Recently, "25-year-old trainee suicide" has become a hot search, and many medical students have shown up to react, and during the training period, it is "free cattle and horses" and "cheap labor", which has caused controversy from all walks of life. Since 2014, the mainland has implemented standardized training for resident doctors, and in the past ten years, a total of 1.1 million doctors have been trained in a standardized manner, and regular trainees generally need to go through 1-3 years or even longer training depending on the source. What are the pressures faced by the "prospective doctors" during the training period? How should we view the current situation of the regular training? Based on the actual investigation and interview information, this paper makes a systematic analysis of the training system.
The article points out that in the transition period of professional socialization, regular trainees are in a marginal state. (1) Compared with the attending physician, chief physician and other second- and third-line formal doctors, the first-line resident physicians are responsible for prescribing medical orders, writing medical records, and talking with patients, and need to take turns on night shifts once or twice a week, and their professional status and medical power are relatively low; (2) As a newcomer, on the one hand, they have to run in with new people, things, spaces and cumbersome medical processes, and are in an abnormal stage, and on the other hand, because they only master the basic knowledge, they are still in the "semi-finished product" of the transition to qualified doctors (3) In clinical practice, regular trainees are not treated as colleagues by regular doctors, and they will be scolded and disciplined if they are not prepared properly.
The author points out that marginal and ambiguous identities are the basis of professional interactions and the source of contradictions and conflicts. On the one hand, it is of course necessary to achieve the balance of medical resources and improve the overall quality of clinicians, and this process is actually the inheritance and continuation of hospital culture and medical rules. Although the "transitional" status of regular trainees has a time limit and can be changed, in the marginal experience of the regular training period, how to help the regular trainees achieve the gradual improvement of their professional ability and start a promising career in the future needs to further explore China's regular training system.
This article is excerpted from Sociological Research, Issue 3, 2023, and was originally titled "Career Socialization in the Transition Period: Marginality and Conflict in Career Interactions for Trainees". It represents the author's point of view only and is for readers' reference.
Career socialization during the transition period:
Marginality and conflict in professional interactions
▍ The origin of the problem
It is only in the last decade or so that there have been signs of revival on key issues related to medical education. That's because today's medical students and graduates are very different from the "boys in white" of the mid-20th century: they come from a more diverse background, require more types of knowledge and skills, and go through a more pronounced professional socialization process. Unlike the previous medical graduates who could directly become independent doctors, in many countries and regions, if they want to become qualified doctors with full clinical autonomy, they must also go through 1~3 years or even more of standardized residency training in hospitals rather than medical schools. This period of transition is referred to as "regular training" or "resident training" in the Chinese medical community, and their status at this stage is "regular training" or "resident training".
The goal of training is to improve and balance the professionalism and core competencies of clinicians, however, the seemingly good goals do not seem to be fully embraced by trainees. For trainees, although various systems give them the status of "resident doctors", it is still an ambiguous and plausible question of whether they are students or doctors in the practice of regular training. They often deride themselves as "tool people", who are largely regarded as cheap labor for medical record writing, dressing changes, and surgical hooks, and have neither the clinical autonomy of attending physicians nor the treatment of regular employees, and are in a marginal state.
According to the circle of friends posted by the deceased before her death, she had symptoms of heart discomfort
Judging from the relevant theories, it seems that there is also a tension that is difficult to reconcile. The training process is undoubtedly an important part of professional socialization. According to Merton et al.'s original definition, occupational socialization refers to the process by which individuals develop their professional self and acquire values, attitudes, interests, knowledge, and skills specific to a profession, in short, the process of acquiring the culture of the occupational group in which they belong or intend to be. In the two basic theoretical perspectives of occupational socialization, the structural-functional theory led by Merton emphasizes the inheritance of occupational culture and norms, as well as the reinforcement and reproduction of social structure, while the symbolic interactionism represented by Beck advocates the understanding and redefinition of situations in occupational interaction (the type of interaction carried out by professional identity and occupational mode to distinguish it from everyday interpersonal interaction), as well as the new meaning they continue to create, thus deconstructing the norms and content of occupational stereotype. The new institutionalist perspective attempts to integrate the meaning generation of socializers and institutional norms into the same framework, but it still emphasizes the stability of institutions and the guiding significance of institutions in occupational socialization, which is no different from structural function theory.
Understanding the contradictions and uncertainties in these experiences, as well as reconciling the conflicts between relevant theoretical perspectives, is the starting point of this paper. Specifically, this paper aims to answer the following questions: why is the training aimed at improving the professional quality of clinicians leading to the marginal state of the trainees?how is the marginal identity of the trainees shaped in the practice of the training?What is the significance of the marginality in the process of forging qualified doctors? Based on the ethnography of the hospital department, the following article attempts to discuss the training system, professional structure, and meaning generation within the same framework based on the ethnography of the hospital department and the "edge" in the professional interaction of the trainees. We hope that this study will contribute to a comprehensive examination of the growth process of qualified doctors, to regulate the tension of related theories, and to reflect on the significance of training in the healthcare system and in the career of doctors.
