Sot.

Ser. Med. Vol.20.iho.

2.pp. 133-143,1985 0277-9536/X5
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PROFESSIONAL SOCIALIZATION AND SOCIAL CONTROL:

FROM MEDICAL STUDENTS TO GENERAL
PRACTITIONERS*

ISABELLE BASZANGER
CNRS, Centre d’Etude des Mouvements Sociaux. 54 Boulevard Raspail, 75270 Paris, Cedex 06, France

Abstract-Most American research considers the assimilation of the norms and values of a given profession
to be the most important way in which that profession controls the socialization of its future members. This
view of social control is based on a problematic pattern of socialization. Using the results of a research into
the socialization of general practitioners, a different approach to this problem of social control is suggested
that takes into account the specific manner of integration into the university-hospital structures and the
ways in which future doctors gain access to the professional world. The hospital with its scientific logic is thus
the chief instrument of social control, even though this control is limited by the very nature of the hospital:
hospital training only partly controls the application of this scientific knowledge by general practitioners.

The question of social control is at the centre of standpoints but elaborated a common approach to
problems of professional socialization. To study the basic questions such as: how are students transformed
period of schooling that opens the way to a profession into phsicians? and: how much does the profession
involves asking how the profession sets its boundaries control this transformation?
and determines its identity through mechanisms for The present article examines the answers given to
granting or refusing admission to would-be members. these questions. After a close look at the model of
This questioning leads even farther: what means does professional socialization that these studies, beyond
the professional group use in its attempt to make these their differences, have proposed, the problems raised
members conform to a model that is proposed and by it are explicated.
shared by the profession? Finally, inquiry about this
period of schooling must assess the implementation THE ASSIMILATION OF VALUES AS A MECHANISM OF
and effectiveness of these means by taking into account CONTROL?
the active roles of those who are to be socialized. The functionalist position hypothesizes that school-
Professional socialization, social control and deviance ing is the key moment in professional socialization.
are closely related topics. Once and for all during this period, the profession
Studies of professional socialization have implicitly takes control over its members by initiating them into
raised questions about mechanisms for reproducing their new culture. According to Merton, who develops
the profession. The reason for this becomes clear if we this hypothesis,
recall that among the formal criteria for defining a
trade or craft as a profession are education and “The profession of medicine.. has its own normative
training. According to Freidson, what distinguishes a subculture, a body of shared and transmitted ideas, values
profession is “its legitimate, organized autonomy”, the and standards toward which members of the profession are
fact that expected to orient their behaviour. The subculture, then, refers
to more than habitual behaviour; its normscodify thevaluesof
“professions are de/ih’erate!~~granted
autonomy, including the the profession” [4, p. 7 I].
exclusiveright to determine who can legitimately do its work
and how it should be done” [I, p, 721. These values and norms define the requirements of the
physician’s role [S]. Since many doctors. during
By its essence, a profession must define and control the practice, face situations in which they can hardly live
education that leads to membership. Therefore, it has up to these requirements, they have had to acquire
an active part in the mechanisms of socialization. exactly those values that have been made for
The medical profession has often been considered regulating their behaviour.
the archetype of the professions. Questions about
professional socialization have crystallized around it. ‘. the effective acquisition of these values by medical
During the mid-1950s in the United States, the students is not a matter only of’medical ethics’ which attaches
concerns of sociologists converged with the interests of significance to these values in their own right. They can be
the medical profession in training, through a new considered, quite neutrally and without reference to their
curriculum, the best possible physicians. The now undoubted ethical status, in terms of their instrumental
significance for the effective provision of health care.. They
classical research studies, which came out of this are, presumably, values which serve as effective means to a
juncture [2.3] started from different theoretical socially important end.. [namely] facilitating sound medical
practice.. ,. Medical schools are socially defined as the
guardians of these values and norms. The schools have the
* This article was published in altered form in Rewe,fr. Social. double function of transmitting to students the cognitive
22,223-245.1981.1 wish to thank J. D. Reynaud for his standards of knowledge and skill and the moral standards of
helpful comments. values and norms” [4, pp. 76-771.
133
134 ISABELLE BASZANGER

