model of
learning.
Students often felt
in the way and lacked a
genuine role in patient care.
Students felt that their individuality was not
valued and perceived pressure to conform to
doctors’ expectations.
Female, ethnic minority and
quiet students
felt that they would be at a disadvantage in
their future careers.
autobiographies written by medical students, which
record individual impressions of specific schools.6
Sociological studies have also helped to explain how
the clinical learning environment is perceived by and
impacts on students.7,8 A difficulty with the ques-
tionnaire approach is that it may miss important
elements specific to a particular context, whilst the in-
depth studies or recollections of single schools are
limited by their narrow focus. However, common
themes can start to emerge from a range of single
studies and lead to the development of theoretical
generalisations.9 Another limitation of many of the
sociological studies, particularly the older ones, is
that they were undertaken in the context of a fairly
homogeneous group of students, who were mostly
white, male and middle class. Thus, their findings
may not reflect the experiences of the more diverse
group of students in many medical schools today.
This paper reports findings about students’ percep-
tions of the educational environment at a single,
traditional medical school with a diverse student
intake.
METHOD
Research design
The research was part of a longitudinal ethnographic
study of a single British medical school carried out
between 1995 and 2000. The school was set in a large
city, and had an annual intake of about 120 students.
 Blackwell Publishing Ltd MEDICAL EDUCATION 2004; 38: 659–669
During the early part of the study it had a traditional
2-part curriculum (2 years of science followed by
3 years of clinical teaching). From 1996, a new
curriculum was gradually introduced, based on the
General Medical Council’s recommendations of
1993.10 The main teaching hospital to which the
school was attached employed approximately 900
medical staff and served a socio-economically
deprived, multicultural population.
The study aimed to explore the culture for teaching
and learning using ethnographic research meth-
ods.11 In order to avoid predetermining what might
come out of the study, a grounded approach was
taken, which allowed themes and theories to
emerge
from the data.12 The processes of data collection,
analysis and interpretation were interwoven, with
progressive focusing to concentrate later data collec-
tion around emerging issues.13
Data collection
Data were collected during the normal work activities
of the researcher (an educationalist within the
school), through, for example, participant observa-
tion during curriculum meetings, teaching, assess-
ment and evaluation activities, and informal
discussions with staff and students during these
events. Additional data were collected through spe-
cially organised events, comprising individual,
in-depth, semistructured interviews with 22 doctors
and 19 students and a research focus group.
Documentation from committee meetings, including
evaluation reports, was also collected.
This paper uses student-derived data, primarily from
the interviews and evaluation activities. Interviewees
were selected using purposive sampling (Table 1),
and interviews lasted 45)90 minutes; Table 2 shows
the interview schedule used. All the students who
were asked to participate in the study agreed to be
interviewed. Most were in Year 3, their first year in the
hospital, as it was felt they would be more sensitive to
its culture at this stage and would not have had time
to internalise its norms and values. Although students
in the new curriculum had experienced some early
clinical contact in general practice, they expressed
similar concerns and perceptions to students in the
old curriculum who had not.
Seven focus groups were held, of which 6 were part of
the school’s evaluation process. Between 4 and 11
students attended each, with selection based on
the location of their clinical attachment, gender and
 661

