the cross-cutting edge
Making sense of differences between medical schools
through Bourdieus concept of field
Caragh Brosnan
OBJECTIVES Most basic medical education
studies focus on one medical school, and the
social and educational significance of differ-
ences between schools remains poorly under-
stood. Sociologists have called for more
comparative studies and for research on the
institutional context of medical education. This
paper introduces Bourdieus concept of field
as a tool for conducting such analyses.
CONTEXT A field is any arena in which there
is a struggle over resources (capital), akin to a
game between players who occupy different
positions depending on the resources they
have. Prior studies show that higher educa-
tion institutions compete in a field for various
forms of capital which are reflected in their
curricula and the students they attract.
METHODS This paper argues that medical
education can be conceptualised as a field
within which medical schools compete for
different forms of capital, such as students,
funding and prestige. The structure of the UK
Medical Education 2010: 44: 645652
doi:10.1111/j.1365-2923.2010.03680.x
Centre for Biomedicine and Society, Kings College London,
London, UK
Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 645652
medical education field is analysed as a specific
example of how Bourdieus framework can be
applied. It is argued that UK medical schools
varying curricula and admissions criteria serve
to distinguish them from their competitors and
to facilitate access to different forms of capital.
Competition within the field helps to maintain
inter-school differences, with implications for
both curriculum reform and students beliefs
and aspirations.
CONCLUSIONS Medical schools have varying
curricula, reputations, and types and levels of
resources. They compete with one another on
all these fronts and attract different types of
students and staff. Research and practice in
basic medical education must take account of
the position of any given medical school in
relation to its competitors and to external
agencies in order to critically consider the ethos
of its curriculum and the perspectives of its
students and staff. Bourdieus concept of field
offers one useful way of accomplishing this.
Correspondence: Caragh Brosnan, Centre for Biomedicine and
Society, Kings College London, Strand Building (6th Floor),
Strand, London WC2R 2LS, UK. Tel: 00 44 1223 514 159;
Fax: 00 44 207 848 1800; E-mail: caragh.brosnan@kcl.ac.uk
645
C Brosnan
INTRODUCTION
Recent years have seen medical education research
employ an increasingly sophisticated repertoire of
theories and methods. However, a striking tendency
remains: the vast majority of studies of basic medical
education are conducted within a single medical
school. This narrow research design has a number of
implications: it is unclear whether findings are
generalisable outside the school under study; bias
may be introduced by researchers only studying their
own institution, and, as this paper argues, too little
attention may be paid to the social and educational
significance of differences between medical schools
a topic worthy of study in its own right. The little
existing comparative research suggests that medical
schools do vary on important dimensions, such as
students examination scores both before1 and after
graduation,2 and graduates views on their prepared-
ness for the workplace,3 but little is known about why
medical schools differ and what these differences
really mean.
There are several possible reasons why studies typi-
cally focus on just one school, including convenience
(most researchers study the school in which they
work), etiquette (researchers may fear offending
colleagues by critically examining other schools
practices) and competition (researchers may be eager
to showcase innovations within their own schools).
Another reason may involve the theoretical training
of many medical education researchers, whose back-
grounds are often in clinical disciplines, education or
psychology, and who are perhaps more oriented
towards the study of individual behaviour (e.g.
medical student learning) than the study of organi-
sations such as the medical school itself.
Sociologys hallmark is its attempt to explain indi-
vidual behaviours and attitudes in relation to social
structures, such as economic and political systems.4
Sociological research on medical education has a long
history, in which there has been some recognition of
the significance of the medical school as an organisa-
tion with its own social characteristics, mediating the
education of students.57 Samuel Bloom, for example,
has argued that modern American medical schools
have become unwieldy bureaucracies more oriented
towards biomedical research than to teaching, and that
this overarching mission, combined with competition
between the goals of the basic science and clinical
faculty members, prevents effective curriculum
reform.6 There have been repeated calls within
sociology for more research to pay attention to the
646 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 645652
institutional context of medical education and for
comparative studies of medical schools.5,810 This
sort of organisational analysis could further our
understanding of problems such as the impediments
to curriculum reform, the ethical socialisation of
students and the effect of funding cuts, to name just a
few. However, sociological studies have only rarely
subjected the medical school as a whole to analysis and
the differences between schools are largely unexamined.
