Habitus transformation of students from low socioeconomic backgrounds at medical school: the five core narratives

Abstract

Background

Widening Participation initiatives aim to attract students from non-traditional backgrounds to study medicine; students from diverse backgrounds will be better equipped to cater to the needs of a diverse population. But medical students are moulded by our expectations of how a doctor should think, feel, and act, and this may fundamentally alter their behaviours, attitudes, and tendencies (habitus).

Methods

Semi-structured interviews were conducted with 16 students and 5 family members who came from low socioeconomic backgrounds. Bourdieu’s habitus was used as a theoretical framework. Interviews were analysed using narrative analysis.

Results

Five core narratives were identified. ‘Outsiders’ have poor social integration prior to and at medical school. Those with ‘Enduring Identity’ narratives have strong social networks outside of medical school. ‘Pre-socialised’ students have experiences which prepare them for the middle-class culture of medical school, and ‘Encouraged Upward Mobility’ describes those who are strongly guided by their parents’ desire for middle-class status. Finally, those with ‘Personal Growth’ narrative describe a transformational experience, adopting new behaviours, values and tastes.

Conclusions

The extent of habitus transformation in students from low socioeconomic backgrounds varied. Financial constraints, not drinking alcohol, and being on the gateway course all discouraged habitus transformation. Further research could explore whether this affects their interactions and abilities to empathise with patients from similar backgrounds.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07580-2.

Background

In recent years, new medical schools have opened in the UK with the goal of improving healthcare provision in socially deprived areas. The primary aim is to attract students from low socioeconomic backgrounds [1]; the aphorism of ‘like-treats-like’ suggests that those who have come from the same background as the population that they serve are better equipped in meeting the health needs of that population [2].

The term socioeconomic status refers to the intrinsic link between income, assets and social standing. Whilst these measures facilitate the categorisation of individuals according to a mostly linear scale in terms of wealth and occupation, they do not tell the full story– social class forms part of one’s identity [3] and differences can be observed in the manner in which those from different social classes think, feel and behave [3–7]. Within this paper, the terms ‘working-class’ and ‘middle-class’ have been used as descriptors of the culture which tend to align with those from more advantaged backgrounds (middle-class) and those from low socioeconomic backgrounds (working-class).

Working-class students enter university with a sense of class pride [8–10] and desire for social change [9] but immersion in university, an environment dominated by the middle-class, can lead to personal transformation. The extent to which working-class students embrace their new student identity influences the magnitude of this change [11] with students who live at home, have families, or otherwise compartmentalise their university and outside life retaining more of their working-class roots [12]. There is also evidence to suggest that less elite, post-1992 higher education institutions exert less pressure upon working-class students to change, owing to their arguably more progressive cultures [8, 13]. Studies internationally have shown that typical self-reported changes from working-class students include the adoption of a different speech pattern or accent [9, 10, 14–16] change in physical appearance or attire [9, 14, 16, 17] and new tastes and interests [10, 15, 17].

Whilst medical school expansion is UK-specific, ensuring medical school is a viable option to all social classes is a wider reaching issue and so lessons learned in this space are applicable globally. The medical education pipeline exacerbates social inequalities even prior to admissions, where fundamental discrepancies in resources and opportunities for applicants to build a competitive application can be misperceived as lack of merit [18, 19]. For those who gain entry, underrepresented groups go on to face additional challenges throughout the duration of their studies in relation to their peers [20].

A restrictive discourse in medical education of who a doctor is allowed to be in terms of their values, and behaviours [21, 22] microaggressions directed toward the working-class [23, 24] and the predominant demographic of White doctors occupying senior posts in medicine [25] compound to undermine efforts to improve healthcare equality and build a more representative workforce.

Most educational research focuses on the positive development of attributes and values deemed desirable for a doctor, with less attention paid to the side effect of losing the pre-existing, discarded identities (such as being working-class) that one holds prior to attending medical school. In order to understand why these discarded identities may be important, we need to understand how they manifest in our behaviours and interactions with others– Bourdieu’s theory of habitus [26] provides a mechanism for this and is used as a theoretical framework to explore the experiences of medical students from low socioeconomic backgrounds.

