Envisioning future roles: How women medical students navigate the figured world of medical school

Women medical students experience tensions as they learn to become doctors. These tensions reflect the cultural world of medical school and clinical medicine, spaces that are highly gendered, racist and exclusionary. This study describes how women medical students are envisioning themselves as future doctors during their first 2 years of medical school while experiencing these tensions.


| INTRODUCTION
[3] Unfortunately, socialisation and identity formation experiences for women medical students occur in spaces that are highly gendered, 4,5 racist, 6 hierarchical 7 and exclusionary. 8,9These characteristics are ones that shape the culture of medical education.To deepen understanding of the socialisation experiences of women medical students, we draw on a critical approach of Figured Worlds (FW) theory.FW theory offers ways to describe how women medical students' experiences are shaped by the complex cultural setting of medical school.Furthermore, FW theory can illuminate how women medical students exercise their agency to make sense and navigate the culture of medical education.
p. 52 FW can play a key role in how medical students understand their formation as doctors within the cultural characteristics of medical education and the larger field of clinical medicine.Other scholars have drawn on FW theory to describe how physicians, health professionals and students are interacting within the culture of medical schools and the larger health care field.2][13] For women medical students, these tensions include perceiving women as caregivers 5 and more often being considered less qualified doctors. 14We appeal for the need to understand how women medical students grapple with the gendered tensions in their medical education journeys.This study advances scholarship on women in medicine by employing FW theory to illuminate the interconnectedness of individuals, their interactions and their intentions within a cultural world of medicine.Without these understandings, medical schools will continue to reproduce inequities despite the medical field's call to educate more diverse students.
Figured Worlds theory can play a key role in how medical students understand their formation as doctors.
FW theory is built upon several interlocking concepts essential to understanding how individuals are navigating a cultural world.In our study, we consider US medical schools and the larger field of US clinical medicine as the FW.This world includes any previous encounters with clinical medicine the women students experienced, as well as their present experiences in medical school.To learn how participants envision themselves as doctors and negotiate the gendered culture of medicine, we drew upon five points of FW theory, grouping them into three separate but related concepts: (1) positionality and discourse, (2) power and agency and (3) improvisation.First, we include positionality, or the social standing and identities of participants, alongside discourse, or the verbal and embodied cultural artefacts of a FW, to explore how participants consider themselves and their place in the FW.Second, we include power, or the influence or privilege derived from an individual's positionality, and agency, or how participants generate a plan that makes sense for their role, to investigate how participants are orchestrating the discourses of the FW alongside their positionality, that is, how they are pulling on their potential power to enact agency.Finally, we include improvisation, or how participants exercise agency to respond to contradictions, to understand how participants are reconfiguring their roles, developing their own narratives and devising a novel or appropriate response to their experiences in the FW.
Given the contours of the FW of medical school, we sought to explore the following research question: How are women medical students envisioning themselves as future doctors during their first 2 years of medical school?We use FW to showcase how women medical students experience, recognise and interpret the culture of the FW of medical school in their early medical education, using the FW concepts to better define who they want to be as physicians.

| METHODOLOGY
This study is a secondary analysis drawn from an ongoing longitudinal study exploring how women medical students are becoming doctors.
We utilised qualitative longitudinal research (QLR) with narrative inquiry.QLR proposes that research done over long periods of time allows for deeper understanding of lived experiences. 15Narrative inquiry is a natural extension to QLR and centres shared experiences and common phenomenon in and within time by storying shared experiences. 16,17Through the lens of FW theory, we focused on four participants from the original, larger study over a 2-year period.These four participants share an important attribute that supported our selection of them as part of this secondary analysis: They all hope to serve communities that are underserved, a reflection of both their personal passion and their own histories in growing up in underserved communities.Pseudonyms were given to all participants to promote honest and critical discourse without fear of repercussions because participants were enrolled in medical school during the time of data collection.
After receiving institutional review board (IRB) approval, participants were interviewed four times: October 2020, April 2021, September 2021 and March 2022.Each interview lasted on average 45 minutes and was transcribed by temi.comsoftware and checked for accuracy by a research assistant.During their first year of medical school (August 2020 to July 2021), each participant also provided written personal reflections at four different times about their experiences in medical school in response to prompts provided.All data collection was performed by A. E. B.