Accordingly, the functionalists investigate how the To account for a minimum of social regulation. the
medical student acquires these norms, which. by authors of this book implicitly reformulate the
definition, enable him to function efficaciously. problem in terms of the internalization of values.
Merton defines socialization as Merton’s definition is relativized through the idea of a
selective assimilation of the medical culture. As they
“the process through which individuals are inducted into internalize this culture’s kev values such as re-
their culture. It involves the acquisition of attitudes and
sponsibility and clinical experience. students redetine
values. of skills and behaviour patterns making up social roles
them with respect to their immediate situation. The
established in the social structure” [4, pp. 40-41 1.
final word is that professional values. particularly the
core value of medical responsibility. are assimilated.
The student’s education is, we might say, certified by
Beyond their differences. functtonalists and in-
his acquirement of an internal balance between paired
norms with both of which, as a practitioner, he will teractionists admit that the acquirement of values by
students is a mechanism of social regulation. Within
hardly be able to comply [6]. This balance places the
new doctor squarely within his peers’ system of values. the present article, a single value-medical
The socializing institution thus controls young responsibility-will be used to discuss this proble-
physicians who ‘think, act and feel’ [4, p. 71 like matic assertion. This discussion will throw light capon
members of the profession. the consequent limitations of the hypothetical model
Unlike functionalists, symbolic interactionists deny of professional socialization. The results of a survey
the possibility of a general theory of the professions, [lo] about the socialization of general practitioners.
which they consider to be the objects of daily practices (GPs) will be used to propose another approach to the
[7,8]. There is no predefined professional role that problem of the control exercised by the profession
students must learn to play. The authors of Boys irz during the socialization of members-to-be.
White concentrate upon the educational institution According to both of these theoretical approaches.
and upon the ‘student’ status. Medical students are not there is a medical culture that has no contact with the
so much junior professionals as members of a ‘lay’ world. Students have to discover and internalize
subordinate group who are striving to adapt to and this culture’s key values so that they may. in turn.
succeed in a very hierarchical organization. participate in it. But to what extent do they actually
have to learn-discover and assimilate-a value such
“The young man finds out quite soon that he must learn first as responsibility? In the lay world, this value pervades
to be a medical student; how he will act in the future, when he the image of medicine. No studies are needed to prove
is a doctor, is not his immediate problem” [3, p. 51. this. Literature of all sorts. television serials and
movies portray medical responsibility in the form of a
Like other persons in large organizations, students conflict between the physician as a private person and
have to set their ‘levels and directions of effort’ [3, p. 91 as a dutiful professional. Of course, his principal duty
As a group in medical school, they draw up (sometimes is to take full care of ‘his’ patients. Detective novels
covert) strategies in order to graduate. Becker et al. even go so far as to ‘catch’ doctors in the act of
show how they develop a subculture that provides becoming irresponsible. Many other images could be
them with a degree of autonomy from authoritarian called to mind that show doctors being crushed under
demands. This autonomy is important for the control the weight of the responsibilities that they have to
that the profession exercises over education. What is assume.
definitively disproven is that students, passive like Apparently, medical students do not need to learn
modelling clay, let the school socialize them. Their this value; rather, they have to learn how to use it
degree of autonomy limits the extent and nature of the within a professional practice. They are confronted
profession’s control. with-and socialized through-the way that the
profession actually functions. This functioning has
“One thing IS certain, they never develop exactly as the faculty more to do with the profession’s practices and
would wish them to” [9. p. 1971. hierarchy than with its values in themselves. In the
passage about pairs of norms. Merton hints at the
Although BOJS in White shows how student necessity of learning to redefine a situation:
autonomy limits professional control, it does not
demonstrate how a minimum of social regulation “For each norm there tends to be at least one coordinate
occurs. Of course, the authors do not directly reason in norm, which is, If not inconsistent with the other, at least
these terms, for socialization is taken to be a sufficiently different as to make it difficult for the student and
situational adjustment-students are socialized into the physician to live up to them both” [4. p. 721.
the institution or, in the authors’ words, ‘in-
stitutionalized’. To face up to situations after Medical education teaches students how to blend
graduation, new adjustments will be necessary. The incompatible norms into a whole that works
experiences earned at medical school will be of little consonantly. Physicians have apparently learned to
use. Here, interactionism runs up against a general balance these pairs of norms. but how is this balance
difficulty: how to conceive the continuity between achieved‘? From norm to coordinate norm is a
these situations’? Although interactionists meti- continuum that makes it possible to explain all shades
culously describe actors’ adjustments over time within of attitudes. Beyond its legal and lay implications. is
a given situation, yet time is ‘pin-pointed-it is taken the physician’s responsibility so ‘dramatic’ if anything
to be the immobile framework of the situation that at all can be justified?
calls for adjustments. In Boys in White, this lapse in If responsibility is taken to be only a value, a
continuity opens a gap between present and future. confusion tends to arise between. on the one hand.
Professional socialization and social control 135

responsibility in the practical, factual sense of the word passively, socialized-to learn the values of the
(and in this sense, it is not the prerogative of the profession rather than those of professionals. Doctors
medical profession alone) and, on the other hand, the and professors are only bearers of norms whose
way responsibility as a value is used by the profession. attachment to widely different practices is not taken
Finding out whether students directly assimilate or into account. Furthermore, the relationship that
else redefine such a value would probably not be of brings students and faculty together is not really
much help. As Becker et LII.suggest, what separates clarified. The socialization process is isolated from the
medical students and physicians is not so much the underlying network of social relations, whether inside
conception of responsibility as their relative positions or outside the profession. As a result, what had been
in a ranking system. These positions on the but a means for dealing with the diversity of social
profession’s hierarchical ladder create various possibi- reality is reified.
lities for assuming responsibility. This set of difficulties led me to bring medical
education and professional integration together in
ANOTHER APPROACH TO SOClALlZATlON : order to deal with the processes of socialization. These
THE CASE OF GENERAL PRACTITIONERS processes cannot be reduced to the period of schooling
that all physicians have had in common. They must be
A problematic model of’sociulization
analysed at least up to the point at which both rather
Beyond differences. the functionalist and inter- definite career choices are made and professional
actionist model of socialization assigns much weight to integration has effectively begun. In this article,
the period of education. There are, however, three professional socialization refers less to the process for
problems with this model. In the first place, it training professionals than to the mechanisms that
postulates, at the start of the socialization process, a lead to exercising a profession. In the case of medicine,
‘lay’ student body that has no past, is extrinsic to the these mechanisms involve the student’s choice of an
medical profession and only exists in opposition to it. academic discipline and, within it, the way that he as a
Secondly. it also posits a homogeneous but incomplete new doctor will actually practise medicine.
socializing institution since it leaves out of the picture Such an analysis entails studying how young
other-predominant-functions (medical care and physicians set up professional practice. Regardless of
research) of the hospital system. As a consequence, the the chosen discipline, professional integration can
status of students is not analysed in terms of their occur in various ways that depend upon the
position within this institution’s division of labour. individual’s choices, which are the outcome of what can
These overlooked functions, in fact, determine a be called a process of professional socialization. Young
productive role for students within the hospital doctors’ career lines have been staked out upon a
organization. Finally, this model delineates a unique common field because of the organization both of
process limited to a precise period, namely the time of schooling (universities and hospitals) and of the
schooling as a sequence of events programmed by the profession (replacing colleages and setting up prac-
institution, Although, as mentioned, these two tice); but other forces (having to do with previous
dominant theoretical approaches analyse the content socialization or participation in extracurricular
of the socialization process differently. both of them activities) continually pull upon these lines and
make this process and schooling perfectly overlap and, reshape this field. This constant interaction of forces
as a result, globally assess socialization without from various, sometimes conflictive, sources (such as
referring either to the actual practice of medicine or to the faculty, hospitals, professional segments and
professional integration. Hence, choices determining personal roots) either helps or hinders the student
the nature of this integration are not taken into physician on his way toward his first professional
account. In this model. the outcome of the educational practice. Owing to this interaction, career lines
process is a new entity: the physician, or rather the ideal running across this field of forces cannot be projected
typ of physician. into a single meeting point, at graduation for instance.
Any attempt to more accurately describe this ideal The socialization processes have many outcomes.
type runs up against the diversity of real doctors. This conception of professional socialization has
Nowadays. diversity rather than uniformity character- been applied, herein, to GPs. Before delving into
izes the medical profession. Look at the way the explanations, a few comments are necessary to
profession is organized so that distinctions are made in describe the French medical system, particularly of
terms of both external structural variables (types of education.
practices. forms of payment for services) and internal The 1958 reform of medical education and hospital
ones (specialties). Even the specialties are subdivided structures [ 121 has oriented the whole system around
into professional ‘segments’ [ 111 each of which defines two poles : general medicine and university-related
for its members components of the physician’s role. All teaching hospitals (centres hospitalo-universitaires,
this puts the ideal type of physician in its place. hereafter CH Vs). Whereas CHU doctors are the
Functionalist and interactionist research has sys- dominant group in the medical profession, general
tematically emphasized the homogeneity of this role medicine has been gradually pushed out onto the
and the cohesion of its components. The concept of fringes of the CHUs to the point of becoming a
professional socialization has thus been transformed secondary discipline, which is mainly used to sort out
into a model-an act that has theoretical implications. or deselect candidates so that specialized services are
The principal one is that reality is made not richer but not overloaded. Although general medicine is prin-
poorer. The coherency of the proposed model cipally exercised outside hospitals, all doctors are
presupposes the exclusion of social actors as such. trained in CHUs.
Students come into this model only to be. more or less At the time of the survey [13], medical education
136 ISABELLE BASZANGER