This paper aims to demonstrate the importance of
rendering the medical school an object of study and of
examining the differences between schools. It intro-
duces Pierre Bourdieus concept of field as a useful
tool for doing so. Bourdieu (19302002) was an
influential French sociologist whose work showed how
power differences are reproduced through cultural
practices, including through higher education.11 Prior
studies of medical education have drawn on Bourdieus
work, particularly his concept of habitus, but his
theory of field has not been used before to analyse
the meaning of differences between medical schools.
This paper first outlines Bourdieus theoretical
framework and its prior use in medical education
research. The usefulness of the field concept in
understanding the medical school as a social organi-
sation embedded in a network of relations is then
illustrated through an analysis of differences between
UK medical schools. Although the empirical exam-
ples presented are drawn from the UK, Bourdieus
theory of field has been applied to a wide range of
empirical areas and the aim here is to demonstrate its
value as an analytic tool for elucidating relations
between medical schools; this purpose may also be
useful in other medical education contexts.
BOURDIEUS THEORETICAL FRAMEWORK
Bourdieus theoretical framework was developed
through the extensive empirical research he carried
out in arenas as diverse as law, housing, science,
television, art and academia. His recurrent finding
was that each field is characterised by an internal
struggle for resources or capital.12 Capital takes
many forms, including economic (associated with
money), cultural (associated with having the right
knowledge or tastes), social (being associated with the
right people) and symbolic (associated with prestige
and reputation).13 Having a lot of one type of capital
often facilitates access to another. Precisely what
counts as capital differs between fields and the
definition of legitimate capital is also a point of

contention within the field. Bourdieu often likens
this struggle to a game in which players occupy
relatively dominant or subordinate positions accord-
ing to how much legitimate capital they can access.12
Any arena in which there is a struggle for capital
between players in different positions constitutes a
field in Bourdieus terms.
The players positioned within the field are individ-
uals or institutions, and how much capital they can
access is determined by their respective habitus. The
concept of habitus can be thought of as fitting
somewhere between social class position, identity and
schema. According to Bourdieu,14 a persons habitus
is structured by his or her past experiences (such as
family upbringing and education), and in turn
structures his or her tastes, perceptions and aspira-
tions, thereby linking past, present and future.
Different habitus confer and facilitate access to
different amounts of capital, so that the unequal
positioning of players in a field is typically
reproduced over time.12 Within medical education
research, habitus has been used as a model to explore
the socialisation of students and junior doctors into
the role of doctor with its attendant forms of social
and cultural capital together comprising a medical
habitus.1517 The concept has also been used to
examine influences on the aspiration to study
medicine among under-represented groups, such as
students from low socio-economic backgrounds.18,19
These studies show that the dominant forms of
capital valued within the medical profession are not
equally accessible to all students.
A key tenet of Bourdieus theory is that habitus and
field are inextricably inter-related: it is the struggle
within the field that determines which players
habitus can access the most capital, while the
relations between players are what shape the
field.12,20 Players follow strategies to try to distinguish
themselves within the field by accumulating higher
levels or different types of capital from their com-
petitors. Studying the relations between players in a
field is therefore crucial.10,12 Albert et al.21 show that
medical education research can itself be seen as a
field, where the central struggle is over which sorts of
research are most useful. Players in this field are
positioned along a spectrum: at one pole are those
who advocate theory development and the autonomy
of medical education as an academic discipline; at
the other are those who favour applied research and
the involvement of non-academic practitioners.