| Data analysis
Keeping in mind our research question of how women medical students are envisioning themselves as doctors during their first 2 years of medical school and our focus on FW theory, we proceeded with an analysis in five phases typical of qualitative research.First, all researchers (A.E. B., S. M. and C. W.) independently performed readings of the transcripts, writing analytic notes about how participants discussed envisioning themselves as doctors.Second, A. E. B. and S. M. performed a narrower reading, drawing specifically on the FW theory concepts of positionality and discourse, power and agency, and improvisation.See Table 1 for examples of our analytic memos and coding schema applied during this reading.Third, A. E. B. and S. M. wrote interim texts.In narrative inquiry, interim texts serve as the step after data collection with participants.
p. 47 Our interim texts were drafts of findings where A. E. B. and S. M. pieced together excerpts of large narrative portions to describe more coherent stories about participants' experiences within the FW of medical school.
Fourth, all researchers regrouped to discuss our interim texts and combined similar narrative portions together based on FW concepts.This phase included ensuring final texts were framed by our research question and we strove for the findings to reflect how experiences of the FW informed envisioning themselves as doctors.During this fourth phase, we incorporated the critical perspective of the FW, as one where women still experience deeply gendered stereotypes even as they represent the majority of those enrolling in medical school. 14nally, in the fifth phase of analysis, C. W. led a deeper analysis drawing on the grouping of the three related concepts of FW to interpret how participants discussed their roles as future doctors.
Taken together, the research team recognised these roles as ones oriented towards serving the underserved, one that helped them reimagine the FW of medicine.See Table 2 for an outline of our analytic process.
T A B L E 1 Coding schema for five codes with notes on application and examples from the transcripts.

Excerpt FW constructs Codes/notes
Esmé So I think that ultimately, yes, because you'll get the training, you will get, you know, the structure of how to become a physician and you just have to find your own opportunities.Maybe you have to work a little harder to like, try to navigate the system and trying to find your own resources and stuff like that.
Agency: Orchestrating the FW whether through how they talked about themselves, thought about their roles as future doctors, shared experiences or worked together.
Agency: 'Find your own resources' and taking action to do so.
Thalia I have had similar experiences with the phrases above in settings reminding me that I am a woman and that choosing a path in medicine will be especially challenging for me because I will want to raise children.This was ALWAYS said by a male doctor thinking he was being considerate and sympathetic towards my situation.
Discourse: Artefacts that communicate the culture of the FW (verbal and embodied).
Positionality: Social standing and identities of participants.
Discourse: Gendering and raising a family, having men signal or reinforce this norm.Positionality: As a woman medical student interacting with faculty and physicians who are men.

Wren
It feels good to be a part of leading a team of people who are focused on members of the community going through the toughest times in their lives.I think being a woman has helped me better understand some of the obstacles people can face in life, which makes me more empathetic when considering other obstacles people may have faced that I have not.
Agency: Orchestrating the FW whether through how they talked about themselves, thought about their roles as future doctors, shared experiences or worked together.
Agency: Improvisation-Wren also notices the discourse of women being empathetic and places herself there as well.

Wren
There's so much pressure to be a good parent, especially as a woman, sometimes being a good parent puts pressure on us to spend more time with our kids.And I worry about this.
Discourse: Artefacts that communicate the culture of the FW (verbal and embodied).
Discourse: General discourses about women's roles, Wren worries about not being a good parent when she is a doctor.
Esmé I hope as a physician, I can connect my patients with the resources that they need and encourage them to seek out those support.
Improvisation: Intentional actions in response to a given situation.
Improvisation: Thinking about ways to reimagine her role as physician to care for community.
Abbreviation: FW, Figured Worlds.This awareness of her position informed her experiences, particularly how her experiences may or may not be valued, understood or respected.Esmé drew on her background and experience in medicine to inform how she understood her position.She pointed to the hierarchy of medicine as a discourse in the FW, one that may not recognise her position as a first-generation Latina in medical school, nor value her calling to serve the underserved.Even as the participants were learning to be professionals in the esteemed field of medicine, they experienced the culture of the FW of medical school very early on.These cultures and social norms were present as participants felt responsible for domestic and family duties, potentially exacerbated by the hierarchies of medical school.
T A B L E 2 Five phases of analysis.
Reading transcripts, writing analytic memos.Linked memo writing to how participants discussed themselves as future doctors.
2 Narrower or more focused reading directly informed by FW. Specific concepts of FW were identified in transcripts.
3 Interim texts: Where researchers begin to draft possibilities for how coded excerpts will be written, flow together and 'fit' towards the larger research question.