Bourdieu defines habitus as “a subjective but not individual system of internalized structures, schemes of perception, conception, and action common to all members of the same group or class” [26]. In essence, habitus is a term used to describe the behavioural tendencies of a particular group, and acts as a schema from which the thoughts and actions of an individual are unconsciously derived. Habitus influences one’s mannerisms, behaviours, thoughts, perceptions, and tastes. Different social fields are distinct in their habitus, with tendencies to prefer certain foods, music, and clothing tied with different social classes.

Habitus is not innate and permanent but rather built through our social processes. It is susceptible to change over time and across social environments. Individuals within a new field may find their habitus transformed through external pressures. Students learn during medical school that their success is dependent on learning the importance of the hierarchy [27] and select role models in medicine who they perceive to be knowledgeable and powerful, and who are most frequently White and male [28]. Since students learn to tolerate this norm, in their simultaneous effort to both “survive” and “join the club” [29] medical school culture reflects that of senior doctors. This reinforces inequalities and influences the types of capital which are valued.

Bourdieu’s concepts of social, economic, and financial capital have been used previously to understand the difference in resources available to Widening Participation (WP) groups (referring to students with characteristics traditionally under-represented in higher education) as compared to the traditional medical student [24, 30–32]. We add to these studies by exploring the changes students experience in relation to their individual journeys through two different medical schools, with the added perspective of their family.

Our research question is: “How is habitus transformation experienced by medical students from low socioeconomic backgrounds?”. To facilitate the answering of this question, the following research aims were conceived:

• To identify the extent to which habitus transformation occurs during the medical course.

• To identify the factors affecting habitus transformation.

• To explore the impact of institutional culture on habitus transformation.

Methods

To answer the research question above, positivist research traditions are not suitable - there is no hypothesis to be tested, and the topic of interest cannot be quantified. Interpretivism refers to a research paradigm based on the fundamental belief that reality is subjective, with the nature of knowledge itself (epistemology) shared and co-constructed between the researcher and the participants [33]. Making use of qualitative research methods, which explore the how and why of human experience, permits in-depth exploration of issues of human experience where the variables are not always clear [34].

This study forms part of a larger case study, a methodology which is used to examine phenomena within bounded system(s), purposefully selected to provide perspectives on the topic of study [35]. One of the strengths of the case study approach is the use of data triangulation and converging lines of enquiry, increasing confidence in the findings and increasing construct validity [35]. The data and analysis presented here form a central strand of these lines of enquiry, employing narrative analysis to study texts within their storied form [36].

Participants were recruited from two medical schools in England, which are linked medical schools running the same degree programme (with the same curriculum and course structure). One school is part of a traditional ‘red-brick’ university (University A) whilst the other is a new medical school targeted at improving health provision in an underserved area (University B). According to their respective directors of admissions, the traditional university has approximately 30% of students from a WP background in a cohort of approximately 400, whereas the new medical school has 50%. The new medical school had only one year of 90 students at the time of recruitment for the study, so only first year students could be sampled.

Semi-structured interviews were conducted with a purposeful sample of students and, where possible, their nominated family members. All students in the first, third and fifth years of the two medical schools were invited to participate. Respondents completed a brief online survey in order to assess their eligibility. Informed consent was provided by all participants.

There is often a mismatch between a person’s socioeconomic status and their self-reported social class [7]. This had particular implications for the present study since those with higher occupational status might align towards middle-class tendencies despite identifying as working-class [7]. In the absence of a single objective identifier, the best individual descriptor of social class is occupation [37] a measure also recommended by the Social Mobility Commission [38]. Therefore, the Office for National Statistics Socio-economic Classification (NS-SEC) [39] groups 4–7 were used as a proxy for ‘working-class’. Parental occupation was used for students aged 21 and under at the point of starting their medical course. Students were selected for interview in order to maximise diversity in the sample according to ethnicity, sex, disability status, school type, and mature student status.