This sort of bipolar structure is common to many
fields.21 In Bourdieus study of the French higher
Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 645652
Making sense of differences between schools
education field, he found that different universities
attracted different types of students who went into
different professional areas:
On the one side, we find establishments that, in their
selection criteria, their faculty, and their curricula, as
well as in the career prospects they open up, have
close ties to industrial and commercial firms. [] On
the other side, we find establishments that stress
strictly academic demands and are relatively
independent of the demands of the economic
system.20
Jewel22 recently analysed the field of American law
schools and found that students from lower socio-
economic groups rarely enter the elite law schools and
consequently seldom obtain the best-paid jobs in large
law firms. She notes that the prestigious schools
curricula tend to emphasise abstract knowledge rather
than practical skills. Because the structure of the field
is reproduced over time, abstract knowledge in itself
has come to connote prestige in American legal
education.22 The differences between universities
illustrated by these prior studies suggest that research
conducted within a single medical school, without
accounting for the position of that school in relation
to its competitors in the field, the sort of students it
attracts and the sort of knowledge it values, can only
tell us a limited amount about how medical education
works. In the next section, I will show how medical
schools might be conceptualised as being positioned
in a field and how, in the UK context, this can help
us understand why schools have reacted in different
ways to external curriculum reforms.
APPLYING BOURDIEUS CONCEPT OF FIELD TO
MEDICAL EDUCATION: UNDERSTANDING
DIFFERENCES BETWEEN UK MEDICAL SCHOOLS
The 30 medical schools in the UK range from
schools which are part of ancient universities to those
which have been established in the 21st century to
meet the need for increased numbers of medical
practitioners. They also vary in their curricula: some
are integrated, emphasising early clinical exposure,
with many now using problem-based learning (PBL),
and others place an emphasis on basic science and
retain a more distinct pre-clinical clinical divide.
These differences are reflected in the admissions tests
different schools use for standard undergraduate
courses: four medical schools require applicants to
take the Biomedical Admissions Test (BMAT), which
tests knowledge of maths and science alongside
skills,23 whereas the majority use the UK Clinical
647
C Brosnan
Aptitude Test (UKCAT), which tests reasoning rather
than knowledge, checks for attributes such as empa-
thy and does not include any science content.24
The General Medical Council (GMC) has a statutory
responsibility for regulating UK medical education.
Having historically deferred to the more powerful
medical schools,25 the GMC has, since the publica-
tion of its curricular guidelines Tomorrows Doctors in
1993,26,27 played an increasingly active role in mon-
itoring medical school curricula.28 Now in its third
edition,29 Tomorrows Doctors advocates the integration
of basic science and clinical practice in medical
curricula, early patient contact and an emphasis on
student-directed learning. However, although all
medical schools have changed their courses to
some degree since 1993, some have aligned their
curricula much more closely to Tomorrows Doctors
than others. This is shown in the GMCs reports on its
inspections of medical schools published on its
website30 in which some schools are admonished for
the lack of integration of basic science and clinical
work in their curricula. These different reactions to
Tomorrows Doctors suggest that UK medical schools
are involved in a struggle of some sort, as per the
players in a field. To comprehend this struggle, we
must ask how the players are positioned in relation to
one another within this field and what forms of
capital they are struggling over.
The analysis which follows is supported by interview
excerpts drawn from a larger study which examined
faculty members (n = 15) and students (n = 37)
perceptions of the curriculum at two UK medical
schools. University Medical School (UMS) was
founded within a long-established university and
emphasised basic science in its curriculum. Hospital
Medical School (HMS) was a former hospital
medical college which had merged with a multi-
faculty institution and employed an integrated
curriculum and PBL. Interviewees were selected
through theoretical sampling,31 gave informed
consent and were assured of anonymity. Interviews
were recorded, transcribed and analysed thematically.
Ethical approval was granted by the University of
Cambridge Psychology Research Ethics Committee.
Medical schools competition for capital
One way of gauging the relative positioning of
medical schools and how much capital they possess is
via the league tables published each year in national
newspapers. The best known of these in the UK is the
Good University Guide produced by The Times,32
which compiles an overall ranking of medical schools
648 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 645652
according to their research quality (currently based
on the UK Research Assessment Exercise results),
entry standards (based on the average school-
leaving grades of entrants), student satisfaction
(according to the National Student Survey) and
graduate prospects (based on employment destina-
tions of two year groups of previous graduates).33 All
medical schools score virtually the same on the
graduate prospects dimension, so success in this
league is achieved by high research output, by
attracting and selecting the students with the highest
grades and by maintaining student satisfaction with
the course. This in turn can be seen to equate to
possessing high levels of particular forms of capital:
academic capital (i.e. quality research and high-
achieving students), economic capital, because gov-
ernment funding is awarded on the basis of success in
the Research Assessment Exercise, and symbolic
capital, because a high ranking in itself confers
prestige upon the school. The league table is there-
fore a proxy for assessing which schools possess high
levels of these specific forms of capital. So which types
of medical school have accumulated enough legiti-
mate capital to succeed in this competition?
