Är det bara jag? Om sexism och rasism i läkarutbildningens vardag : erfarenheter, förklaringar och strategier bland läkarstudenter

Sammanfattning: Background: Medical education is characterized by unequal conditions for women/men and white/racialized students. Even subtle interactional processes of inclusion and exclusion convey messages about who rightfully belongs in medical school. Insights into these processes, though, are scarce – especially in the Swedish context. In this thesis, the concepts ’everyday sexism/racism’ and ’gendered/racial microaggressions’ serve as a theoretical framework for understanding these processes.Aim: The main objective of this thesis is to explore and analyze how medical students experience, understand, and handle the norms, perceptions, and expectations about gender and culture/ethnicity that are expressed and (re)created in the specific contexts of medical education and clinical practice. In the analysis, a particular focus is placed on power inequalities. The role that the image of Sweden, which is characterized by equality, and the notion of medical education as characterized by objectivity and neutrality play in the participants' understanding and actions is discussed.Method: The four articles that make up this thesis are based upon three empirical studies conducted among medical students at Umeå University. In the first study, focus groups were performed with 24 students (15 women, 9 men) to explore their experiences of situations during clinical training where they perceived that gender mattered. The material was explored using qualitative content analysis. In the second study, 250 students’ written answers to two short essay questions were analyzed to explore the impact of medical school experiences on specialty preferences. Utilizing a sequential mixed methods design, their responses were analyzed qualitatively to create categories that thereafter were compared quantitatively between men and women. In the third study, generating two articles, individual interviews were conducted with 18 students (10 women, 8 men) who self-identified as coming from cultural or ethnic minority backgrounds, exploring their experiences of interactions related to their minority position. Inspired by constructivist grounded theory, data collection and analysis were iterative.Findings and reflections: In individual interviews and focus groups, many participants initially described the medical school climate as equal and inclusive. Still, in their narratives about concrete experiences they gave another picture. In interactions with supervisors, staff, and patients almost everyone had regularly encountered stereotypes, discriminatory treatment, and demeaning jargon. Simultaneously, a subtle favoring of male and white majority students was noted. Thus, values, norms, and hierarchies concerning gender and culture/ethnicity were crucial dimensions in their narratives.These experiences made female students feel like they were rendered invisible and not taken seriously, and marked racialized minority students’ status as ’Others’ – making both female- and minority students feel less worthy as medical students. However, most were unsure whether they could call their experiences “sexist”, ”racist”, or ”discriminatory”. Instead, they found other explanations for people's actions such as curiosity, fear, or ignorance. Participants strove to manage the threat of constraining stereotypes and exclusion while maintaining an image of themselves as professional physicians-to-be. They opposed being seen – and seeing themselves as – problematic and passive victims. The clinical power hierarchy, fear of repercussions, and lack of support from bystanders affected what modes of action seemed accessible. Consequently, participants tended to stay silent, creating emotional distance, and adapting to avoid stereotypes rather than resisting, confronting, and reporting unfair treatment. The school climate also had consequences for specialty preferences. Both women and men expressed that working tasks and potential for work-life balance were motifs for their specialty preference. These aspects, however, were often secondary to feeling included or excluded during clinical practice. More women than men had been discouraged by workplaces with perceived hostile or sexist climates. In contrast, more men had been deterred by specialty knowledge areas and what they thought were boring work tasks. Conclusions: Medical students experience everyday sexism- and racism or microaggressions, i.e., practices that, intentionally or inadvertently, convey disregard or contempt. However, the contemporary discourse, which confines sexism and racism into conscious acts perpetrated by immoral or ignorant people, and the pretense that these phenomena no longer pose a problem in Sweden or in medical school, obscure their structural and systemic nature. In fact, this limited view of sexism and racism leaves inequities normalized and disempowers those targeted by discrimination. Constraining stereotypes and exclusion are not caused by the actions of their recipients, that is, female or racialized/minority students. Consequently, their behavioral changes like avoidance and adaptation will not eliminate discrimination but, instead, tend to re-establish the white male medical student as the norm. As long as students who do not fit the norm, rather than the norm itself are regarded as the problem, the sexist and racist practices described in this study will remain part of the hidden curriculum and part of the process of becoming and being a physician. Simultaneously, formal commitments to equality are at risk of being only symbolic while inequities persist. To counteract these inequities, the medical community needs to acknowledge female and racialized medical students’ knowledge about sexist and racist practices within our institutions. Further, medical school leadership should provide students, supervisors, and teachers with an account of structural and everyday sexism and racism, encourage them to engage in critical self-reflection on their roles in sexist and racist power relations, and with strategies and training on how to intervene as bystanders and allies.