Upon recruitment, consent was requested for interviewing the parents or an immediate family member of the participating student, with the hope that an alternate perspective would provide source triangulation. Previous work has demonstrated that family dynamics may be strained by the upward trajectory of young family members [10, 14, 17, 23, 40] which may be perceived as ‘class betrayal’ [41]. Interviewing family members enabled exploration of the effect of habitus transformation on this process. To optimise the size and diversity of the sample, consent to interview a family member was not a pre-requisite for inclusion into the study; some participants may not wish for their family to be contacted, and others with fractured relationships with family, such as care leavers or refugees, would not be unconsciously excluded.

Interviews with family members were conducted separately to the student participants, and content of these interviews was not shared with the other person. Interviews were conducted with 16 students and 5 family members, primarily on Microsoft Teams (with one telephone interview) and audio recorded. The interview schedule has been provided as a supplementary document. Interviews were conducted and transcribed by the first and second author.

Individuals use stories to make sense of their experiences, and the way in which these experiences are retold can give important insights [42]. The focus of narrative analysis is to preserve the sequence of events and structural features, rather than a cross-sectional view. Narrative analysis can take many forms depending upon the aims of the research [36]. Our study focused on the content of the narratives, with the goal to keep each participant’s story intact as a unit of analysis. This aligns with Bourdieu’s conceptualisation of habitus as dynamic and relational, making narrative analysis well suited to understanding transformation processes in longitudinal, context-bound cases. Grounded narrative analysis [43] is an inductive method of content analysis with methodological borrowing from grounded theory [44] which involves the identification of core narratives or categories into which the narratives can be split to aid interpretation (see Fig. 1).

Fig. 1.

Process of grounded narrative analysis [43]

Two independent researchers (first and third author), read through each of the interview transcripts and made notes summarising the story told by the participant. Following this, individual cases which were distinct in their elements were allocated short labels which summarised the story. Whilst an inductive approach was used, Bourdieu’s theory of practices was utilised as an interpretive frame to explain the differences between these core narratives. The researchers worked through each of the transcripts, identifying whether they fit into one of these categories or if they were distinct in their features, until a set of core narratives was established. Following this, the features of each of the core narratives were studied further in-depth, including ‘push’ and ‘pull’ factors affecting habitus transformation.

The first author was a PhD student in medical education who had previously worked for the medical school at University A. They had a background as a resident doctor. They were not involved in a student-facing role. The researcher’s position was made explicit to the participants of the study. The second author was a medical student at University A. Both interviewers identified as having come from a working-class background, however analysis was conducted between the first and third author, a doctor who identified as coming from a middle-class background.

Ethical approval for the study was granted by the University of Nottingham, Faculty of Medicine & Health Sciences Research Ethics Committee (ref: FMHS 86–0820).

Results

The attributes of the students interviewed are shown in Tables 1 and 2. Their experiences could be broadly grouped into five core narratives (see Table 3), which reflect the differences between participants as they progressed into and through university, despite the similarities in their origins.

Table 1.

Attributes of students interviewed

Attribute	Number (%)
Academic year
Year 1  Year 3  Year 5	8 (50) 4 (25) 4 (25)
Medical school
University A  University B	12 (75) 4 (25)
Ethnicity
Any White background  Any Asian background  Any Black background	8 (50) 5 (31) 3 (19)
Sex
Female  Male	13 (81) 3 (19)
Disability status
Has a disability  Does not have a disability	1 (6) 15 (94)
Secondary school type
State school  Private school	15 (94) 1 (6)

Table 2.

Crosstab of students interviewed by institution, year group and ethnicity

Student group	Ethnicity
University A	Any White background	Any Asian background	Any Black background
Year 1	2	2	0
Year 3	2	1	1
Year 5	3	1	0
University B
Year 1	1	1	2

Table 3.