4
Research team meeting: Gathered interim texts to discuss the larger narrative of the study (which specific experiences will be 'storied'?).Make decisions about which excerpts to include and how analysis flows between FW and research question as well as researcher positionality.

5
Final analysis towards the shared identities of participants and their commonality in serving the underserved and returning to community.
[Participants] experienced the culture of the FW of medical school very early on.

| Power and agency: How women medical students draw on potential power to enact agency
Power in the FW derives from positionality and informs who is and is not able to take critical actions.Historically, medical schools and clinical medicine have adhered to norms about who a doctor is and what a doctor looks like. 13Despite gendered discourses in medical school, participants drew on their positions as women in medicine to find strength.By doing so, participants garnered power, or the ability to take critical action.Moreover, participants interrupted gendered discourses, drawing on their perceived limited positionality as women medical students to see and imagine new aspects of their own agency.
Despite gendered discourses in medical school, participants drew on their positions as women in medicine to find strength.Other participants demonstrated knowledge about the discourses of medicine.Their awareness of their positions gave them an ability to employ a sense of power towards agency.This recognition often occurred during the middle or later period of data collection.Near the end of her first year, Wendy, for example, recommitted to her reasons for entering medicine, affirming her work to overcome the hierarchical practices in medical school to achieve her goal of returning to communities that need her skills as a physician.Wendy herself comes from a community that is underserved.As an Asian American, she was raised in an isolated area lacking resources or access to resources for health care and other amenities often taken for granted in urban settings.
She explains, 'Becoming a doctor is to help underserved communities.
That's what really drives me to learn more about medicine and how to improve health outcomes for communities that have been overlooked.' During her second year, Esmé shared a similar sentiment, recognising the discourses of medicine and her position, then using that to shape her sense of power and agency: I understand that some people have parents that are physicians and maybe they have more knowledge than I do in medical terms.I try not to get intimidated by that.We all start somewhere.I am bilingual, a woman and immigrant woman.I know that I will make that patient population super comfortable, and I'll be able to provide a deep understanding of what they're going through and what their limitations are.
Near the end of her second year, Thalia shared similarly: Sometimes if we're in clinic and I see a patient of a diverse background, it doesn't necessarily need to be my background, I can make it easier for them to talk to me.I feel more comfortable talking to them.I see it being acknowledged because of how I was raised, thanks to my culture.
Participants orchestrated the discourses of medicine, finding power and agency by stating their strengths in being able to reach certain patient populations others may not be able to reach.Moments of agency culminate in improvisations where the participants moved intentionally towards where they see themselves in medicine.
Wren signalled her commitment to returning to the community that raised her.Wren's community is one that has experienced deep socio-economic hardships and historical and ongoing structural ineq- These examples illustrate how (1) women students are exercising their agency to embark on paths that honour their previous lived experience and (2) these agencies evolved into improvisations over the 2-year period.Participants envisioned how to consider the practice of medicine as a service to their communities, rather than a hierarchical activity, where they hold the power to 'give' to those society sees as 'having less'.