The field site of this paper is the gastroenterology ward of a large comprehensive teaching hospital (pseudonym Z Hospital) in South China. The Department of Gastroenterology is composed of a digestive ward, a digestive laboratory, an endoscopy center, and a digestive specialist outpatient clinic, which is a national key clinical specialty. It has 12 professors and chief physicians, and 6 associate professors and deputy chief physicians. There are two areas in the digestive ward, which are symmetrically distributed on both sides of the elevator, and the size and number of beds are the same, with 40 beds each. Each district has two chief physicians in charge of 20 beds, who also serve as mentors, and one of them is the head of the district. Each ward has at least 2 doctors on duty every day, including a main shift and 1 deputy shift. If there are too many trainees, 2 deputy shifts will also be arranged. The main class is filled by trainee doctors, postdoctoral fellows or doctoral students who have obtained the primary professional titles, and they are already qualified as practicing doctors, while the secondary classes are mostly held by regular trainees who do not have a medical practitioner qualification certificate (mainly clinical professional master's degree trainees). Under normal circumstances, the two wards conduct their own ward rounds, but the morning shift and case discussion, admission training, and discharge operation assessment on weekdays are jointly completed by the two wards. From October 2020 to December 2020 and from October 2021 to February 2022, the second author of this paper entered the Department of Gastroenterology as a trainee and conducted fieldwork in two wards for a total of 5 months, obtaining more than 100,000 words of field notes, which are the main sources of information below.
▍Shaping and strengthening marginal identities
The complete pattern of transitional liturgy consists of three parts: dividing (preliminary), marginal (mid-liminal), and aggregated (postliminal) liturgies, but in practice, the details of these three sets of liturgies are not necessarily equally emphasized. Due to space limitations, this paper will focus on the analysis of the marginal identities of trainees in liminality and the professional interactions based on this identity.
(1) The edge of the occupational structure
The modern hospital is not only a place to display medical miracles, but also a strict departmental structure, showing the hierarchical division of labor. Doctors, nurses, nurses, medical technicians, managers, service personnel, plus patients and their families form the main objects of interaction in the hospital. In the medical field, despite the presence of administrative power, doctors remain the center of medical care, while nursing and other work are considered medical auxiliary work, and even nursing training is considered a lower level of medical education in the early days.
Among the symbols that symbolize their professional identity, work clothing is undoubtedly the most conspicuous symbol. The "white coat" has almost become synonymous with the professional community of doctors. Although nurse gowns and nurse hats are no longer limited to traditional monochromatic colors, but come in a variety of colors, patterns, and stripes, they are still different from the doctor's lab coat and make it easy to identify who is the doctor and who is the nurse. Nurses in hospitals don't wear nurses' uniforms and lab coats. It can be said that the different costumes not only show their different division of labor, but also actually reinforce the different identities of health professionals and service providers.
Medical students also wear lab coats (with the medical school logo) during their time at medical school, such as in the dissection room, clerkships and internships, but they can still wear everyday clothing to reflect their hobbies, personality and tastes during regular and non-school hours. However, once they enter the hospital to become a regular trainee, they are required to wear a white coat with the emblem of Hospital Z on it during working hours. Since the trainees spend most of their time in the hospital, wearing a white coat has become almost a daily routine for them. Every time he enters the locker room at work, the first thing he does is to change into his work clothes and start working "as a doctor". They also have a common name - "a certain doctor". All of this symbolizes that they have finally become part of the community of doctors at Z Hospital.
Wearing a white coat shows Gui Peisheng's status as a doctor, and it seems to indicate that they enjoy the honor and status of doctors in the hospital, symbolizing their professional community attributes. However, a small badge pinned or hung from a white coat reveals their true marginal position in the medical community. In Hospital Z, the person wearing a rectangular red-framed acrylic badge with a white background may be either an official doctor of the hospital, or a doctoral student or postdoctoral fellow in need of regular training in the hospital. This shows that highly educated trainees are given near-formal doctorate status. However, there is still a slight difference in their badges, that is, only those with a 6-digit number indicate that they are official doctors, while those with 4 digits and letters are doctoral students or postdocs. In contrast, the listing of clinical master trainees is much simpler, and the white card in the transparent plastic bag makes their training status clear at a glance. In fact, even without the word "discipline", this simple badge symbolizes their informal, temporary, marginal identity.
The different occupational hierarchies symbolize different occupational status and the benefits and benefits that come with it, and also indicate that they have different medical powers and even differences in working hours. In the specialized wards of large general hospitals, a three-line duty system is usually implemented. Generally, according to the professional title, taking into account factors such as working years (seniority), first-line doctors, second-line doctors and third-line doctors will be formed. Front-line doctors, who are mostly qualified residents, are responsible for prescribing medical orders, writing medical records, talking to patients, and taking turns to work night shifts once or twice a week according to a schedule. Second-line and third-line doctors are full-fledged doctors at a higher level (from attending physician to chief physician). In the gastroenterology department of Hospital Z, the front-line doctors include the main shift and the deputy shift, all of whom belong to the regular trainees, but the clinical autonomy of the main shift is higher than that of the deputy shift, and even the overtime pay between the main shift and the deputy shift is different.