was organized as follows. The first level includes 2 essential. Since the hospital svstem does not need them
years of undergraduate study in basic sciences. The for its staff, does it not deliberately treat them like
second level comprises 4 years of which the first is also rejects from a socialization process that has not been
devoted exclusively to basic sciences but each of the made for them‘? Or on the contrary but for the same
other three, to both lectures in the classroom and reason, does the profession have other means of
clinical training in the CHU. During these 3 years, controlling their education and training? Not
students are officially Ptudiants-hospitaliers, ‘hospital provided by the hospital institution itself, these means
students’. All student physicians go though the same might come into play in other places and during other
first two levels of education. During a third one-year phases.
long level, they undergo, in the CHU, a training period Loosely structured interviews of GPs at the start of
(stage interni) that presumably enables them to practice seemed to be the most appropriate way to find
exercise general medicine. Actually during this seventh answers to these questions. The aim was to sketch
year of schooling, they have no clinical responsibilities. biographies [ 15 ] over a period of more than 10 years.
Their experiences are much the same as whenever they For analysis, I retained 37 interviews with GPs who
were hospital students. For this reason, most of those were setting up or had just set up private practice as
wanting to do general medicine try to learn how to well as a few other interviews with GPs who were
practise it by replacing private practitioners. After this postponing this act. During interviews, parallels were
seventh year, students graduate as physicians. Some of drawn between events having to do with medical
them may decide to specialize by obtaining a CES education and those related to extracurricular or
degree (Certljicat d’Etudes SpPcialisPes) after, on the background factors. To ‘ground’ [16] my in-
average, 4 more years. They have to pass, each year, terpretation in the everyday reality ofmedical school, I
examinations and, in the last year, a national spent a quarter in a Parisian CHU and. particularly, in
examination in their specialties. a service specialized in blood diseases [17]. Phases
So far medical education in France does not during the process for socializing GPs were thus
fundamentally differ from that in other Western discerned and will now be briefly described in relation
countries. There is one noteworthy difference however: to questions about control over training.
specialists can be trained through a second program.
Through an extremely competitive examination, the Medical school years
concours de l’lnternat (not to be confused with At the centre of medical education. the CHUs bring
internship), the CHUs recruit candidates for training together functions of teaching, research and pro-
as future staff-members. Only students who have fessional practice. They follow an internal logic, or
passed the lnternat may pursue careers in the CHUs rationality, that does not place teaching at the top of
and expectantly enter the profession’s elite [ 141. To sit their priorities. Moreover, these other functions make
for this examination, students have to have been demands on students. The ‘hospital student’ status is
admitted to the third year of the second level. In other defined, in fact, by a socializing institution that differs
words, the decision is normally made before the significantly from other academic institutions. Because
completion of this level common to all medical of its specificity, roles can become ambiguous; and
students. Academic destinies, or fates, differ depending conflicts arise. The student status does not necessarily
on choices at this point. Stopping our analysis here, count above all else, for students have a productive role
before students’ careers diverge and before they obtain in the CHUs.
any professional qualification, would lead us to posit This institution provides two formally recognized
an ideal type of physician. situations for training: during doctors’ rounds with
The way medical education is organized reflects the students and during students’ duties on wards. GPs
way the health system is organized: at one end, the CHU vividly recalled these eventful situations during which
elite and, at the other, GPs. This organization incited minimal socialization occurs. The implicit con-
me to study the socialization of GPs rather than of tradiction in the ‘hospital student’ status is part of
specialists for several reasons. First of all, a critical these situations. During the rounds, students are
phase of student GPs’ training takes place outside the reminded that they are ‘students’. They remain passive.
CHUs during replacements. Whenever they seek out During ward duty on the contrary, they are active and.
replacements of practising GPs, their socialization in many ways, productive.
process does not coincide with the period of schooling Students’ activities follow the beat of the ward
and is no longer organized by the CHU. Secondly, GPs rounds. There are usually three a week: one by the chef’
constitute the category of professionals that the de clinique. one by the agrPgG and one by the chej’de
socializing institution does not train for itself. Since service [14]. The ‘grand round’ by the last normally
general medicine is practised privately as a ‘liberal brings together doctors from all ranks. It is part of
profession’ (in other words, by self-employed pro- medical folklore. With their patients’ records in hand,
fessionals), GPs as such are seldom present in the students must be ready to answer any and all
hospitals. Students in general medicine hardly have a questions. Wishing to go unnoticed. they usually
glimpse at their future role as long as they stay within cluster as far as possible from the ch<J an act that
the CHU. This institution does not directly furnish the reflects their objective position in the ranking order.
GP role with contents. Notwithstanding that they do not receive from these
In spite ofbeing the largest group within the medical rounds the impression of participating in medical care
profession, GPs, often presented as the profession’s or in hospital activities. they do thus learn-mainly
unwanted children, have been pushed out onto the through watching-various ways to behave toward
fringes of the hospital system. Therefore, understand- patients. For instance, they observe how to neutralize
ing how the socializing institution exercises control is patients by disqualifying what they say or how to act
Professional socialization and social control 137