| DISCUSSION AND CONCLUSION
Our participants' stories illuminate how women medical students' interactions with their FW are ongoing processes-their lived experiences shaped their decision to enter medical school and continue to shape how they navigate their educational experience.These interactions have implications for their positionality and agency, informing their experiences and decision making in medical school as well as their decisions and improvisation about how they envision practising medicine in the future.Our data describe how women students enter this FW carrying the knowledge of lived experience and of the barriers facing women in medicine.These women apply this knowledge to their goals for their medical practice and their visions for how they aim to shape their interactions with patients.However, this position does not limit women medical students in the sense that they might be better able to serve a specific community; rather, it illustrates how students are actively using their own experience to exercise agency in remaking the FW of medicine.p. 176 Thus, women medical students engage in their whole selves when considering the FW of medical school and clinical medicine, drawing on their intersectional identities and reflecting on their history to actively construct a future clinical practice that embodies their values. 18,19men students enter this FW carrying the knowledge of lived experience and of the barriers facing women in medicine.
Using FW theory as our method, we also demonstrate the versatility of FW and propose various entry points for understanding issues of women, gender and medicine.For example, FW can highlight the deep connections between organisational culture and policies for women.Using FW in medical education research may aid in describing the web between cultural norms and individual experiences. 20Additionally, FW offers specific entry points to positionality and agency.It highlights how women make negotiations in their professional identity formation and how this formation influences specialty choice. 13Continued work in this arena may uncover shared experiences of women in the FW of medical school and how these students improvise powerful discourses in ways traditional scholarship may overlook.These students are acutely aware of their positionality and intersectional identities, reflecting on their roles as women, their body size and shape, their ethnicity, and religious identities, and the implications this has on their interactions with patients.Even though their clinical experience is limited, our data demonstrate that women medical students are actively considering how to engage in and push the boundaries of the FW of clinical medicine even during their first 2 years of medical school.
Women medical students are actively considering how to engage in and push the boundaries of the FW of clinical medicine.
Despite the gains women have made in medicine, there remain barriers and discourses about 'women's roles' and their place in clinical medicine. 21Continued efforts to amplify women in specialties dominated by men, as well as showcasing how women are forging their own paths between work and life, such as American Medical Women's Association's Ignite programmes, are imperative for upcoming cohorts to envision how they will be doctors.Providing supports as medical educators, such as increased mentoring 22 and intentional encouragement towards careers dominated by men, 23 can empower more students to learn from one another about how they are similarly pushing the boundaries of the FW of medical school.Additionally, pipeline programmes may offer cohort-based models to support women medical students. 24Organisational and structural supports combined with individual representation and relationships may help shift the culture of the FW our participants encountered.
Ultimately, these women medical students represent a shift in the diversity of the physician workforce we hope will continue to grow.
The statements of these women students expressing their desire to create a practice oriented towards community and serving the underserved reflect broader trends in US medical care that show that 'nonwhite physicians cared for 53.5% of minority and 70.4% of non-English-speaking patients'. 25Offering more support to women students during their medical education can help them more effectively navigate the FW of medical school.

3 | FINDINGS 3 . 1 |
figured kind of curvy, and I go through my wardrobe because I don't want to give off the wrong impression.

3. 3 |
Improvisation: How women medical students respond to the contradictions in the FW of medicine When there are incongruencies with sense of self and the cultures of the FW, individuals may engage improvisations, or intentional actions in response to a given situation.The above moments of agency culminate in improvisations where the participants moved intentionally towards where they see themselves in medicine, despite the contradictions of the FW.At the end of her second year, after learning the discourse of the FW and pulling on her agency, Wren restated her intentions for medical school: I love this community [where I was raised].And my intention in life is to go back and serve this community … I'm able to relate to people that are going through financially, emotionally, mentally, physically tough times.That's something I was raised with.I don't always think about it as an immediate example of where I shine, but I can relate very well and work very well with those patients because of my own personal background.
uities.Her ability to identify with her community, especially as one embedded and born from this community, really make her 'shine' in providing patient care, turning her previous experiences with hardships into an asset.Wren engaged in an important form of improvisation, working against the discourse of the FW of medical school, and responding with purpose towards what she believes and envisions.At the end of her first year, Wendy shared a similar sentiment, starting to form how her positionality would inform future improvisations in medical school and her purpose for pursuing medicine: I do think that growing up on a tiny island, I had no idea what I was getting into in terms of going into medicine.That is a huge determinant [of how I think about being a doctor].These are the things that I think have really humbled me because I came from an island with such a very simplistic life and pretty low income compared to the US … where I grew up has really shaped my entire way of thinking, which is uplifting communities, pushing for representation, being an advocate for others.Finally, at the end of her second year, Thalia described moments of 'surprise' and using those surprises in her future to help others who have shared similar experiences.I think witnessing struggle or facing your own struggle, I want to apply that to medicine.Before I applied to medical school, I'd experienced hardships and the fact that I've gone through this will hopefully make me help patients who have gone through this.And hopefully I can be that doctor to help people, you know, taking the stuff that are surprises and then using that to be able to help someone who might have been in this situation.