Five core narratives identified from the analysis, summarised

Core narrative (number of participants)	Synopsis
Outsider (5)	Feel like they do not fit in either a working-class environment or a middle-class environment. Their life story is one of having always been different, aspiring to university and exceeding expectations, but unable to integrate fully once in higher education.
Pre-socialised (2)	Were able to take advantage of scholarships or other circumstances which allowed them to attend high-performing secondary schools despite their background. As a result, they spent a lot of time with middle-class peers prior to medical school and had few issues integrating once there.
Enduring identity (3)	Tend to have strong ties with communities from their hometowns and outside of medicine which contribute to their sense of identity, and they socialise less with medical school peers as a result. Content to not be a part of medical school cliques and have a desire to return home after graduating.
Encouraged upward mobility (2)	Had a strong parent or guardian figure who pushed them to work harder in childhood despite the low ambitions of their peers. Complex relationships with family as a result. Have less difficulties fitting in with peers at medical school because of wide ranges of interests and achievements.
Personal growth (4)	Excited by the prospect of elevated social mobility and desire for change in oneself. Readily accepts the medical school culture and lets go of friendships from childhood. May feel superior to their working-class roots and look down on family and friends who have not escaped their deprived environment.

Narrative 1: story of an outsider

‘Ayesha’ is a first-year medical student at University B from an immigrant family. She is one of two children to a single mother, who suffered a number of health difficulties, meaning Ayesha did not apply and enter undergraduate medicine until several years after leaving school.

The focal point of the narrative is what she lacked– this contrasts with how she describes the typical medical student. She consistently presents herself as an outsider, both prior to and at university. Ayesha describes an uphill struggle at her secondary school wherein students did not value education and teachers did not encourage them. The ambition that helped her strive towards a place at medical school is juxtaposed with her view of other people as having no desire to make anything of themselves.

“And even in the school in GCSE’s teachers are just teaching you enough that you most everybody should get C, so that the person who’s trying to get an A or A* they have to work harder on their own… nobody was motivated enough to apply for medicine.” - Ayesha.

Initially Ayesha began medical school with an optimism that her peers would share similarities with her. Being faced with the reality of class difference between herself and the rest of her cohort therefore was surprising, and she handles this by maintaining her position as an outsider rather than attempt integrating.

“I was surprised with the fact that yes, most of the people are a lot more privileged than me, but I told myself that I’m not going to let that put me down… So if you’re an outgoing person you have to spend on your night outs or like on your drinks, on your clothes… But a person like me, I’m not going out, so I don’t have to worry much about that.” - Ayesha.

Another student at University A, ‘Bina’, found that medical school demanded a lot of other skills beyond studying, including knowing how to present herself confidently and communicate in a particular way which was not natural for her.

“I feel I had to change my accent to be being more, I don’t know, a bit more posh?… And so I felt then other girls I would have their attention and they will listen to me and be able to communicate. And maybe dress in certain ways as well, I feel. How you put yourself across erm, like as confidently and loudly.” - Bina.

These students were reluctant to be open to friendships with middle-class peers for fear of vulnerability, remaining fairly unchanged in their habitus. However, it was significant to note that they didn’t feel as though they conformed with their peers prior to university either. This lack of fitting in with any group throughout their story resulted in the title ‘story of an outsider’.

Factors which were common in students describing this narrative were significant financial struggles, being a mature student, and being from an ethnic minority group, which were all felt to compound their status as being different to others.

Narrative 2: personal growth story

‘Sophie’ is a fifth-year student at University A from a large, blended family with many siblings. She grew up in a small, rural village. Sophie describes a purposeful effort to integrate into her new circle and leave her old, undesired life behind.

Sophie reflects that seeing the privileges of her middle-class peers led her to resent her parents for a time. Students who described a story of personal growth and habitus transformation described middle-class attributes as something to strive towards.

“I was quite bitter like seeing how everyone else… And I think that made me want to like dissociate from like the working-class life, and I think that meant that I didn’t reach out to [my home friends] as much because I just wanted this new life with like the new friends who like had a higher social standing… I just wanted this new life that all my friends kind of had.” - Sophie.

As Sophie developed friendships with middle-class peers, she began to adopt middle-class interests and tastes. She became more interested in her physical health, started running, and bought and learned to play a ukulele.

The hallmark of the ‘personal growth’ narrative is the shift in priorities in the storyteller to themselves. Sophie explains that one of the most important things she has learned at university is self-worth and taking time for yourself. Sophie does not want to return to her hometown when she graduates, because moving to a new area of the country represents to Sophie moving on from her old life.