toward those who are held blameworthy for their academic requirements; but there is room for
condition (e.g. alcoholism). During rounds, some maneuvering within these limits.
students come to see how far certain values, including Why is this so? Because the CHUs as university-
responsibility, exalted in discourse are from the reality related hospitals have not been made for the bulk of
of medical practices. students. They have developed research and teaching
All students are required to spend a given number of functions, but mainly for members of the medical tlite
hours on duty in the hospital. These hours are whose careers are grounded, through the Inter-nut,
scheduled by the wards or by the hospital itself (in within the CHUs themselves. The model of pro-
admissions or on the emergency ward). Assignments of fessional integration proposed by this socializing
the latter sort, so-called ‘door duty’, occur more institution emphatically distinguishes between, on one
frequently. Time spent on duty provides an oppor- hand, the internes who have passed the Internot and,
tunity for training. The student evaluates cases (an act on the other, the second- and third-level students in
that is not among his daily chores), has the chance to hospital training. Because of this distinction, students
learn technical gestures and manipulations and, often, have room for drawing up strategies of adaptation
has firsthand contact with patients (even if during more or less independently of the CHU. Lacking
emergencies) in the absence of any intermediary from clearly defined roles and positions, they have to ‘learn’
the medical hierarchy, apart from nurses. Because of the hospital-how to obtain instruction and what
the hospital setting, these experiences are not identical activities to perform. Each student must adapt himself
to what happens when a patient goes to a GP’s private and create his program. In this sense, his socialization
office. Nonetheless ward and door duties are within the institution lies in his own hands.
symbolically important for the formation of a Three types of student adjustments to the hospital
professional identity. .system have been constructed out of field work and
For the institution, this student-patient contact interviews. Unlike the situational adjustments de-
carries a risk that the CHU assumes in order to push scribed by the authors of Bqvs in White. which come
students to ‘take the leap’. Besides, the hospital has the out of negotiations between students (or rather a
means to make up, the next day, for any mistakes (at student body) and the faculty, these three types are
least we hope so). Through its hierarchical organi- personal, or individual, implicit means of ‘staying
zation, the socializing institution allows students to above water’. The most frequent way that a student
play a minimal role. The first role that the student adjusts is to adapt offhandedly, when necessary. This is
physician tries is that of hospital doctor. The all the easier inasmuch as hospital students have a
importance of ward and door duty reaches even farther position or status in default or for want of anything
inasmuch as students may assume responsibility in the better having been prepared by the socializing
factual sense of the word. Although time spent on duty institution. In this first type of adjustment, the
is necessary to the running of hospitals, it is also student’s integration into a hospital service depends
organized to enable students “to acquire a good upon the reception that he is given. This adjustment is
experience of what must and must not be done in more an effect than a cause of integration. A second
emergencies” [ 18, p. 111. type emphasizes the student role to the detriment of
A reservation has to be made about control by the any integration. For instance, the student does his job
profession over this phase of the socialization process. well but unenthusiastically or even refuses ‘the least
Given the present day conditons under which most of little effort’. Students who are critical of the hospital
the hours on ward or door duty are spent, the system often adopt this strategy. ‘raving staked out a
profession does not fully control the earned ex- place for themselves on its fringes, they are less
periences. Although a student’s evaluations and responsive to hierarchical differences and less sensitive
actions during door duty may be contradicted by staff- to their own position. A third type of adjustment
doctors the next day, he will hear nothing about these occurs less often [19]. Using a ‘parasitic’ tactic, the
criticisms because he will have been assigned for duty student makes the most of any opportunities for
on a ward ! receiving training or assuming responsibility. He takes
Ward or door duty and the rounds are the two high his fate into his hands and pushes back the limits that
points of socialization within the institution, but the the institution has set on his role.
way a student is socialized depends upon his personal Although these types of adjustments cannot be
adjustments and choices, which the CHU does not expounded herein, attention must be drawn to the
necessarily control. Unlike the United States, in the value of external factors for explaining them. Among
195Os, the socializing institution in France does not these factors that lie outside the CHUs and beyond
offer students a highly organized program. As their logic, some have to do with the medical
mentioned previously, it has established two thresh- profession but not with the socializing institution. For
olds where decision must be made, namely instance, an attraction toward general medicine leads
whether or not to sit for the lnternat examination and some students to enroll in medical school although
whether or not to specialize by enrolling in a program they have not been adequately prepared to know how
for the CES degree. Before one or both of these to ‘decipher’ the hospital system and make room for
decisions. which must be made respectively starting in themselves therein. Attracted to general medicine
the fifth year or at the end of the sixth year of medical through the example of (usually distant) relatives or
school. students make other choices that characterize even through childhood experiences with a family
their personal adjustments to the hospital system. For doctor, such a student usually adjusts offhandedly to
instance, they have to choose the wards on which, as each new situation as it crops up. In fact, most students
hospital students, they want to work. These choices who adopt the first strategy of adjustment are. in social
are, of course, restricted within the limits set by terms. far removed from medical circles. Another
138 ISABELLEBASZ.ANGER