together with field notes from the observations,

committee meetings, evaluation activities and infor-
Table 1 Data relating to students inter-
mal events. Each document was read and re-read, and
viewed (n = 19)
codes (a word or phrase summarising the main idea)
No. of were assigned on a line by line basis. Eventually over
Category Subcategory students 200 codes were created and defined using NUD*IST
software. The content at each code was then reviewed
*Sex Male 10 in order to produce descriptions of the phenom-
Female 9 enon. Codes were grouped into categories (an
*Race ⁄ ethnicity White 10 analytic device used to suggest a relationship between
Asian 7 a number of codes), and these in turn were eventu-
Chinese 1 ally grouped into 6 overarching themes (Table 3).
Black 1 Concept maps were drawn to illustrate how the codes,
BSc Yes 9 categories and themes related to each other.
No 10
Maturity School leavers 13 The analysis and interpretation of findings were
Mature students 6 validated through triangulation and participant val-
Year of course 1 0 idation. The former involved comparing data from a
2 0 range of sources and respondents, comparing the
3 (1st clinical) 12 researcher’s coding of data with those of colleagues
4 6 who agreed to assist, and getting feedback on
5 1 interpretation of results via conference presentations.
Previous Yes 6 Participant validation was carried out by continuously
acquaintance Slight 1 seeking to confirm or deny emerging findings during
No 12 the research, getting comments on draft chapters
* Male and female students and those from from individual respondents, and presenting draft
different racial backgrounds were sampled findings to groups within the school.
in approximate proportion to those in the
school.
 School leavers ± gap year ± BSc. RESULTS
 Mature students refers to students who
started the course 2 + years since leaving The data presented in this article are drawn from
the
school. teaching ⁄ learning atmosphere theme, the concept
map for which is shown in Fig. 1. This emerged as an
important theme as students commented more fre-
quently on it than on the content of the course. This
ethnicity. Students were asked to comment on pos- is illustrated by a field note recording a discussion
itive and negative aspects of the firms and suggest with a group of four Year 3 students who had been
improvements. The other focus group was run for asked what would make a good firm:
research purposes to explore whether students felt
that their experiences had been affected by their
They came up with all the usual things really:
gender or ethnicity. As these areas could be sensitive, feeling valued within the firm; the firm teachers
individual interviewees were not asked about them being interested in what they are doing; being
directly, but they were explored if they arose. The given more responsibility; being made to feel
focus group was held with students from a Year 3 firm useful; having a forum to discuss their own ideas
already known to the researcher. Seven of the 9 and ‘‘not be laughed at’’; having patients ‘‘to hang
students attended, including 6 non-white and 4 your knowledge on’’. They said that they often felt
female students. The 2 white male students on the like a hindrance. They said that they needed to feel
firm chose not to attend. that ‘‘if you take initiative you wont be stamped
on’’. They said too many people were scared to
take the initiative in case this happened.’
Data analysis
Students’ perceptions of the clinical learning envi-
All the individual interviews and the research focus ronment are presented below under 2 headings:
group discussion were tape-recorded and transcribed,
Teaching ⁄ learning atmosphere (the main theme)

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662 original paper

Table 2 Schedule for students’ interviews

What firm are you doing now?
Can you describe what happened at the beginning of the firm.
How did you first hear about it and what happened on the first day or two?
What did the firm expect from you?
What other firms have you done? How have you found them?
Can you think of two firms you’ve done which have been very different? How did they differ?
What was the best firm you’ve done? Why was it so good?
What firms have got good reputations? Why?
What is your relationship with the firm doctors like?
How do you think this differs from the other relationships you’ve had with teachers,
for example in the preclinical course or at school?
Is it the same with all doctors here, or does it vary? How?
What sort of experiences have you had clerking patients? What do you see as the purpose?
What do you think you can learn from clerking patients?
How do patients react to you?
How did the preclinical course relate to what you’re doing now?
Did you do a BSc? What made you decide to do ⁄ not to do one?
How do you think you learn best? What helps most? What is unhelpful?
What have you done that has seemed particularly relevant?
Has your attitude to medicine changed since you’ve been here?
What sort of person do you think makes a really successful medical student?
Are there any students that you think will go far in medicine? Why?
Do you think being older gives you a different attitude to studying? (mature students only)
Have you got any thoughts about what specialty you’d like to go into?

patients, and that in practice they found this

enjoyable and motivating. However, they often
Table 3 Overarching themes derived from described their early months in the hospital as
the data
daunting. When asked to elaborate, they described
Teaching ⁄ learning atmosphere factors such as: seeing expert clinicians in action
Course cohesion and realising what a huge task they had taken on;
Doctors as teachers difficulties in accessing appropriate patients for
Teaching structure clerking; difficulties in finding medical staff who
Student perspectives were available and willing to help and guide them;
Teaching practice dealing with nursing staff whom they often per-
ceived as unhelpful, or even hostile towards them,
and having to cope with patients who declined to be
clerked.