Table 1 lists the medical schools in the top five
positions of the current ranking of 30 schools,
alongside the admissions test each uses for its
standard medical course. The four schools with the
most science-oriented curricula, which use the BMAT
rather than the UKCAT, dominate the table a
pattern also found in previous years rankings. In the
field of UK medical education then, the schools that
Table 1 Medical schools in the top five positions in the 2010
Good University Guide produced by The Times32
Admissions test
required for basic
Ranking undergraduate course
1 Oxford BMAT
2 Cambridge BMAT
3 Edinburgh UKCAT
4 Aberdeen UKCAT
=5 University College BMAT
London
=5 Imperial College BMAT
London
BMAT = Biomedical Admissions Test; UKCAT = UK Clinical
Aptitude Test

have accumulated the most academic, economic and
symbolic capital are those which emphasise science in
their curricula.
There is an obvious impetus towards reproduction in
the table: for instance, those institutions with the
highest rankings are able to attract the students with
the highest grades, helping to secure a high rank-
ing the following year and to garner further applica-
tions, funding and prestige. It is therefore dubious
whether the ranking is actually a measure of the
quality of the medical course, but it is treated as
though it is by applicants and institutions alike:
medical schools are typically concerned about their
ranking and promotion is celebrated. Because of this
association with quality, the ranking has also come to
represent a measure of cultural capital, of being seen
to produce the right sort of knowledge or, accord-
ing to The Times, to be a good school. Although a
schools curriculum does not determine its ranking in
the league, a high ranking confers legitimacy on a
curriculum. In the same way that elite American law
schools help to perpetuate the pre-eminence of
abstract knowledge through their curricula,22 the
positioning of science-oriented medical schools at the
top of the UK league table helps to maintain the
legitimacy of the traditional, science-oriented medical
curriculum and, by extension, to equate scientific
knowledge with cultural capital.
This was made clear in interviews with faculty mem-
bers at UMS, who viewed the scientific emphasis in
their curriculum as a resource, a form of capital which
distinguished them from other schools in the field:
Well, the main strength [of the UMS curriculum] is
it gives the students who go through it a rigorous
scientific background in biomedical science, and
thats still one of the main objectives of the course.
The philosophy is different to other medical schools
where they run whats called integrated courses. Just as Bourdieu20 found that some French universi-
(UMS faculty member 1)
Furthermore, UMS faculty members hoped that their
distinct curriculum would produce a distinct type of
doctor:
I would like to think that we are trying to produce
those that are going to go into the more academic
aspects of medicine, the ones who are going to be the
academic and clinical scientists. (UMS faculty mem-
ber 2)
This is an example of how the tastes, perceptions and
aspirations of individuals their habitus help to
Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 645652
Making sense of differences between schools
reproduce the structure of the field over time.
Producing a large proportion of clinician-scientists
will enable a medical school to cement its reputation
as a science-oriented institution and to continue to
reap the cultural and other forms of capital associ-
ated with this stance.
If basic science counts as a form of cultural capital
within the UK medical education field, then why have
so many UK schools adopted integrated curricula with
an emphasis on clinical practice? It appears that more
than one set of values shapes the UK medical
education field and medical schools are able to obtain
valued forms of capital in different ways. Indeed,
schools which align their curricula more closely with
Tomorrows Doctors are regarded with approval by the
GMC,34 and GMC approbation is also a form of
cultural capital, an affirmation of having the right
knowledge. The more clinically oriented medical
schools are also likely to have a higher ratio of
clinical to basic science staff than the science-oriented
schools and therefore possibly to have a different
institutional ethos or habitus, one more oriented
towards the health care field than the academic field.