The above analysis shows that, on the one hand, these regular trainees enter the department for training, put on white coats, and form a kind of professional community with the existing doctors; on the other hand, after careful observation, it will also be found that there are not only differences in their professional level with the regular doctors, but also obvious differences within the regular trainees. Some postdocs have obtained the junior title of assistant researcher during the training period, and have the opportunity to apply for drug prescription rights, which further strengthens the hierarchical order within the trainees. This reminds us that the original social identity of the trainees is still partially brought into this liminal period, and that the community and the structure are not completely separated, but dialectically and emphatically united.
(2) As the edge of the newcomer
The complete process of training medical professionals includes three stages: college education, post-graduation education and continuing education. These processes require the collaboration of medical schools, hospitals, and communities to shape medical graduates into qualified doctors in hospitals and to excel in lifelong learning. At a special meeting on talent training held by Z Hospital, the vice president of the hospital, M, bluntly said that although medical graduates have experienced 5-8 years of study in medical school, they can only be "half doctors". That is to say, in the stage of college education, they only master the necessary theoretical knowledge of medicine, and only participate in part of the clinical work through clinical clerkships and internships, and there is still a considerable distance from the requirements of independently and standardly undertaking the diagnosis and treatment of common and frequent diseases, and they are only "semi-finished products". The only way to make the transition from "half a doctor" to a qualified doctor ("finished product") is the training discussed in this article. Among them, the first step is to train newcomers in a clinical setting.
Intensive admission training for newly admitted trainees is the routine work of the department at the beginning of each batch of trainees. The training is generally carried out by the supervisor professor and the head nurse of the ward. According to the regular training system, regular trainees need to rotate to different departments and receive no less than 1 month of training in each department according to their respective training programs. In the three-year training, a trainee needs to complete several admissions, exits, re-entry, and exits, and finally a unified assessment. During an induction training, the professor in charge not only introduced the peculiarities of gastroenterology diseases, but also emphasized their own "little traditions". In terms of the duty system, she proposed that "you can't ask across levels, you have to report at all levels", and told everyone the preferences of discipline leaders, reminding everyone not to "touch mines". She said:
The total number of hospitalizations, the second value (second line), and the third value (third line), you have to know who it is, and don't ask three questions and don't know it. Don't be afraid of questions, if you are not sure, you must report to the senior doctor, but you can't ask across levels, you have to report at all levels. In addition, our discipline leader does not like to prescribe a CRP (C-reactive protein) in the emergency postoperative combination, because it is different from our usual CRP reference, and is often criticized by him. So remember not to just open this thing. (Interview with Dr. 20211203 Bai)
The induction training and subsequent clinical training show that in the process of shaping these novices into qualified doctors, the mentor doctor will not only teach them the relevant clinical skills, medical procedures, but also some rules that belong to the department itself. In this way, at least for a few months of regular training, they will be able to interact with other personnel according to the "rules" and begin to act like official doctors in the department. The state, local governments and hospitals have also introduced a series of institutional arrangements for the enrollment objects, training modes, training contents, assessment and certification of regular training, etc., from this level, regular training as a kind of professional socialization has the characteristics of institutional embeddedness, and every change in the regular training system is also related to the career of many future doctors. However, the specific implementation of regulation and training is not a standardized and uniform reproduction of the system, and in the teaching interaction, the "subculture" of the hospital and even the "small tradition" of the department have also been inherited and reproduced intentionally or unintentionally.
We would like to emphasize that, in addition to the relatively low position of the trainee in the professional hierarchy mentioned above, the term "newcomer" itself also means marginal. On the one hand, for these trainees, the new is not only that they join the community of doctors in the department as a new member, but also that they have to face new people, things, spaces and cumbersome medical procedures. They do not have a sense of control when dealing with the relationships between people and things, and they must gradually turn into familiarity in the process of temptation and humble learning in order to "adapt to the rhythm of the hospital". In the normal state, these new members are a small number of individuals in the "abnormal" state, and thus in the "marginal" state of normal group life. Therefore, the transition from new to old, from raw to mature, has social and psychological transitional significance. On the other hand, in the eyes of the formal doctors who have passed the "coming-of-age ceremony", these newcomers have only learned the basics in medical school, and they can only be "half doctors" or "semi-finished products", and they must go through several years of "repeated training" in the hospital before they can become qualified skilled hands or "finished products". Although these trainees participate in the training as residents in terms of system design, they cannot be regarded as qualified residents before they pass the training assessment, and their rotation in different departments also indicates that they are only short-term colleagues and "passers-by" in the department, and they are on the periphery of the fixed members, who are prone to have a subjective sense of alienation from the outside world.
(3) Strengthening marginal identities
If the professional level and admission training only indicate and symbolize the marginal identity of the trainees, then in clinical practice, we will find that their marginal identity will be further strengthened and confirmed. Let's illustrate this point of view with the scenario of shifting and teaching rounds.