Students often expressed surprise when they realised

and
Respect for students (a category within this
theme).
The teaching ⁄ learning atmosphere
Student interviewees often mentioned that they had
looked forward to Year 3 because of the contact with
that the early years of the course had not prepared
them for the clinical years in terms of the knowledge
or method of learning required. They considered the
basic science they had learnt necessary, but, despite
some links to specific illnesses, the focus had been on
underlying scientific processes rather than applied
aspects. Thus, students found that they had insuffi-
cient knowledge to answer the kind of questions

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 663

Figure 1 Codes and categories from which the Teaching ⁄ Learning Climate Theme was derived.

doctors asked, which required them to recognise
disease from a patient’s history and signs.
Of the teaching received, students invariably found
clinical teaching the most useful. They described how
linking the learning to individual patients helped
them to remember it and motivated them to study
further. However, they felt that they needed to be
shown these links and did not believe they would pick
them up by clerking patients on their own or
observing practice:

Theres no point going on a ward round if, you
know, you can do what you like – you can do your

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664 original paper
own research, you can read up the notes and the
results, but because you haven’t got that clinical
knowledge, and that’s what it’s for after all, you do
need to be told … something about what’s going
on from the informed person’s point of view. and
that doesn’t happen on ward rounds that I’ve
noticed … You feel aggrieved. You turn up at 7Æ30
in the morning to go to these things, to get a good
mark, and get completely ignored.’ [Year 3 stu-
dent]
Firms varied widely in the extent to which students
felt involved in them.
Good firms were characterised
as having staff who were friendly and available,
helped students to access resources in the hospital,
(for example, by introducing them to patients), and
made their expectations clear. Students were partic-
ularly motivated when they were made to feel part of
the clinical team.

Poor firms were those where staff were unfriendly or
hard to access, gave little guidance, and students
learnt what was expected by getting things wrong and
being told off. Students disliked it when they were
expected to be ever-present on the wards as this
invariably meant a lot of
hanging around. Many saw
this as unproductive, and were unwilling to wait for
teaching opportunities which could, but might not,
happen. Students sometimes got mixed messages
about doctors’ expectations, for example, being
invited to attend at weekends, and then being told,