“I think that’s one big thing like just having a nice steady job and not having to worry about the little things so much is like yeah, one thing that I really want… Just living in a nice neighbourhood, a nice house, somewhere where you’re surrounded by nice people I think. I’ve come to value like surrounding yourself with kind people a lot more.” - Sophie.

The title ‘personal growth’ was attributed to this narrative to reflect that these participants had made efforts to make changes in themselves, prioritising introspection and developing their new sense of self. Her depiction is coloured by her new attitudes towards the working-class; a “nice neighbourhood” where you are surrounded by “kind people”, implying a negative viewpoint towards those that live in deprived neighbourhoods.

Narrative 3: encouraged upward mobility

‘Uma’ is a third-year student at University A who grew up in central London. Uma’s mother was also interviewed as part of the study.

Even among medics, Uma has always been a high achiever. Whilst she attended a comprehensive school which she described as disruptive and lacking respect for authority, she explains that she was pushed by her mother to focus on her schoolwork and her extracurricular activities in a way that her peers were not. Uma’s mother describes how she dedicated herself to her children’s education.

“I have invested everything in [Uma]’s education and her younger brother’s education and our world revolves around education… Education is so important, it opens so much to an individual, opportunities, you know and sky’s the limit. I think part of it is because I myself have had a lot of goals and I haven’t been able to reach my goals.” - Uma’s mother.

Whereas a lot of the participants described a self-motivation to learn and having to work alone to achieve their place at medical school, Uma instead described that, left to her own devices, she lacked focus and misbehaved. Uma’s mother felt that her child had potential but needed a push. Whilst Uma’s mother says that the choice to study medicine was Uma’s own, she later elaborates that she was ‘steered’ towards it.

When parents hold aspirations for what the middle-class possess, they may push their children to behave in a certain way in order to better transition into that world. Uma, along with another participant, discussed their parents influencing which children they befriended, which adjusted their social capital. Another student explained that her mother encouraged her to dress well in order to be perceived as a higher class.

Ultimately, Uma’s early childhood experiences led to her entering university with many of the attributes which were usually unique to her middle-class peers: being very confident, competitive, and having a wide range of interests. But despite this, confrontation with her disadvantage upon meeting her privileged peers remained difficult.

“I used to do sailing but I used to do it through a charity… And the girl in my seminar group she also did sailing, we were talking about it and a difference that happened was when actually really when I realised that she mentioned the cost of her course… that’s where I sort of started noticing they were from a different background than myself… I was like, like I’m going to struggle like in a sense… Because every students like, ‘oh I don’t have any money!’… I’m sorry if you don’t have money then what do I have?”– Uma.

The title of ‘encouraged upward mobility’ represents the increasing social status of the participant which has been largely directed by their parents, rather than intrinsic motivation, like the ‘personal growth’ narrative.

Narrative 4: the pre-socialised student

‘Adam’ is a third-year student at University A, whose mother was also interviewed as part of the study. She described her family as being downwardly mobile– her financial situation is worse than that of the generation above her. Nevertheless, Adam was a bright student and successfully gained a place at grammar school. Throughout his story, Adam draws upon similarities between his grammar school environment and that of medical school, attendance at which improved his readiness to accept medical school culture.

He describes his school as a more hardworking environment than the comprehensive school his siblings attended. Playing a prestigious sport at school and then becoming a member of a strong social network at university in the Medics society for that sport provided him with an important sense of belonging and the social capital necessary to gain access to resources and study help.

“I lived with friends that were privately educated, I have no real issue with private education or anything like that… But I’d say [sport] is the one thing that joined me and my friends on the course… we all went to the initial training session and then all sat together in lectures from there. And yeah, it sort of just fell into place.” - Adam.

Participants note how learning etiquette within the profession make them feel that they are part of medicine’s inner circle. When working-class students are educated at private or grammar schools, they may find these ways of interacting are already familiar. However, Adam explains that he does modify the way that he speaks whilst on clinical placement, to be softer and in a different accent, including changing the way that he says his name. When asked to demonstrate this, he laughs and becomes embarrassed, reflecting that he is uncomfortable with the change in an outside situation.