The shift is usually at 8 a.m. from Monday to Friday and takes about half an hour. In the conference room, after the department director and chief physician were seated, other doctors (including trainees) sat around the conference room. In general, the deputy shift (regular trainee) is the assistant shift, and if the department head or other doctors have questions, the main class will answer if the deputy class cannot answer. For example, once, the deputy said that the 7-bed patient had fever symptoms after surgery and had subsided last night. The director asked if there was a recurrent fever this morning, but the deputy class member couldn't answer. At this time, the 7-bed doctor (Gui Peisheng) looked up and replied:
"My body temperature was normal this morning, and I asked the nurse just before the shift." The director looked at her and affirmed: "Don't just hand in the evening, you also have to keep track of the patient's condition before you finish your shift" (20211109 meeting room minutes).
From the formal point of view, the handover is the handover of two shifts, which plays a role in the medical arrangement. From the perspective of the department, the process of shifting is still a reproduction of the department's norms and processes emphasized above, because the department director and other professors often re-emphasize the medical rules in the actual cases of shifting; Because the debriefing of the shift may be interrupted at any time to answer the questions of other doctors. Therefore, skilled, accurate, and focused handovers are seen as a manifestation of a novice's comprehensive ability. When he or she does not make a statement or answer a question that is suddenly asked, the shift changer will face the possibility of being "scolded" in full view. When I asked the above trainee how he knew the patient's body temperature, she said:
When you get to the ward in the morning, even if it's not your shift, you have to take a look at your patient before you turn your shift, and I asked the nurse in the bed before I came in. You'll know if you've been scolded a lot. (Dr. 20211109 M)
Another postdoctoral trainee (who needs to rotate in internal medicine for half a year after the foreign institute commissions for a Ph.D.) also said earnestly:
Before the professor comes to the ward, you have to make a judgment whether it is a treatment problem, a recurrence of symptoms, or a new situation. If you don't know anything when the professor comes, be prepared to be scolded. (Dr. 20211109 F)
For formal doctors, although there are differences in their professional titles and administrative levels, they generally belong to a professional community and are colleagues with each other. In terms of professional jurisdiction, as a group, they have the right to control their own sphere of practice in order to prevent competition from other professions or professions, and as individuals, they enjoy autonomy in their clinical work, and in most cases they tend to think that they are blameless, which leads them to be particularly sensitive to criticism from others, and in their work, they even resist the supervision of their colleagues. However, "scolding" is a common occurrence in the process of regular training. The "scolding" here is not to humiliate others with vulgar or malicious words, but a kind of condescending accusation and guidance, reflecting the unquestionable authority of the teacher and the senior doctor. Not only will they be scolded by their superiors and professors, but nurses will even cross the boundaries of their jurisdiction and act as "teachers" to reprimand (instruct) them when they "keep teaching" on certain common problems. During the on-site assessment of the shift, although the trainees stated the medical treatment and the patient's situation as doctors, in the eyes of the department directors and professors, they were still "students" in the process of learning. It's only natural to scold them in order to spur them on.
Similar to the morning shift, the daily teaching rounds are more of a reproduction of the teacher-student relationship than the colleague relationship. Different from ordinary hospitals, as a large-scale teaching hospital, the daily ward rounds of Z Hospital are not only a channel for doctor-patient communication, but also a live demonstration of teaching. This model has gradually become an important way of medical education since the birth of clinical medicine. Didactic ward rounds are also a quiz for regular trainees. The bedside doctor (trainee) is required to report to the supervising doctor on the physical indicators of the patient he is responsible for. In order to demonstrate their proficiency, they often need to write down the indicator data in a notebook in advance, and try to summarize a set of statements to the instructor about the current treatment situation as proficiently. At this time, the trainees referred to the supervising doctors as "teachers", which further illustrated their teacher-student relationship in the special context of ward rounds. If the part of the complete participation of the trainees, such as the initial diagnosis and the discharge summary, shows their status as doctors, then in the routine work of the senior doctor's rounds and early shifts, these trainees participate in the medical process as students. In the liminal stage of the student-doctor identity jump, the trainees were able to experience the process of becoming doctors, and their marginal and ambiguous identities were constantly strengthened in the process of changing roles from time to time.
In his study of the transitional etiquette of new entrants, Turner emphasized that there is a special "social structure" between these new entrants and their mentors, as well as between them and each other: there is often an absolute authority and absolute obedience between the mentors and the new entrants, and there is often an absolute equality and blending relationship between the new entrants. Our field data supports part of Turner's view that the relationship of authority and obedience between the supervising physician and the trainee is still subtle, but there are still subtle differences within the trainees, as mentioned above, although they share the same identity characteristics as "trainees", differences in academic qualifications, previous clinical experience, and even the schools they graduated from make it difficult for them to achieve absolute equality within them.