Wow, youre keen – being here on a Saturday!’ A
minority of firms provided a thorough induction to
the firm, such as introductions to key staff and good
written information. Students wanted clear guidance
on what was expected, particularly for the examina-
tions. However, they found that the depth of know-
ledge required was rarely made explicit by doctors,
and they had to rely on picking up clues about the
relative importance of topics during firms.
Students frequently mentioned that they felt
in the
way of the doctors and nurses and sometimes the
patients too. Part of this related to how they were
treated by staff, who could be unfriendly, occasionally
hostile, or who ignored them. Aspects of the tea-
cher)student relationship reported as stressful
included: being asked questions continuously until
they got an answer wrong, being expected to have
medical knowledge which they had not been taught,
and incidents when they were shouted at or felt
humiliated. These findings are reported in more
detail elsewhere.14 Certain specialties, such as general
practice, were commonly considered to provide a
more supportive climate than others. Students also
 Blackwell Publishing Ltd MEDICAL EDUCATION 2004; 38: 659–669
found the district general hospitals they attended for
short attachments to be more student-friendly than
the main teaching hospital.
Another important factor in students’ feeling of
being in the way was their lack of a real clinical role.
Although present during much clinical activity, stu-
dents were rarely able to contribute in any meaning-
ful way. As one student put it:
The cleaner has more
reason to be here than I do. In evaluations, occasions
when they felt they had been able to gain hands-on
experience and do something useful were singled out
by students as positive experiences.
Students felt that experiences on their first hospital
firm had an important impact on their overall
attitude and motivation towards studying medicine.
They often struggled to fit into the firm initially (e.g.
knowing when to attend and how to contact staff),
but had usually learnt
the system, gained in confid-
ence and were enjoying the course more by Year 4.
Respect for students
This category was formed from a group of codes that
seemed to relate to the teacher)learner relationship,
and in particular to the respect, or otherwise,
accorded to students.
Students were very aware of their position in the
hierarchy – at the bottom, or, as one student
described it, as
the lowest of the low. Students
perceived their relative unimportance in the hospital
through various signals, such as doctors not learning
their names and stating that they were not paid to
teach. Doctors’ lateness for or cancellation of teach-
ing was a particular irritation, frequently mentioned
in committee meetings and course evaluations. For
example, in the 1995–96 Year 3 curriculum evalua-
tion meeting, the students’ report mentioned can-
cellations as a problem in 8 of 15 firms, and
commented positively on teachers’ attendance in 1 of
15. Although students recognised that clinical emer-
gencies took precedence, they were frustrated at the
level of cancellations and lateness, particularly when
they were not informed and wasted time waiting for
the teacher. One interviewee commented that stu-
dents had become so used to late or cancelled
sessions that they regarded them as the norm.
Mature students were generally more outspoken and
critical about aspects of the system than were younger
students. In particular, they found the hierarchy
more difficult to handle. Some had had successful

careers in other fields and were used to being treated
as colleagues on a more equal basis. Mature students
also commented more on political and ethical issues.
They were less likely than younger students to excuse
poor clinical or teaching practice, or to locate the
problem in themselves. They made more conscious
decisions about how to deal with issues (e.g. whether
to challenge doctors), and in this they found each
other an important source of support and advice.
Respect for individuality
A particular aspect of the
Respect data related to
students’ perception that their individuality was not
valued. Some students suggested that there was a
certain mould they were expected to fit into, and a
certain image they were expected to project. This
related, for example, to appearance and confidence.
Students felt pressure to present patients and answer
questions confidently, even if they were not confident
about the subject. Some objected to this on principle,
feeling that they should not be encouraged to sound
confident when they were unsure of their facts, whilst
others worried that they could never sound confident
enough even when they knew the facts. Students also
perceived that they had to conform to the clinical
style of the doctor whose firm they were on (rather
than developing their own).
Another area relating to individuality was assessment.
Students often complained at committee meetings
that the firm grades were not discriminating. For
example, some firms regularly gave the same grade to
all students regardless of individual levels of attend-
ance and performance, and occasionally the same
comment too.
The mature students interviewed felt that their
individuality was not recognised in that their existing
skills and experience were neither acknowledged by
doctors nor used in teaching. Other groups of
students felt that they were at a disadvantage in the
medical profession. These included
quiet students,
who felt that their personalities were not valued, and
that this could hinder their careers. They thought
they would be disadvantaged in firm assessments if
they did not push themselves forward, and this
resulted in some competition amongst students to
speak first, for example, in ward rounds.
Various groups of students who did not fit into the
traditional, white, male stereotype also perceived that
they were disadvantaged. A questionnaire on dis-
crimination devised by and distributed to Year 4
 Blackwell Publishing Ltd MEDICAL EDUCATION 2004; 38: 659–669
665
students in 1996 was presented at a curriculum
committee meeting.15 It was completed by 48 of the
116 students, of whom 24 (50%) stated that they had
been unfairly treated in the medical school. Grounds
given were: gender (19 students); race ⁄ ethnicity (8);
religion ⁄ culture (5); parents’ status, appearance and
political views (4 students each; the latter 2 categories
were not given on the form but nominated under