The faculty members interviewed at HMS emphasised
quite different values to those at UMS in that they saw
their curriculum as designed to produce patient-
centred clinicians, rather than academics:
I think were producing extremely friendly, patient-
oriented doctors. I think their communication skills
are very good. I think they are able to work in
teams very well because of the problem-based
learning and Im hopeful that they have reasonable
self-study skills. (HMS faculty member 1)
The HMS stance can be seen to fit more closely with
the GMCs vision of what medical schools should be
emphasising.26,27,29
ties were focused on purely academic success and
others were more connected to the commercial
sector, this analysis suggests that the structure of the
UK medical school field is bipolar in nature in that
some schools strive for academic recognition and
others are more focused on producing graduates for
the health service and fulfilling the GMCs agenda.
Analysing medical education as a field then, in
which players are positioned differently and are
struggling for capital, can help to explain why
different schools have followed different curricular
strategies. Such differences between schools have
further implications for medical education which
Bourdieus concept of field can help to illuminate.
649
C Brosnan
Implications of medical schools competition for
capital
The inter-relation of medical schools in a field, within
which each school aims to distinguish itself through
the accumulation of capital, potentially has a number
of practical consequences for medical education.
Because the structure of fields is continually repro-
duced, a given fields central values are difficult to
change.12 This helps to explain why mass medical
curriculum reform is hard to achieve because schools
which have successfully accumulated capital within
the existing field structure will resist reforms that
threaten to change the values of the field. A given
schools receptiveness to external reform will depend
on whether the reforms recognise the schools
existing forms of capital as legitimate. In the case of
the UK medical education field, for example, not
all schools have fully implemented the GMCs
curricular changes. This statement from a faculty
member at UMS suggests that some institutions see
the reduction in scientific content advocated by the
GMC as threatening to redefine the values of the field
in favour of the new medical schools:
The General Medical Council in their curriculum
reforms came down very hard on [UMS] I think
that in many aspects they were wrong, and thats
actually the attitude interestingly not just in our
medical school, but actually quite a few of the
medical schools the old medical schools think that
the GMC went too far in basically dumbing down.
And we see that now in the extreme in some of the
new medical schools... which apparently have barely
any intellectual content at all. Theyre effectively
vocational degree courses, and thats of great concern
across theyve tailored their courses to what the
GMC want, the end result being, and a lot of us agree,
[were] concerned about the depth of biomedical
knowledge that lies underneath the course. (UMS
faculty member 3)
At HMS, which can be seen to be positioned at the
opposite pole of the medical education field to UMS,
faculty members were more accepting of external
reforms, again indicating that rather than competing
for academic prestige, they saw HMS as fulfilling the
needs of the health service:
I think the need to respond to change is imposed by
external changes such as the [GMC and the
Postgraduate Medical Education and Training
Boards] production of the Foundation Years curric-
ulum, which mean that our output needs to change
to match their input. And the fact that theyve got a
650 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 645652
curriculum thats very much competency-based and
has specific measurable outcomes, and particular
assessment methodologies, means that we have to
catch up with it and actually begin to help our
students to get experience of the kind of assessment
methodologies that will be used there. (HMS faculty
member 1)
As this example illustrates, understanding differences
between medical schools may help predict the effec-
tiveness of curricular or other policy innovations.
Inter-school differences and competition also have
implications for students: as Bourdieu demonstrates,
the experiences, attitudes and aspirations of stu-
dents within a given school are likely to be shaped by
their schools position in the field.20 At UMS and
HMS, students had contrasting perceptions of the
type of doctor their school was training them to
become. Students at UMS had the impression
confirmed in interviews with faculty members that
the school was aiming to produce academic doctors:
I think they want consultants and people that are
getting the more the high-powered ones that are
in control of their own departments and things.
People that they can get a lot of money off afterwards!
People that make lots of discoveries. I think that
definitely theyre pushing us to be the more research-
type people who get the top jobs, who get papers
published. (UMS Year 2 student)
This student, only in her second year, had already
gained the impression that UMS was hoping to reap
economic, symbolic and academic capital from its
graduates.