external factor is involvement in nonmedical activities, replacements follow the guidelines laid down by the
such as outside jobs, student unions, politics or Conseil de i’0rdre des .lfi;dr~~ir~~ a sort of General
religious groups. These commitments incline students Medical Council. The frequency of these opportunities
toward the third type of adjustment. By diversifying argues in favour of an analysis of socialization that
the participant’s experiences and-unlike his student connects schooling to the beginning of professional
status-providing him with social ‘roots’, these integration. Students may replace GPs on appointed
activities furnish him with a framework for analysing days or every day for up to 3 months. In private offices.
the reality that he faces as a student. He adapts to-but pay conditions are. in principle. agreed upon by the
does not necessarily intend to become part of-the two parties. In nonhospital-related clinics or dispen-
CHU. Accordingly, he tries, for instance, to maximize saries. the student substitutes are subject to the
his learning experiences by taking training in a second- conditions that govern all employees.
class hospital where he will have more and broader In the careers of prospective GPs. these replace-
duties. His decision is not motivated by any ambition ments are a critical phase that lies outside the
for a hospital career since he is too ‘far’ from the best socializing institution. Since the CHUs do not. as such.
hospital services. include representatives of general medicine in their
These external factors weigh upon the decision ranks, would-be GPs find out, during replacements.
whether or not to become a GP and elucidate for us the what general medicine is like and what its standards
choice between two different paths that each student are. Most student substitutes have to create. if need be.
has to make when deciding whether to sit for the and test their conceptual framework of general
Internat [20]. If he prepares for this examination, he medicine in actual practice. This framework is
will scarcely have time for any other activity. External constructed and reconstructed during replacements.
factors carry their full weight here. His decision is often This experience generates choices and leads to
expressed in terms of life-styles, personal interests, adjustments that emphasize certain dimensions in the
family concerns, etc. In short, he chooses ‘not to role of GP that the substitute is tiying to construct.
sacrifice his life’. The decision to study for the lnternat During replacements. students face a new
involves more than temporarily or permanently giving situation-consultations in general medicine -which
up other interesting activities. It is a choice between apparently raises few technical problems. The
not only two different paths but two different worlds. substitute has at his disposal the GP’s files. By going
Perhaps uis-ci-cis such an alternative, factors having to over previously administered treatments, he is initiated
do with personal lives and relations carry decisive to the prescriptions of general medicine. This source of
weight upon whatever choice is made [21]. Integration information should not be overestimated since the GP
into these two worlds is at stake. The one world-the is not there to explain his records, Moreover. the
medical hierarchy and Clite-is more distant. substitute, who seldom sees the sick person a second
Relations, friends and family make it seem nearer and time, cannot evaluate the efficacy of treatment.
integration possible for students who choose the path Substitutes do not think that hospital pathology. to
leading to hospital careers. To most interviewed GPs which they have been accustomed. and pathology in
however, nothing was offered as a counterpart for their general medicine, which they are discovering, are
involvement in activities and groups outside the worlds apart. They have new experiences to acquire.
medical profession. Their decision not to sit for the but basically, medical care-diagnosis and therapy-
Internut seldom ran up against any obstacle. It was is the same as what they have observed in the CHUs.
backed by arguments, in common to most students, Replacements are training exercises during which
about rejecting hospital medicine along with its way of substitutes adapt what they have learned to medical
dispensing care and. especially, its ranking order. The problems that. though new, lie on the same scientific
dead weight of hierarchical relations borne by’ students continuum. From this point of view. no gulf separates
tips the scales: the hospital and its doctors serve as a hospital from general medicine.
negative model. Nonetheless, this new situation that substitutes face
The professional klite uses the position or status breaks with the one to which they have been
assigned to hospital students in default as a means of accustomed in the CHUs. Even though the doctor still
selecting its future members. This selection relies upon has a dominant role [Xl, the underlying social
students’ direct choice ‘not to become like them’-like relationship is different. Besides. the student may not
hosital doctors. Thereby, students refuse to adapt to know how to handle this position ofdominance. In any
the model ofa physician that the socializing institution case, the sick person now has the possibility of
has made for itself. A first selection-or deselection- imposing some of his own standards. Bargaining, or
takes place. The institution itself performs a second negotiation, occurs-the student has seldom, if ever,
one ~--an elimination-through the Internat exam- observed this in the CHU. In hospitals. the opinions of
ination. This second selection is based more upon what medical professionals carry more weight than those of
candidates have learned than upon their readiness to the patients or of nonmedical personnel. Hospitals
adapt to the given model of behaviour. depend mostly upon a professional network of
referrals in order to recruit patients. On the contrary,
The first step into the prwtice of’gmerul medicine:
the private practitioner depends upon clients who
rrplacements
choose, in conformity with their ‘lay’ conceptual
Although replacements are not obligatory, they framework, their doctor and try to afiect the proposed
constitute an informal phase--not organized by the therapy.
CHUV in the training of would-be GPs. Students
who do not want to specialize usually seek out “In client-dependent practice. the patient IShkely to be in the
opportunities for replacing practising GPs. These position ofan equal or. at least. ofan actwe partiapant m the
Professional socialization and social control 139