other); socio-economic background (3), and sexu-
ality (2). Several students commented that they had
experienced discrimination from other students as
well as, or rather than, from staff.
These issues were further explored in a focus group
specially convened to elaborate on some of the areas.
Ethnicity
Non-white students who commented on ethnicity felt
that they were sometimes treated differently from
white students, not usually through any overt dis-
crimination but in more subtle ways. They tended to
see this as a reflection of society rather than anything
particular to medicine.
Subtle ways in which students felt that their
differ-
ence was highlighted included their ethnic back-
ground being a frequent point for comment. This
started at interview stage – foreign students expected
to be asked about their backgrounds, but second or
third generation Asian students who had lived in
Britain all their lives saw this as unacceptable. One
student described how in each of his 5 or 6 interviews
for medical school, his ethnic background was
referred to in some way. He said that he became
conscious of it, and it left him with
a funny sense.
Once at medical school, non-white students were
frequently asked where they came from by teachers.
One student gave an example that had obviously
affected him:

An experience that stuck in my mind was, um, at
the end of the year, I had a distinction viva for
[named subject] ... and the first question I got
asked was ‘‘Where are you from?’’ – and that
completely knocked me off, and I was like ‘‘Well,
Im from London,’’ and ‘‘Well, where are your
parents from?’’ […] tried to justify it in my head,
and I was thinking […] ‘‘Should I say something
here?’’ um, and then I thought perhaps it’s
because they can’t give […] the prize to, you know,
if you have to be a British dependency […] for the
rest of the viva I didn’t really care, you know.
666 original paper
I didn’t get the prize and I don’t care. I got a
distinction […] For that to be the first question I
was asked was totally, totally inappropriate […] I
don’t remember any of the other questions. That’s
the one thing that sticks in my head.’
Other students described similar puzzlement over
why this question was asked, particularly in view of the
large percentage of non-white British students on the
course. Generally, they felt that doctors should stifle
their curiosity in most situations, and especially in
large groups. It was considered acceptable to ask,
however, if a doctor had built up an individual
relationship with a student, or if s ⁄ he came from the
same minority group.
Having their names mispronounced was another
irritation for non-white students, making them feel as
though they were in some way outsiders.
Students also felt that the sheer numbers of non-
white students (about 50%) was an advantage that
lessened any possible impact and gave them a feeling
of solidarity.
Gender
Female students sometimes felt that they were not
taken as seriously as male students, for example, that
they were not seen as potential colleagues in the way
that male students were. For the males, this some-
times meant that they were given a harder time by
consultants, for example, being questioned and
assessed more rigorously. Conversely, some female
students felt they were treated more harshly by
female consultants. Some perceived that they were
still thought of as nurses by male consultants, as well
as, often, by patients.
Female students in the focus group felt particularly
out of place on surgical firms. They felt that they were
tolerated: surgeons were pleasant to them, but they
perceived their behaviour as paternalistic. The stu-
dents described various tactics they used in an
attempt to be taken more seriously, such as wearing
high-heeled shoes so that they would appear taller,
dressing more smartly and wearing make-up.
Examples of perceived discriminatory behaviour
reported in the student questionnaire on discrim-
ination included expectations that women would
become general practitioners,
leery remarks,
being patted on the shoulder and being called a

good girl.
 Blackwell Publishing Ltd MEDICAL EDUCATION 2004; 38: 659–669
Gender, ethnicity and career aspirations
Students did not claim to have experienced direct
discrimination; nevertheless their decisions about the
future were affected by their perceptions of being at a
disadvantage. The highest status specialties, partic-
ularly medicine and surgery, were perceived as the
most difficult to get into generally, and particularly if
one was not a
traditional student. There were also
perceived differences between subspecialties. For
example, within surgery, orthopaedic surgery was
thought to be the hardest to get into, whilst in
medicine, paediatrics was considered comparatively
easy. Students observed that although there were
many ethnic minority junior doctors in the hospital,
there were very few consultants. Some also noted how
doctors from ethnic minorities appeared to be
concentrated in certain specialties, with, for example,
many black doctors in obstetrics and gynaecology.
Women and students from ethnic minorities felt they
would have to do better than other students to
progress in their careers. They expected a long fight
if they tried to get into high status specialties, and
some did not want to fight. Others felt strongly about
going into a particular specialty and were determined
to try no matter what, as the following student
describes:

At the moment Im thinking of doing surgery, and
it’s a very ‘‘Old Boys’ Club’’ sort of thing and that
does make me, I mean I automatically feel already
that my chances of getting the same position are
slightly less. That doesn’t stop me wanting to do it
because I want to do it and I will do it.’
[
Mohammed, Year 3]
Some students wanted to go into a competitive
specialty just to prove that they could do it, but did
not want to sacrifice other areas of life, such as having
a family, in order to achieve it. Generally, students
tended to temper their ambition with a sense of
realism about where they would
fit in and be able to

get on. Some (both male and female) wanted a
career path that was flexible enough to allow for
other interests and having children.
DISCUSSION
This study has reported perceptions of the clinical
learning environment from a diverse range of
students. The data suggest that the early part of the
hospital-based course represented a difficult period
for many students as they had to adjust to an

unfamiliar environment, often with minimal support
or guidance. Their perceptions in this transitional
period therefore may not be representative of their
feelings at later stages of the course. The researcher’s
status as a member of staff may also have affected
what students chose to talk about. For example, they
may have focused on negative aspects that they
thought they could influence or change, in a way that
did not accurately represent their overall experience.
The use of data collected for different purposes and
from different sources is helpful in this respect as
triangulation strengthens the reliability of the find-
ings. However, combining such data can be prob-
lematic because of their different qualities and
limitations, thus attention must constantly be paid to
the contexts in which the data were produced.
One of the hardest aspects of clinical training for
students seemed to be adjusting to their unimpor-
tance in the system. In contrast to school and the
university-based early years of training, in which they
were the focus of teachers’ efforts, in hospital the
service element predominated and teaching was at
best a secondary activity. They also had difficulty
adjusting to a different style of learning and teaching
that was more diffuse, unbounded and opportunistic
than in the earlier years, when there were clearly
defined objectives and learning material. Students
expected the direct teaching that they were accus-
tomed to, whilst teacher-derived data from the same
study suggested that doctors espoused the appren-
ticeship model of learning from engagement in, and
observation of, clinical work. In practice, and for a
variety of reasons, the historic apprenticeship role
has declined to the extent that students were rarely
able to contribute to clinical care and felt themselves
to be constantly
in the way. Students’ relationships
with nurses could also be difficult, reflecting some of
the tensions between the two professions, and the
lack of a formal role for nurses in medical education.
These issues affected student commitment and
motivation to learn.
These findings suggest that greater efforts need to be
made to induct students into the clinical environ-
ment, by, for example, providing guidance about
ward routines, more liaison between medical and
nursing staff, and assistance in adjusting to the
different style of learning required. Two current
trends should facilitate these changes: greater integ-
ration between clinical and basic science aspects of
the course should make the transition less marked,
and an increase in interprofessional learning, which,
it is hoped will facilitate better teamwork, although
the evidence for this is uncertain.16 Finding a
 Blackwell Publishing Ltd MEDICAL EDUCATION 2004; 38: 659–669
667
genuine role in which students can contribute to
patient care whilst learning would also help them to
feel that they have a legitimate place in the health
care team.
From early in the clinical course, students started to
feel pressure to conform to medical norms of
appearance and behaviour. They were anxious to
impress their teachers, and very aware of the long-
term influence that teachers might have on their
careers in a system that is still, to a large extent, based
on patronage.17 This implicit threat may have been
partly responsible for a perception by some students
of an intimidatory atmosphere. The motivation to
impress teachers has been described in other stud-
ies9,18 and may be particularly strong in medicine, as
in other professions teachers are not usually pros-
pective colleagues and employers. Whilst a degree of