Fewer HMS students felt they were being pushed in a
particular direction, but those who did all said that
HMS was training them to become general practitio-
ners (GPs):
[T]hey are, I think, trying to raise GPs at the end
of the day. Thats what they see the need as, which is
fair enough medical schools do different things.
(HMS Year 4 student)
These comments suggest that students are aware of
the differences between medical schools and may
perceive that particular schools are aiming to pro-
duce particular types of doctors. Whether students
beliefs are well founded or not, it is important for
those involved in medical education to be aware of
how students expectations are shaped by schools
efforts to distinguish themselves within the field.

CONCLUSIONS
This paper has sought to show how Bourdieus
concept of field can be used to explore the meaning
of differences between medical schools. Bourdieus
theoretical model, along with the findings of empir-
ical studies by Bourdieu20 and others35,36, help us to
predict that, like other higher education institutions,
medical schools are likely to compete with one
another for various resources and, consequently, to
have contrasting institutional priorities and values.
Such differences will be sustained by the students each
school attracts and the way it shapes their career
aspirations. This pattern is illustrated by the UK
examples, which show that different schools have
different curricula and use different criteria to select
students, and that schools have accumulated different
amounts of academic, economic, cultural and sym-
bolic capital and vary accordingly in their receptivity
to external curricular reform. Understanding the
position of a medical school within the field is
therefore crucial to understanding the ethos of its
curriculum and the learning experiences of its
students. Precisely how medical schools are positioned
within a field and what forms of capital are most
valued within that field must always be empirically
verified: the resources for which UK medical schools
currently compete may have less value at another
time-point or in another geographic location.
As a model for conceptualising relations between
medical schools and the socialisation of students,
Bourdieus twin theories of field and habitus are
potentially useful in both medical education research
and practice. For those involved in teaching, an
awareness of how students perceptions are shaped by
the field and how faculty members help to reproduce
the fields structure (such as by asserting that some
forms of knowledge are more valuable than others)
could enable them to counteract attitudes that fuel
the competition between medical schools and med-
ical curricula a competition which impacts on
students aspirations. For policymakers and would-be
reformers, knowledge of how medical schools are
positioned within the field and what forms of capital
are currently most valued may help anticipate the
likely success of any interventions. Understanding the
factors that mitigate medical schools implementa-
tion of externally produced reforms will become
increasingly important if the trend towards the
standardisation of medical education continues.28,37
For researchers, Bourdieus concept of field can serve
to explore aspects of medical education which have
Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 645652
Making sense of differences between schools
been largely overlooked. Medical schools are not all
the same. They have varying histories, curricula,
reputations, and types and levels of resources. They
compete with one another on all these fronts, with
each school claiming the legitimacy of its own
forms of capital. Different schools attract different
types of staff and students, whose perceptions and
aspirations are shaped by the struggle for capital
between schools and who, in turn, become part of
that struggle. Ideally, studies of medical education
should include more than one school in order to take
account of these differences. However, any research
on how or what medical students learn, and what they
think about new learning activities, must take account
of the position of the medical school under study in
relation to its competitors and to external agencies,
and how this positioning is likely to shape students
and faculty members perspectives. Bourdieus con-
cept of field offers a useful way of accomplishing this.
Acknowledgements: the author is grateful to the two
medical schools examined in the study from which this
paper draws, and to the staff and students who agreed to be
interviewed. She would like to thank Bryan Turner and
Martin Richards for their guidance over the course of the
project.
Funding: funding for the research on which this paper is
based was provided by the Australian Federation of
University Women Queensland, the International
Federation of University Women, the Cambridge Political
Economy Society Trust, the British Sociological Association,
the Foundation for the Sociology of Health and Illness, the
Cambridge Board of Graduate Studies and Magdalene
College Cambridge. The writing of this paper was
supported by a Wellcome Trust Biomedical Ethics Strategic
Award (no. 086034).
Conflicts of interest: none.
Ethical approval: this study was approved by the University
of Cambridge Psychology Research Ethics Committee.
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Received 31 October 2009; editorial comments to author 6
November 2009; accepted for publication 28 January 2010