process of diagnosis and management. Being in a relatively during diagnosis. These raw data are variously
early stage of illness and not yet overcome by pain or fear, he processed depending upon the value attached to the
always has before him (as the practitioner well knows) the academic and scientific knowledge that the socializing
prospect of leaving the office and. instead of coming back, of
institution has furnished. Such decisions orient the
looking elsewhere for a consultant who uses more familiar
notions of illness and treatment” [l, p. 3071.
way that medicine is exercised and the care that is
dispensed [23].
The problem for the substitute is to secure his position These decisions are made under conditions in which
in this new social relationship. He might have students doing replacements must situate themselves
trouble asserting his authority and professing a in this new. client-dependent relationship. Money is a
professional image. Interactions with clients are major dimension thereof. Nearly all interviewed GPs
decisive, less because they are patients by professional talked about how difficult it was at the start to face up
standards than because they are ordinary people who to the resulting interdependency, which they were used
have their own standards, different from those of the to overlooking during hospital training. Owing to this
profession. Clients affect and even control, in yet difficulty, some of them even chose to work in clinics or
another way, how the student substitute settles into dispensaries where patients do not directly pay the
this new social relationship. doctor.
The student physician uses the replaced doctor in an What is really at stake, however, in this relationship
attempt to more clearly define the role of GP or else to is the dequalification r_f general medicine. More
corroborate his tentative definition of it. Because the important than directly paying fees, the client imposes
replaced GP has very little contact with the substitute. some of his own standards and thus defines the GP’s
the former serves less as a model for the latter than as work. For example, he asks his doctor to make a house
an absent, positive or negative, reference mark as call simply to renew a prescription. The client partly
clients recall the replaced GP’s explanations, treat- controls the situation. The content of the GP’s
ments, prescriptions and habits. Of course, all this workload is up for negotiation.
happens outside the CHUs. on the fringes of the The hospital system also has means for designating
professional world. the contents of the GP’s job. As medical students in the
How much does the hospital system control this CHUs see it, this job is on the fringes of medical care.
situation? Might the socializing institution not For instance, when a client goes to a doctor’s office to
exercise. through the clients, control over how this obtain a sick leave or vaccination certificate, the GP
social relationship is learned? Significantly, leaders of performs a chore that is peripheral to the tasks that the
the medical profession. especially when they address profession values. As students have observed, these
the general public through the mass media, have chores are, in hospitals, left up respectively to the
publicly advocated a ‘special dialogue’ between ‘the’ administration and to students (or even nurses). Once
doctor and ‘his patient’. This two-sided relationship again, GPs fear lest their job be downgraded.
hardly characterizes doctor-patient contacts in Facing this situation in which two parties-clients
hospitals. There. the patient is under the care of a and hospitals-define their role, young GPs react by
medical team. not of a single doctor, and the making career decisions. Different decisions, such as
doctor-patient relationship becomes lopsided. The whether to work for fees or for a salary, spring from a
‘special dialogue’ refers to a different, single desire: to have control over their own work.
practitioner-client, relationship that exists in general Each choice can be a way of resisting this
medicine. The perpetual propagation of this kind of dequalification of general medicine and the downgrad-
discourse is neither an accident nor the sign that the ing of the general practitioner. The cleavage,
deeds of hospital doctors lag behind their words. It is recognized by the profession, between private practice
one of the means that the hospital segment of the for fees and employment on salary is, in fact, not
profession uses in its attempt to control the nature of pertinent to understanding young GPs’ choices. Some
the relationship between GPs and their clients. In this doctors who actively support salaried employment
way, the latter are socialized. By the kind of have, given the actual organization of the health
relationship that a client expects to have with his system, set up. as private, self-employed (‘liberal’)
doctor, he is part of the process for socializing would- professionals. They thus feel freer to define their work
be GPs. Obviously, discourse about the special according to their own standards than if they were on
dialogue also aims at consolidating the scientific salary. In short, young doctors have started using, to
prestige of hospital medicine in the eyes of the general their own ends, this cleavage that the medical
public and. by ricochet. among GPs. profession has interpreted as an alternative between
Although the medical profession indirectly in- two opposite health or even social systems: ‘free vs
tervenes in this social relationship. it has nothing to say bureaucratic’ medicine. Unaware of GPs’ concerns, the
about the content of the GP’s role. Everv student. profession and. in particular, the socializing institution
during replacements. has to define this role’s content. now seems so distant from the young GPs that it has
Much of the GP’s work is not open to view. It takes ‘produced’.
place behind closed doors within a closed relationship
inside the doctor‘s office. Much room is left for the
GP’s individual initiative. He actively ‘works up’ the THE HOSPITAL SYSTEM AND ITS SCIENTIFIC LOGIC AS
A MEANS OF SOCIAL CONTROL
client. What the latter brings is raw data that not all
doctors process in the same way-. For instance, the In a way the socializing institution has failed to
client. while describing his physical symptoms. might socialize GPs. Paradoxically, they make up the majority
mention problems at work-problems that the of the medical profession yet have been kept on the
physician chooses or refuses to take into consideration fringes of the hospital system. Graduates in general
140 ISABELLE BASZANGER

medicine seem to be much the same as they were when “I feel I’m going to go into reverse and regress intellectually.
they were admitted to medical school. Confronted with technically and practically. In other words. I’ll no longer have.
various hospital situations during student years, they behind me, the whole system pushing me forwards”.
mainly adjusted offhandedly without changing their
other involvements (especially with families and As a place where advances in theoretical knowledge
friends); or else in order to ‘survive the hospital’, they are made, the CHUs consolidate their superiority. even
emphasized the student dimension of their role as in the eyes of GPs who are cut off from them. through
‘hospital students’. Whenever they adjusted more their scientific activities and the resulting intellectual
willfully, their motivations tended to come from prestige. The supremacy of hospital medicine and of its
factors outside the profession. At first sight, young GPs doctors over the whole medical profession is thus
seem not to have been much socialized by the CHUs. legitimated. As a reference mark for all physicians, this
Replacements showed them to what extent their scholarship provides operational categories for diag-
relationship to the medical school system was nosing and treating illnesses. It matters little that these
ambiguous. Experiences acquired during schooling do categories are criticized by some groups of GPs as
not enable them to solve the major problem awaiting being inapplicable in the exercise of general medicine
them, namely the dequalification of general medicine. or as being too narrow because they exclude other
There is no systematic relation between, on one branches of knowledge. such as psychology.
haad, adjustments to the hospital (and the strategies What is also legitimated through this intellectual
underlying them) and, on the other, choices about how prestige is the right of hospital doctors to speak out as
to practise medicine. The factors that affect students leaders of the profession, especially during discussions
throughout their school years come from other sources about health policies. The Entretied de Bichat, a
(family, religion, student activism. etc.). This lack of yearly conference that brings hundreds of GPs
correlation is not due to chance, at least not in the case together at Bichat Hospital in Paris, illustrates this
of GPs. It corresponds to a reality: general medicine is point. As it diffuses information about scientific
not hospital medicine of a lesser quality. It has specific advances to the lower ranks of the profession, this
characteristics, in particular the client relationship, conference also reminds participants that discoveries
that students do not observe in hospitals. are made in the CHUs. Through the mass media,
Medical students do, however, become certified which spend much time reporting on it, this conference
physicians. The socializing institution has successfully also reminds patients and clients of the preeminence of
socialized GPs. Bedsides the forementioned ward and the hospital and of its scientific medicine.
door duty or the rounds, the medical profession, as a
social system, seems to have more durable means of
exerting control over members than those used during
schooling. ..%FRENCH MODEL?
Even more than through imparting key values, the Before leaving the hospital system, students
hospital system (along with the profession’s elite) acknowledge this institution’s superiority, which is
perpetuates its domination through its hierarchical founded upon the value attached to scholarship
organization and legitimating scientific logic. and upon the status socially assigned to abstract
Regardless of student criticisms of the hospital system knowledge. GPs have been led to internalize the belief
and of hospital medicine, this institution has an impact that the hospital segment of the medical profession has
upon their careers. Besides serving as a negative model a monopoly over theoretical reflection. As GPs, they
in the choice not to sit for the Internut examination, it are excluded from the abstract except insofar as
also marks them in two other ways. practical, e.g. therapeutic, applications are developed.
First of all, the hospital, shut off from the outer What characterizes the French medical system is this
world, operates according to its own logic and its own separation between university-hospital doctors and
internal organization, which leads students to perceive GPs. The capacity for conceptualization and the stock
it as ‘one big family’ with inhouse rules. Daily activities of knowledge, both measured by the rungs that have
are organized around the requirements of medical been climbed in the professional hierarchy, are used to
care, as stipulated by hospital doctors. In this sense, the separate these two groups. Regardless of the latitude
hospital is a cozy place that has been made for the they have had in their choices, students, like members
doctor rather than the patient. Under pressures that of other professional groups in the hospitals, observe
they did not learn how to bear in the CHUs. practising how candidates for all positions in the hierarchy are
GPs become ‘homesick’ for this institution. sorted in compliance with a principle that takes
Secondly, the hospital system marks students for life knowledge to be a value. They make this observation
outside its walls with its image as a place where a even if they themselves are not among these
scientific logic is expounded. All students receive candidates. The meaning of this principle is impressed
thoroughgoing education in basic sciences. Instruction upon them.
tends to present medical problems from a theoretical Although this research did not adopt a reasoning in
approach that is fully developed in hospital medicine. terms of the university system, its career channels and
Most students serve, at least once, on a ward where selection processes, the question does arise: is the value
such an approach prevails. Even though they ridicule it attached to knowledge, both as a principle for selection
(‘Watch out! This is High Science!‘), they nonetheless and as a means of social control, not distinctive of the
meet up with an intellectual process that tempts some French system‘? In comparison, the American system
of them toward the hospital system. The marks left by does not so conspicuously separate hospital doctors
this meeting come out in students’ remarks about being from the others’. Of course, it also selects its members
afraid of falling behind after graduation: and places them in a ranking order: but bridges
Professional socialization and social control 141