socialisation would be expected in any workplace, an
over-emphasis on conformity may be ultimately
damaging for the medical profession if it stifles
debate, creativity and the challenging of everyday
practice, or prevents certain groups or individuals
from fulfilling their career potential.
The data showed that students perceived differences
in doctors’ attitudes towards them related to gender,
ethnicity and personality factors, and both female
and ethnic minority students perceived their career
choices to be constrained from early in the course.
Interestingly, their perceptions of specialties it would
be hard to get into did not match the actual numbers
of female or ethnic minority doctors in these speci-
alties in the main teaching hospital.19 However, their
fears are supported by evidence of direct or indirect
discrimination at various stages of medical training
and careers.20–23
Because only a small number of students contributed
directly to this part of the study, the results cannot be
assumed to be representative of the total student
body. However, they are included because the issues
raised are important and could form an agenda for
further research. The literature would be enriched by
more ethnographic or autobiographical studies of
women and ethnic minority students in medical
school.
The above findings, together with the more general
perception by students of a lack of interest in their
previous experiences, sometimes insensitive teaching
methods and non-specific assessment grades, suggest
that students’ individuality was not valued by teach-
ers. This is of concern, given the current efforts to
broaden the intake to higher education24 and
668 original paper
because it does not model the person-centred
approach which students are expected to demon-
strate with patients. It would be interesting to
investigate links between student-centredness and
patient-centredness in teachers and students.
Changing the culture of medical teaching to address
the above issues, and produce a more inclusive
atmosphere, may be difficult. The UK Race Relations
(Amendment) Act 2000 requires public bodies to
promote equality of opportunity.25 This may lead to
new structures to facilitate the advancement of
groups that are currently under-represented at the
higher levels of medicine, thus providing a wider
range of role models for students. Other approaches
might include: changing the structures which per-
petuate student)employer links (such as the school-
based house officer matching schemes); changing
teaching methods (problem-based learning, for
example, has been shown to promote a more
humane and co-operative climate),26 and staff devel-
opment to help teachers understand the importance
of a student-centred approach and to actively recog-
nise and use student diversity as a learning tool.
Improving the teaching environment is also import-
ant. As Genn observes,
The working or organisa-
tional environment of medical teachers is
inextricably bound up with the educational environ-
ment of students, and is a strong determinant of that
educational environment.27 It is perhaps unsurpris-
ing, therefore, that teacher-derived data from the
same study suggested that teachers worked under
considerable pressures and constraints, and did not
consider their teaching to be valued by the school.28
It is plausible that if staff accountability and reward
systems were redesigned to promote teaching, there
could be a positive impact on students’ perceptions
of the learning environment.
Research in other settings would be required to
determine whether the students’ perceptions repor-
ted here reflect a general culture in teaching hospi-
tals, or are specific to the school studied. It is hoped,
however, that the findings demonstrate the import-
ance of attending to students’ perceptions of the
educational environment in order to facilitate their
learning.
ACKNOWLEDGEMENTS
I am grateful to the students who agreed to be
interviewed; to Dr Alan Cribb who supervised the
research; to Steve Woodfield and Rachael Heath for
secretarial assistance, and to Heidi Lempp, Dr John
 Blackwell Publishing Ltd MEDICAL EDUCATION 2004; 38: 659–669
Rees and the journal referees for their comments on
earlier drafts of the paper.
FUNDING
None.
ETHICAL APPROVAL
A formal mechanism for approval of eductional
research did not exist, but the study was approved by
the Curriculum Sub-Dean. The ethical complexities
of
insider research are thoroughly discussed in the
thesis.
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Received 1 July 2002; editorial comments to authors 27
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