In this section, the status of Gui Peisheng is defined by "marginal", which generally has three meanings: first, the marginal does not mean that they are absolutely inferior in status, and they still have a high status compared to many other staff in the hospital. As a qualified doctor who is about to be "baked", people will also look the other way. Their marginal status is temporary, and once they pass this marginal stage, they gain a higher social status. This is different from the sociological sense of the marginalized group, which does not guarantee that it will eventually find a way up the social mobility and achieve a reversal of social status. Second, the edge also shows that they are still standing above the threshold and have not yet crossed it. It is not known whether they will be able to become qualified doctors and whether they will be willing to become qualified doctors before the end of their training. The marginality here follows the "edge" in transitional rituals, indicating the marginality of their "ambiguous" identities as they swim between the two worlds. Thirdly, the fringe also stems from their newcomer status. When they first arrived, they were not familiar with the traditions and norms of hospitals and departments, and they could not carry out medical work with the same ease as regular doctors. Although they wear white coats, they are still the objects that need to be trained, and they need to gradually cultivate clinical thinking in early shifts, teaching ward rounds, outpatient teaching, clinical "small lectures", medical record discussions, etc., and move towards the goal of qualified doctors. In this section, we discuss the shaping and reinforcement of marginal identities in institutional arrangements and professional interactions, and then we will focus on the conflicts and possible generative forces in their interactions with teachers, nurses, patients, and their families in marginal identities.
▍Experience and conflict under marginal identity
Regular training is a necessary stage for medical graduates to become qualified doctors, and this transitional liminal period inherently determines the marginal status of regular trainees. In this capacity, they gradually shift from the status of medical students to the status of doctors in contact or conflict with the teaching doctors, nurses, patients and their families, and even their peers, and begin to think, feel and act like qualified doctors. For the trainees, professional interaction is not a unilateral acceptance of fate and institutional arrangements, but a positive and reflective work. The different aspects of system, structure and meaning are integrated in the practice of regular training, which jointly constructs the marginal identities of the trainees and promotes the transformation of their identities.
(1) Complaints and trials in writing medical records
In ancient China, the most basic paperwork of doctors was prescriptions and consultations. "Zhou Li: Heavenly Officials" records: "Where there are diseases and sores in the state, then the doctors will divide and cure them." At the end of the year, they will examine their medical affairs to make their food." "Whoever is sick of the people shall divide and conquer, and at the end of his death shall write his own cause and enter the physician." This reflects the dual significance of the instrument: first, the competent authority will inspect the doctor's medical affairs at the end of the year based on the diagnosis and treatment records to determine the amount of his salary, and second, for the death case, the doctor should write a report on the cause of death and send it to the higher medical director for future reference. Modern hospitals are more standardized and systematic in terms of paperwork, especially the writing of medical records. In 2010, the Ministry of Health issued the Basic Standards for Medical Record Writing, which made detailed provisions on the content, format and time of medical record writing. A complete medical record includes the patient's admission history, physical examination, preliminary diagnosis, admission diagnosis, ward round consultation records, informed consent, etc. Our field data shows that the daily clinical work of the trainees is not primarily about dealing with patients. In addition to participating in the third-level ward rounds, they sit in front of the computer for most of the day and keep writing medical records, issuing medical orders and preparing discharge materials, especially the task of writing medical records is the most onerous, so there is a saying that "5 minutes to see a doctor, 2 hours to write a medical record".
For patients, medical records, especially disease course records, are their health records, which record the whole process of the occurrence, development, change, treatment and prognosis of the patient's disease. For medical staff, a complete medical record is a file that records the level of medical technology, reflects the actual situation of medical work, and is also an indispensable and important basis for correct diagnosis and decision on treatment plan. The cooperative nature of modern medicine also determines that without accurate and clear records, detailed clinical examination results and treatment methods, it is difficult for other medical personnel to participate in the treatment and find the best diagnosis and treatment method. At the legal level, the significance of a complete medical record is to restore and record the original appearance of the entire medical operation, which plays the role of original evidence. Therefore, the quality of medical records is included in the medical evaluation system as an indicator to measure the overall level of the hospital. In this sense, the writing of medical records is not only a general written work and a record of the course of the disease, but also a link that connects doctors, patients, the community of doctors, hospitals, and even public affairs such as insurance and law.
However, this basic and important work is not done by all doctors, and in the training base, it naturally falls on the trainees, and other higher-level doctors are responsible for the content and form review. In the daily writing of medical records, the trainees are like clerks, sitting in front of the computer, completing one word after another. Although the significance of medical records is self-evident, the process of writing medical records is generally a tedious and uncreative task, which gives them little sense of accomplishment. The following two excerpts from the interview show the dissatisfaction of the trainees when they wrote their medical records.