apparently exist between the extreme ends of the to mind Hall’s and Freidson’s analyses of the
hierarchy. Unfortunately, there are no comparative organization of the medical profession. Hall [26]
data for assessing how the means of social control are describes an inner fraternity of physicians who, at the
modified as a result of these structural differences. height of success, controls admission into the
This distinctive trait of the French system brings to community. Those who are admitted have certain-
mind what Maurice, Sellier and Silvestre have called professional as well as social-characteristics and
the ‘principle of the extraction of Clites’. Their share certain values. Freidson extends this analysis by
comparison of companies in France and in West describing the profession’s informal organization into
Germany has brought to light interactions between small, homogeneous, exclusive circles. As he declares,
facts of organization and facts of socialization. Unlike “these colleague groups are built up by the
in West Germany. mechanisms of patronage and boycott” [l, p. 1941.
This comparison should not be made too hastily
“the logic of the educational system (and also of occupational however. In the first place, Freidson’s colleague groups
training) is, in France, founded upon the principle of the do not fully correspond to specific disciplines.
extraction of elites.. [In companies] qualified individuals, Secondly, the medical profession’s formal organi-
whether workers or engineers, must rise above the common zation in France definitely separates the private
and thus participate in the elites (which are at the top of every
social stratum and socioeconomic category). Every such
practice from the hospital practice of medicine. The
category produces its own elite stratum following a peripheral position internalized by young GPs
hierarchical model that this stratum constitutes and corresponds to their discipline’s position within the
reproduces at the same time” [24, p. 2231. profession’s formal organization. This fact does not, of
course, preclude the establishment of colleague groups
Considering all categories of physicians (in hos- upon which physicians’ careers depend. What has been
pitals, in general practice or in privately practised described herein is the first stage ofsocialization. Upon
specialties) that have been trained by the socializing this backdrop, more subtle controls involving nar-
institution, the French medical system seems to follow rower segments of the medical profession come into
this principle. A curriculum in common to all students play.
during the first 6 years of medical school not only The control exercised by the profession’s Clite upon
determines career orientations but also guarantees the the socialization of GPs perhaps runs up against its
acquisition of the distinctive traits that the majority of limit at the very moment of professional integration.
physicians have in common 1251. A minimal Although the intellectual prestige of scientific know-
socialization is achieved. Just as there is a category of ledge in hospitals serves as a means of social and
white-collars whose occupational success depends professional control, the very utilization of this
upon their degree of integration in their companies, so knowledge widens the gap between the two ends of the
also there is, in the hospitals, a category of specialists medical hierarchy. The knowledge acquired by GPs is
who have managed to adapt to the proposed model of organized in terms of categories having to do with the
a physician and to the institution’s norms. Since the practice of hospital medicine which, as seen, is not
hospital system is not made for students, it is up to much like that of genera1 medicine. The GP has to find
them to initiate their own process of socialization with out how to fit what he has learned (in the form in which
respect both to this institution and to a hierarchy in he has learned it) in with what he observes and
which they have a place, we might say, through their experiences. This learning can be used in various ways
exclusion. For various reasons, GPs have not to diagnose patients’ symptoms. Nothing proves that
accomplished this. The opposition between specialists the medical profession controls how this recently
and generalists can be likened to that between acquired academic knowledge is actually used during
executive and nonexecutive personnel in a company. the exercise of general medicine [27]. The hospital
Specialists who, until now, have been trained segment of the medical profession sees GPs’ patients
through one of two different channels (the Internat and only when they are referred to hospitals. GPs are
the CES degree) are effectively integrated into the relatively free in their decisions to refer patients. Like
medical hierarchy through what Maurice et al. call a the students in Boys in White, they form a subordinate
‘*community of socialization”. As in companies, this group; but the fact that they are kept at a distance from
community covers up a fracture within a category, in the CHUs leaves them room for maneuvering and for
this acase of specialists. Each of the forementioned redefining their activities. For the profession’s
channels provides its own opportunities for pro- dominant strata, these activities are already clearly
fessional integration-into the hospital system enough defined: GPs do the initial sorting of patients
through the Internar and into private practice and serve a psychological support function. Nowadays
through the CES. most GPs do not silently accept this definition. Since
1973, this segment of the profession has formed new
associations, in particular the Sociktk Fran~aise de
Mhdecine GCn&ale and the Syndicat de la MPdecine
GPs. in France, are led to position themselves within Gdnkrale.
a ranking order by using the reference marks that the Who then does set the boundaries between groups
socializing institution (the CHUs) has furnished them within the profession? By pushing GPs ever farther out
during schooling. Once out ofthe hospital system, they onto the fringes of the health system, the hospital
form a peripheral. poorly socialized group that segment. which is responsible for socializing physi-
maintains limited relations with the profession’s 6lite. cians, runs certain risks. More and more GPs tend to
This system that. through successive eliminations or define themselves in terms not of hospital but of
deselections. assigns each person to his position brings general medicine. They thus enlarge the definition of
142 ISABELLEBASZANGER