“I think he always strived to be better. He always strived to be maybe against the stereotype of the, you know, the area that he came from maybe.”– Adam’s mother.

Whilst there are similarities between the ‘encouraged upward mobility’ and the ‘pre-socialised student’ narratives in preparedness for integrating into university, the latter students lack the parental steer towards middle-class tendencies and instead may find that their relationships with their working-class parents become more distant.

Narrative 5: enduring identity

‘Katie’ is a fifth-year student at University A who is first in family to attend university. She is from a Christian family and her religion plays a strong role in her life. Both Katie and her parents were interviewed as part of the study.

Katie was on a gateway course for medicine, so found herself benefitting from the small, tight-knit cohort of students initially. Upon joining the main BMBS cohort, however, she found that many aspects of medical school culture clashed with her identity fundamentally. Principally, Katie does not drink alcohol, and she found that medical students would react to this with bewilderment or negativity. Katie explains that she is heavily involved within the Christian Union at university and her church back home, and the majority of her friends are derived from that network, as opposed to seeking the friendship of other medical students.

The competitive environment, in addition to the stresses of commuting to different places around the region for clinical placement led to Katie making the difficult decision to take a gap year during medical school, further severing any ties that she had.

“I know [Katie] can’t see the reason for competitiveness. You know, you trained to do a job, to do a job. It’s not a competition, it’s not a sport. And I know that used to get her down, the pure competitiveness of it… I got a feeling it was… I want to use the word favouritism. You know there were, I think there was favourites. Erm, and [Katie] I’d put as a low key student. She will be there in the background, just churning out getting the results. She’s not in your face, ‘Look at me, I’ve done all this, I’ve done all that.’”– Katie’s father.

Those with ‘enduring identity’ shared certain similarities with those with an ‘outsider’ narrative, such as a persistence in their primary habitus, however this was seen as a positive rather than a negative. ‘Alice’, a first-year student at University A, has found that both having a disability combined with the COVID-19 pandemic has been detrimental to her integrating into medical school. However, as Alice explains, the few interactions that she has had with her new peers have not convinced her to put more effort into forming friendships with medics.

“I still feel like I stick out. I still feel like you know there are people in the group chat saying, ‘Oh should I buy this iPad, that iPad?’ Like, why do you need an iPad? You’ve got pencil and paper, it’s much cheaper. It lasts you ages. It probably won’t break within six months. What’s wrong with you?’” - Alice.

Alice is in two minds about the prestige that she now sees her working-class friends bestow on her. Whilst she says that this is flattering, she still wants to be known as her old self and struggles with the idea of straddling two different worlds.

Discussion

Extent of habitus transformation

This study identified five distinct, core narratives which characterise the experiences of students from low socioeconomic backgrounds as they navigate the middle-class environment of medical school. Each of these narratives represents a varying degree of habitus transformation, and a varying degree of autonomy within that process (see Fig. 2).

Fig. 2.

Relationships between each of the five core narratives, the participants’ degree of habitus transformation and degree of autonomy throughout that process

The core narratives largely correlate with those presented in other works exploring the transition of working-class students into higher education more broadly [45, 46].

Alienation archetype [45] or outsiders [46] aligns with the core narrative in this study by the same name. These students were the largest group and had poor academic and social integration into university. This narrative is characterised by having always, and continuing to be, lacking a sense of belonging in their communities. Deficiencies in capital and obligations to family were often cited as reasons as they have a negative influence on the time available that these students have to build capital [11, 47].

Commitment archetype [45] adjusters [46] or personal growth narrative as defined by this study, captures those students who readily accepted habitus transformation with a hope for upward social mobility, motivated by a desire for a financially stable, respected position as a doctor. In contrast to outsiders, those with the personal growth narrative generally described a difficult transition into university but ultimately a positive outcome. These participants demonstrated a growing distaste for working-class culture, as found by a previous study [14].