The so-called course of the disease is actually a running account, and I feel that I am not a doctor, but a historian, and I keep writing and writing there...... You have to write down a record of your conversations, and you have to write down everything that happens, and if you don't write it, it's the same as if you didn't write it, and if you don't sign it, it's the same as if you didn't write it. (Dr. 20211110 L)
A long hospital stay means a long history of your illness. There was a (patient) who stayed for 8 days before and wrote the medical record to the point of collapse. (Dr. 20211007 F)
Medical records are so boring and tedious that they dedicate themselves to being "historians" or to describe themselves as cheap laborers and tools for writing medical records. However, in the eyes of the teaching doctor, the medical record is not just a piece of paper or a written presentation of the disease, but also reflects the clinical thinking of the recorder. In other words, medical record writing is not only an objective statement of the patient's condition, but also reflects the writer's thinking and judgment, and has also become an important indicator for judging whether he is a "real doctor". As Dr. Bai said:
I found that there are many students who don't ask for ideas when they ask about their medical history, and they don't write about the ideas when they write their medical records. Medical records can reflect your ability to think clinically. It is necessary to accumulate little by little, a process from quantitative change to qualitative change, and I hope that everyone can gain something from our gastroenterology department and slowly accumulate their own experience in order to become a real doctor. (20211203 Dr. Pak)
That is to say, for these prospective doctors who are about to enter the medical profession, they need to find "meaningful" information in the patient's description of illness, medical examination results, and diagnosis of senior doctors, filter out some emotions and experiences that do not belong to the scope of medical treatment, and be professionally "coded" and reflected in the medical record in the form of words, so as to integrate the patient's complaints into the medical idiom. In the process, trainees learn to construct a sick person as a patient—a patient who is perceived, analyzed, presented as medically fit for treatment, and then transformed him or her into a document and a treatment plan. As the highlight of the "coming-of-age ceremony" of the training, the medical records reflect the basic skills training of the trainees and are the performance of their clinical thinking in words. In the face of this time-consuming "drudgery", although they complain, they also know its significance. More importantly, they know that once they get through this transition period and are finally promoted to the rank of attending physician and above, the clerical staff in the ward will become a new trainee, and these "basic skills" will become part of their physical memory, showing the years they have been tempered.
(2) Jurisdictional disputes with nurses
In the working environment of a hospital, doctors and nurses not only share the same workplace, but also have common patients, and cooperate with each other to contribute to the recovery of patients. In general, doctors and nurses belong to two systems that are both relatively independent and interconnected. The main responsibility of a doctor is to diagnose the condition and formulate a treatment plan based on the diagnosis, that is, "what medicine to prescribe" and "what tests to do" that we talk about in our daily life. "Prescribing medicine" is actually a doctor's order. A doctor's order is a medical instruction issued by a doctor in medical activities, that is, the doctor's instructions to the patient in terms of diet, medication, laboratory tests, etc., according to the needs of the condition and treatment. Outpatient orders are often concise and clear, while inpatient orders are divided into long-term and temporary orders, including nursing routines, nursing levels, types of diet, body positions, various examinations and treatments, drug names, dosages and usage. Most of the doctor's orders are mainly carried out by nurses after being confirmed by the nursing computer class. This suggests that the nursing computer class acts as a safety lock for the doctor's order, ensuring that the order to be executed is intact, but in the sense that the majority of the nurse's work is assigned by the doctor, the doctor undoubtedly has a higher level of professional autonomy. In the medical field, doctors also have a higher professional status than nurses, and the fact that nursing staff are mostly female is also a reflection of gender and professional bias in the current medical system.
However, when trainees interact with nurses, the power relationship is different. Doctor's orders are generally issued after the daily routine ward rounds, and the medical orders to be issued by trainees basically rely on the prompts of the senior doctor during the ward rounds. However, the senior physician will not explain whether the prescribed medication requires additional medical procedures before or after use. As a result, this kind of "incidental" knowledge has become the most headache for nursing computer classes. In the WeChat group of medical communication in the ward, it is common to see the instructions issued by the nursing computer class to revise the doctor's order: "18 beds should be refunded for the drugs needed for gastrointestinal endoscopy, and the prescription will be refunded for Dajisu, Heshuang and Percy Breast". "There is already an ordinary colonoscope in the 32nd bed, why do you need to prescribe an anesthetic gastroscope?" "Please ask the 15-bed doctor to make up the accompanying doctor's order today."
For trainees, they have five or even eight years of basic medical education. Once they pass the medical practitioner examination and obtain the training certificate, they are institutionally qualified doctors. But in the eyes of nurses, they can only be qualified if they can prescribe "no problem" medical orders. In the department, it is common to hear doctors lament that "young doctors are not as good as old nurses". The old and new here are mainly the accumulation of experience, and it is related to seniority. Therefore, the older nurses are also the objects of study and consultation by the trainees, and the trainees call them "teachers". In the WeChat group, the nurse was publicly corrected, and the trainees were naturally a little embarrassed, or lost face, and they needed to re-issue a "correct" medical order, but in this process of "knowing the mistake and correcting it", they were also one step closer to the goal of qualified doctors.
When learning from senior nurses in doctors' orders, the trainees maintain a humble attitude towards learning, but once the nurses cede their "business scope" to the trainees, resentment and potential conflict are inevitable. During the busy hours of the gastroenterology department, nurses will also assign trainees to complete tasks such as blood pressure and temperature measurements, and during the epidemic prevention and control period, trainees will also participate in checking the health codes of patients and their families, which are usually considered to be the work of nurses. The trainees who have just entered the department have just arrived, although they are a little aggrieved, most of them are still obedient and choose to forbear, but the trainees who have been rotated many times often complain:
Other departments are measured by nurses, body temperature, blood pressure, I don't understand why the gastroenterology department needs doctors to do it, whose job is it?!(20211228 Dr. T)
In fact, it is to squeeze the little doctor. If you look at it, you will see that the gastroenterology department is very short of manpower right now. (Dr. 20211228 L)
Research on jurisdictional conflicts between nurses and doctors shows that nurses are more vulnerable than doctors, with the former often resorting to strategies to blur the lines between nursing and medical care in order to expand their practice and gain more jurisdiction. The conflict between the jurisdiction of the trainees and the nurses is because the nurses give up the jobs that should belong to them (her), and the recipients of the jobs are not the official "big doctors", but these new, marginal "little doctors". The "big" and "small" here are naturally related to seniority, which illustrates the importance of medical experience accumulation, and also highlights the image distinction between doctors due to the difference in authority and seniority. The interaction between the trainees and the nurses shows that jurisdictional conflicts not only arise from competition for business, but also cause complaints about "whose job it is" when one occupational group transfers unskilled business to another occupational group in the same workplace to ease their own work and increase the burden on others.