their activities. The base of the hierarchical pyramid is professionnelle. Doctoral dissertation. presented at the
tending toward self-sufficiency. Ecole de Hautes Etudes en Sciences Sociales, Paris. 1979.
The National Assembly’s adoption in June 1979 of a II. See Butcher R. and Strauss A. Profession in process. Anti.
plan for reforming medical education can be partly J. Socio[. 46, 325-334. 1971.
12. Jamous H. Sociologic tie lu Decision: Lu Refbrme drs
interpreted in the light of these tendencies within
Etudes .Mtdictr/es et desStructures Hospitulieres. CNRS.
general medicine. This reform provides for a 2-year Paris, 1969.
‘residency’ period for GPs (after the first two levels of 13. A reorganization. not yet clearly defined. is under way.
medical school that remain in common to all students). Two major changes are in the works: more thorough going
During this period that unlike the replacements training for future GPs and unifying the training of
described herein is to be organized by the CHUs, specialists.
students will, in principle, have responsibilities during 14. A contours is a competitive examination which. under
training both in hospitals and with practitioners. merit system principles. is used to select the highest
These provisions were maintained in a new bill for scoring candidates to fill a preset number of positions.
The contours de l’lnternut is used to recruit students to fill
reforming medical education that was passed in the
positions as internes at the bottom of the CHU ranking
spring of 1983. Accordingly, the CHUs should keep system. After 4 years of training, these internes (not to be
full control over the education of GPs. Through this confused with English ‘interns‘). if they are not appointed
additional year of schooling, the CHUs should be able as chefs de clinique, usually set up private practices in their
to reduce the distance between themselves and the specialties. Those who manage to stay in the hospital
places where the practice of medicine is learned. They system, specifically in the CHUs, by obtaining this
should thus create a closer socializing relationship appointments may aspire, over the years, to become
with students or at least try to be more directly ugreges or. ultimately, chefs de service. English equiva-
involved whenever GPs begin being integrated into the lents of these French terms could. at best, be
approximate. They have not been given lest the reader be
profession and adjusting to the actual practice of
induced in error. The types of education and training
medicine.
provided through the lnternut and the CES programs are
quite different. The student who is preparing for the CES
degree receives, in his chosen specialty, advanced
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2. Merton R., Reader, G. and Kendall P. (Eds) The under the supervision ofsuperiors, does much of the daily
Student-Physician, Introductory Studies in the Sociology work in hospital services.
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dynamic process: the case of modern medical practice. In Sandal Paris, 1975.
The Social System. Free Press, Glencoe, IL, 195 I. Pages 19. This discussion concerns only GPs. All medical students
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6. R. C. Fox shows how, during medical school, students students who adjust in the third way is certainly higher
acquire a ‘concerned but not too concerned attitude and than that of those destined to become GPs. Students who,
learn to balance an excess of self-confidence with planning to sit for the Internut, strive to be integrated into
uncertainty. See: Fox R. C. The medical student’s the hospital system often adjust in a fourth way: they try
training for ‘detached concern’. !n The Psychological to be assigned on wards where ‘hospital students’ are
Basis o/‘Medicul Practice (Edited bv Lief H., Lief V. and neither wanted nor needed so that they can study full-
LiefN.), pp. 12-35. Harper & Row,New York, 1963. See time for the examination.
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of Medical Education (Edited by Merton R. et al.). pp. becomes a GP. He has no choice to make other than the
207-244. Harvard University Press, Cambridge, MA, initial one namely to enroll in medical school. The
1957. interviews, however, show that GPs deliberately decided
7. Becker H. The nature of a profession. In Educationfor the not to sit for the Internut. They did not fail it. From the
Professions, 61st Yeurhook of the National Societyfor the individual’s viewpoint. a positive. voluntary choice is
Stud-vofEducation. University ofchicago Press. Chicago, made. It consists in deciding to join a dominated segment
1962. of the medical profession. It means staying at the bottom
8. Hughes E. The Sociologicul Eye: Selected Papers. Aldine. of the hierarchical ladder, which others are climbing.
Chicago, 1971. Refer, in particular, to the third part. Notwithstanding that the socializing institution does not
9. Becker H., Geer B. and Miller S. Medical Education miss a chance-through words or deeds-to remind
In Handbook ofMedical Education (Edited by Freeman H., students of this, general medicine is not the haven of
Levine S. and Reader L.) pp. 19 I-205. Prentice-Hall, sloths or funkers.
Englewood Cliffs, NJ, 1972. 21. About the influence of friends, family and close relations.
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Professional socialization and social control 143

22. Freidson E. Pr&ssionul Dominance. the Sociul Structure the end of primary school and the end of secondary
cf Medical Cure. Atherton Press, New York, 1970. school]... the major distinctive traits, which future
23. My thesis (see [lo]) proposes four ways GPs define workers have in common, are shaped. Post-secondary
themselves. Each one is the outcome of socialization education... is but the prolongation of this process of
processes. This typology leads us too far from the stratification beyond the secondary level”. Quoted from
problem of social control, the subject of this article. These p. 340 of Maurice M., Sellier F. and Silvestre J-J. La
four definitions (the doctor as a dispenser of medical care, production de la hiirarchie dans I’entreprise: recherche
the doctor as a guide, the total doctor of the total person d’un effet societal, comparison France-Allemagne. Revue
and the community doctor) involve dimensions such as jr. Social. 20, 331-336, 1979. Of course, this quotation
the importance attached to academic knowledge during holds for medical school too.
diagnoses, the self-assigned position in the dispensing of 26. Hall 0. Types of mecial careers. Am. J. Social. 55,
medical care, and the conception of general medicine. 243-253, 1949.
24. Maurice M.. Sellier F. and Silvestre J-J. Producrion de la 27. For Hughes, the culmination of the socialization
HiCrarchie dans l’Entreprise: Recherche 6un /#et processes occurs whenever professionals bring what they
SociCtal, Allemagne-France. LEST, Aix-en-Provence, have learned back into interactions with the ‘lay’ culture.
1977. See Hughes E. C. The making of a physician. In Men and
25. “During the competition that ranks students [between Their Work pp. 116-130. Free Press, Glencoe, 1958.