Ivemark and Ambrose [36] incorporate within adjusters those which this study defines as pre-socialised. This study makes the important distinction that the starting point of those experiencing ‘personal growth’ and those who are ‘pre-socialised’ is different. Pre-socialised students described several similarities between their high performing secondary schools and the medical school culture, namely competitiveness, encouragement of a wide range of extracurricular activities, ways of dress, and manner of speech, which enabled better integration.

Their final category, strangers [46] encompassed those who have a habitus clivé (cleft habitus) [48] more colloquially described as ‘living in two worlds’. Our study largely found that, with the exception of the pre-socialised narrative, most working-class students experienced this phenomenon to some extent during their studies.

This study found some additional groupings. Whilst encouraging parents and schools meant that some students were preadapted to the university environment [46] consideration has not been given within these models for those for whom their own preferences and the desires of their parents are in conflict (we refer to as encouraged upwardly mobile). This is a particular strength of this study in interviewing family members as well as students, which helped in revealing this alternative narrative. The two students expressing this narrative were steered by their parents to assimilate middle-class characteristics - becoming omnivorous in hobbies and interests [6] and associating with the right people.

As for the students with an enduring identity, whilst they share similarity with the outsider narrative in that they exist on the periphery of the medical school community, for them this is intentional. This distinguishes them from those who attempted and failed to position themselves within it. These students were most likely to have strong networks outside of university.

Factors affecting habitus transformation

Successful habitus transformation appears in this study to be largely related to time and depth of exposure to the field [49] being highly mediated by the several inhibitory and enhancing factors identified (see Fig. 3). For example, students who live at home, or had financial constraints which meant that they could not participate in the social space of medical school, found that this ultimately influenced their experience of habitus transformation. These finding aligns with similar work where the field of medical education shaped but ultimately did not determine individual habitus, due to unique student characteristics [50].

Fig. 3.

Factors affecting habitus transformation

It is important to consider here the impact of intersectionality. Most of the participants expressing an outsider narrative were from ethnic minority backgrounds, which may have impacted their ability to fit in at medical school. For example, where English is not a student’s first language, they may have more difficulty with accent. Social events around alcohol consumption also tend to disproportionally affect students from ethnic minority groups [51].

One participant declared a disability, which impacted her in terms of making social connections. The impact of disability on social inclusion at medical school (particularly during the COVID-19 era, since these students were more vulnerable and may have been shielding) warrants further exploration.

Impact of institutional culture

Medicine is a somewhat closed ecosystem, wherein students studying medicine are seen as distinct from the rest of the student population [52]. Ultimately this forces students to socialise within a bubble, reinforcing the prevailing culture of a medical school, especially as hierarchy is so present within medicine [27, 53, 54]. Students at University B, who were entering as the first cohort of the new medical school, had limited, and mostly virtual, contact with older peers at University A. It was therefore interesting to explore whether the lack of older students to influence them would affect socialisation.

The most frequent behavioural changes were change of accent, conversational skills, and different ways of dress. Whilst presenting oneself outwardly in a more middle-class manner through these mechanisms is a phenomenon found by several studies of upwardly mobile students in higher education generally [10, 14, 16, 17, 55] within medicine many of these tendencies align with the concept of professionalism [56, 57] which can be seen by students as restrictive to their identity [58, 59]. Their naissance on the medicine course and the lack of older students to role model meant that participants at University B, whilst experiencing the same pressures to ‘act the part’, frequently described code-switching [14, 60] as opposed to a fundamental change in their primary habitus.

Whilst behaviours could be masked [14, 60] the development of values which align with that of the university and the medical profession was more challenging. Prevalent in the interviews with students from University A was the emphasis on individuality in both the context of learning and wellbeing. Overall, this represents a shift in values from interdependence (typically a working-class attitude) to independence [4]. Those with an outsider narrative in particular struggled with this transition, failing to accumulate the necessary social and cultural capital to thrive in the medical profession [40]. Interestingly, this was less commonly cited by students at University B, which may be related to the higher proportion of students from WP backgrounds in their cohort.

Whilst demonstrating these early differences is helpful, further research as these students progress through the medicine course and develop their own emerging field is vital in furthering our understanding of the culture at modern medical schools.