(3) Gains and losses in getting along with patients
The professional interactions of trainees above have already involved their relationships with their trainee peers, regular doctors (mainly teaching doctors) and nurses. In clinical departments, they deal with patients and their families the most. After the patient enters the ward and the specific bed is confirmed, the basic information card, the label of the nurse in charge of the bed, and the doctor in charge of the bed (Gui Peisheng) are also inserted into the information compartment at the head of the bed. Next, the bedside doctor begins to take the patient's past medical history, the course of the disease, and sign a series of informed consent forms regarding the treatment and its risks. This is the initial interaction between the trainees and the specific patient.
One morning, a new patient was admitted to the department. The patient was admitted to the hospital for intestinal tuberculosis and was later diagnosed with Crohn's disease, and was discharged from the hospital with abdominal pain, but after the doctor informed him of the treatment plan, the patient gave up the treatment due to family financial reasons. At around 4 p.m., Dr. Huang received a WeChat call from a senior doctor, asking her to sign a declaration of abandonment of treatment. Although the patient gave up the treatment, he still asked Dr. Huang why the original treatment had an adverse reaction (abdominal pain), and when faced with this professional question, Dr. Huang could not answer it clearly, and only urged the patient to sign it. After the patient signed with some disappointment, Dr. Huang immediately completed the discharge procedures for him, wrote a discharge summary and submitted it to the senior doctor for review. After work, she was in a depressed mood.
I actually regretted it when I went back to the duty room. Because he kept asking, but I didn't understand the questions he asked, didn't the professor explain them to him? Although I am the doctor in charge of the bed, there are some questions that I really can't answer. (Dr. 20211210 H)
From the patient's point of view, although the mask covers the face of the doctors, and many patients who do not know the doctor's profession cannot learn the specific information of the doctor in charge of the bed during the few days of hospitalization, they can observe who is the "manager" and who is the "leader" from the position of the doctors on ward rounds, the time they spend in the ward, the order of reporting, and even the aura and title. Therefore, many patients and their families will seize the time of the professor's morning and afternoon rounds to inquire about their conditions, and sometimes the patient's family members will come to the duty room and ask the doctor in charge of the bed to help contact the professor to ask questions. Receiving standardized training in the hospital is the only way for trainees to become qualified doctors, but in the face of these young and inexperienced "little doctors", patients still do not want to become the object of medical teaching, let alone the object of "trial and error". When patients and their families are more willing to consult the "big doctors", the question that remains in their minds is still "Are these little doctors reliable?"
Although they are inexperienced, they are in the middle of the "medical student-doctor" position, and they may also resolve the communication barrier caused by the unequal status of doctors and patients. Compared with the seriousness, authority and unquestionability of the "big doctors", the humble status of these "little doctors" is more relatable to the patients. During an early round, a middle-aged male patient saw a group of doctors enter the room and immediately pick up his glasses from the bedside table and sit up cross-legged while wearing them. He greeted all the doctors and then said to the professor in charge that he wanted to thank the young doctor who had brought him to the hospital that day, because the doctor had shown great patience and made proper arrangements for him throughout the admission process. Although these emotional appeals of patients will not be recorded, the teaching doctor still seized the opportunity to remind other trainees of the equal importance of "clinical thinking" and "humanistic care".
The instructor not only said that, but actually practiced it. Several of the faculty members (and others) walk around the room before each end of the day to check on new patients, assess the need for further testing, and sometimes chat with patients and families to encourage them. It is through these words and deeds that the trainees learn from the supervising doctors and other formal doctors how they interact professionally in the hospital, so that they gradually transform and adapt themselves from the role of medical students to the role of doctors. In this process, clinical training actually provides a realistic scenario of professional interaction and the opportunity to play a professional role. From this point of view, discipline training as a professional socialization is a process of reproduction, which transmits the culture of hospitals and doctors to these novices, so as to shape them into qualified doctors recognized by the professional community. But readers should not be mistaken that these trainees are just passively accepting these norms and values, or "tool people" who go against the grain. To a considerable extent, they will also actively reflect, as mentioned in the above case, regret their immature performance in the diagnosis and treatment process, and even complain about their high workload, weighing the advantages and disadvantages of their marginal status, so as to grow in continuous grinding.
▍Summary and discussion
Based on a field survey of an internal medicine ward, this paper discusses the process of professional socialization before entering a formal job and becoming a qualified doctor. This process has an anthropological "transitional" character, because under the current system of clinical training, it is only through this transitional period that they can participate in medical activities as marginalized in order to achieve social and professional status and become qualified doctors. The basic points of this paper can be summarized as follows:
First, once the training has a transitional nature, then the edge is the stage that the trainee will inevitably go through. As a profession socialization, the purpose of regular training is to promote the transformation of medical graduates into qualified doctors. This transformation is not achieved overnight and instantaneously, it always requires socializers to go through a liminal, marginal stage before they can achieve a new professional identity. In this sense, marginality is an intrinsic attribute in the process of professional socialization of regular trainees.
Second, the marginal and ambiguous identities of the trainees during the training period are the basis of their professional interactions, and they are also the source of contradictions and conflicts. Regular training is an important part of post-graduation education, and before passing the discharge assessment of regular training, regular trainees are not really doctors strictly speaking, and they have not been able to enjoy the clinical autonomy of formal doctors, nor have they been able to fully integrate into the professional community of doctors, and have always been in a marginal position. The identities of the marginal are not only manifested through external symbols, but also constantly constructed and reinforced in professional interactions, and become a source of conflict between them and the hospital (department), the teaching doctors, nurses, patients and their families, etc.
Third, the fringe is not a completely negative force, it also has a generative significance, indicating an imminent shift in competence and professional status. The fringe only means that their situation is awkward and difficult to classify, and it does not indicate the solidification of status. The socialization of training as a transitional period means that it is a transformative and groundbreaking process. Compared with other professions, the pre-service training of doctors is longer and the requirements are more stringent, because these future doctors are not only faced with the question of right and wrong, but also the contest between life and death, which shows the rigor and sacredness of the doctor's profession.
The ethnographic analysis of this paper shows that although occupational socialization runs through the whole career, the transitional period of occupational socialization has a special significance for the trainees. From a theoretical point of view, once we focus on the "transitional" period of professional socialization, using the "periphery" of this process as a link, then the tension between the three perspectives of professional socialization: structure, institution, and individual can be resolved. In the transition period of occupational socialization, the edge has the meaning of one and the same, which is not only the inevitable result of institutional embeddedness and social structure reproduction, but also the basis of the professional interaction of socializers (trainees), and is constantly constructed and strengthened in the interaction. Further, the purpose of professional socialization in the transitional period is not only to reproduce the professional culture, but also to transform and generate the experience during this period for the trainees. After the grind, a new identity is coming. Thus, the edge is both the edge of the structure and the rebirth of the structure. Studying occupational socialization in transition shows us the possibility of resolving the contradictions between different perspectives of occupational socialization.
If we consider discipline training as a transitional occupational socialization, then we must also deal with the tension between occupational socialization and transitional etiquette at the level of social structure. This is because the former has the trainee's meaning-making, and its fundamental purpose is the reproduction of the social structure, whereas as mentioned above, the most important liminal (periphery) stage of transitional rituals is more focused on the vision of communion and community. We need to bear in mind Turner's reminder that blending and community (such as the logo of the physicians' community symbolized by the "white coat" in the main text) may be only one aspect, and when broken down, we will find that the forces of structure are still everywhere, and the result is a mutually compromising and dynamic relationship between structure and community, which eventually leads to the strengthening of structure. If we recognize this, we will understand that professional socialization and transitional etiquette are superficially opposite in the dimension of social structure, but in fact they are on the same path. Table 1 compares different analytical perspectives of occupational socialization for the reference of subsequent researchers.
Finally, this article would like to comment on the significance of the training system for the medical system and the career of doctors. On the one hand, it is of course necessary to achieve the balance of medical resources and improve the overall quality of clinicians, and this process is actually the inheritance and continuation of hospital culture and medical rules. The uncertain and ambiguous identities of the trainees are at the root of many professional conflicts. Therefore, the professional socialization of discipline training as a transitional period means the reproduction of institutions and social structures, which is top-down, even condescending, institutional rationality and power operation, and pain and suffering are full of it. However, from the perspective of its transition, regular training also indicates the gradual improvement of the vocational ability of the trainees, the imminent change of social identity and the promising career in the future. Only by looking at the above results dialectically can we give a fair evaluation of the exploration of China's training system and its impact.
Baker et al. judged in the early 60s of the 20th century that "in recent decades, both new and old occupations have tried to increase the time required for education and training." Medicine has taken the lead in this". At present, this situation continues unabated, and the age of successors in various professions and industries is delayed, and they go through more "tests" and longer transitions before officially entering the profession and industry. Compared with the induction training of other professions such as teachers, lawyers, securities specialists, and social workers, the training of doctors is long and demanding, but they all have the same reproduction and transitional significance. We hope that when future researchers discuss other similar occupational socializations, they will consider the reproduction and transition of socialization at the same time, so that the contradictions, conflicts, and transformational meanings in this particular period will be analyzed and understood as possible.
This article is excerpted from Sociological Research, Issue 3, 2023, and was originally titled "Career Socialization in the Transition Period: Marginality and Conflict in Career Interactions for Trainees". The article represents the author's views only and is for readers' reference.