Limitations

Whilst habitus is described as fundamentally operating in the subconscious [61] many of the students described deliberate changes that they had made in order to fit in. Habitus as a theory is often criticised for being too deterministic and not allowing for individual agents to make choices contrary to societal expectations [49, 62].

At the time of the study, the University B had only one cohort of medical students. It may be that the lack of influence from existing students result in a different experience over the course. Additionally, participants were recruited during the time of the COVID-19 pandemic, which had a significant impact on their socialisation.

Regarding recruitment, since participants were asked to approach the researcher, the sample may be skewed to participants who had a particularly good or bad experience which they wished to share. Of note, whilst efforts were made to recruit both sexes, there were only three participants who were male. Medicine cohorts in the UK are majority female [63] but it is not clear why so few males volunteered to participate. This may have influenced the findings given the identified importance of intersectional characteristics.

Whilst all student participants were asked if their parent or family member could be interviewed, only 5 consented to this and 5 interviews with family were conducted. Those paired interviews which were undertaken were useful in gaining insight into the ways in which family dynamics adjusted during the students’ time at medical school and the impact which parents may have had on the developing of their narrative.

Finally, the first author’s previous role as a member of faculty may have impacted the way in which participants responded. Additionally, with two of the researchers being from working-class backgrounds, existing biases may have influenced the way in which transcripts were interpreted. This was mitigated by having a second researcher analyse the transcripts who was from a middle-class background.

Conclusion

Our findings suggest that medical students from low socioeconomic backgrounds experience multiple ‘push’ and ‘pull’ factors which influence the extent to which they adopt behaviours, values, and tastes which are the prevailing norm within medicine, and this may influence how their journey through medicine unfolds. There are also indications that medical school attended may affect this transition, which ought to be explored further as the new medical schools begin to graduate their first cohorts.

Whilst some students are able to transition into and through university with their primary habitus intact, many students undergo a transformation which they experience as personal growth. By better understanding the influences on habitus transformation, we can provide a more targeted approach to support students from disadvantaged backgrounds who are most likely to struggle adapting to the medical school environment.

However, if students from working-class backgrounds are no longer recognisably working-class in their attitudes and behaviours when they graduate, has class equality been achieved? These findings suggest a paradox: while WP initiatives seek to recruit students to serve underserved areas, medical education may inadvertently strip them of the very cultural capital that would enable this mission. Further research could explore whether such transformation goes on to affect their interactions and abilities to empathise with patients from similar backgrounds, and the likelihood of pursuing pro-social careers within rural and under-served populations [64].

This research should also prompt educators to reflect on the messages that we are conveying to our students about the ways in which one thinks, acts, and feels like a doctor, and whether one needs to have a middle-class habitus in order to do so. Given our wider aims to diversify the profession to meet the needs of the public it serves, medical schools ought to embrace the same diversity of characteristics within their own student body. This can be achieved through cultural and curricular reforms to mitigate the effect of prevailing norms on under-represented students, in particular increasing the prominence of working-class role models in leadership positions and addressing the class-based origins of professionalism.

Electronic supplementary material

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Abbreviations

NS

SEC-Office for National Statistics Socio-economic Classification

WP

Widening Participation

Author contributions

CK conceptualised the study, including the methodology, conducted interviews, analysed the interview data and was the primary author of the manuscript. AT conducted interviews and reviewed the manuscript. LK analysed interview data and reviewed the manuscript. SA is the primary supervisor of CK’s PhD and was involved in supporting the research at all stages, including review of the manuscript. AW is a supervisor of CK’s PhD and was involved in supporting the research at all stages, including review of the manuscript. GD is a supervisor of CK’s PhD and was involved in supporting the research at all stages, including review of the manuscript.

Funding

Not applicable.

Data availability

The datasets generated and/or analysed during the current study are not publicly available in order to maintain participant confidentiality but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for the study was granted by the University of Nottingham, Faculty of Medicine & Health Sciences Research Ethics Committee (ref: FMHS 86–0820). Informed consent was provided by all participants. The research was performed in compliance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number.

Not applicable.