Symbolic Access: Medical students’ awareness of institutional culture and its influence on learning, a phenomenographic study.

Abstract Background: The discussion of access in medical education has its focus largely on physical and epistemological access, leaving a qualitative gap regarding sociocultural factors which enable access in this context. This study introduces and defines symbolic access, a concept with a specific lens on sociocultural enculturation, and the influence it has on student learning within the South African medical education landscape. Methods: A phenomenographic design was used to explore students’ conceptions of symbolic access and its impact on learning. One-on-one exploratory interviews were conducted with fifteen final year medical students at the University of Witwatersrand in Johannesburg. Interviews were analysed using Sjöström and Dahlgren‘s seven-step phenomenography model. Results: Four categories of description were induced, which described students’ understanding of symbolic access, these were rejection, disregard, invalidation and actualization. Five dimensions of variation were discovered, these dimensions expressed the different ways the categories were experienced. These dimensions were; interactions with educators, peer relationships, educational environment, race and hierarchy. Categories of description and dimensions of variation formed the Outcome Space, a visual representation of the student experience of symbolic access. The outcome space had a double narrative related to symbolic access; exclusion (major) and actualization (minor). Medical student’s chief experience within the medical community was exclusion, however experiences of peer-relationships, clinical skills lessons and participation within the clinical setting facilitated community inclusion, enculturation, and impacted learning. Conclusion: Despite deeply exclusionary experiences throughout their programme, medical students articulated attaining symbolic access into the community, which is predominantly influenced by clinical experiences during the pre-clinical and clinical years of study. Furthermore descriptions of valuable learning experiences were connected to clinical events and the involvement with patient care. This study suggests that the actualization of symbolic access and description of meaningful learning experiences are linked. Medical educationalists should design undergraduate curricula with early clinical immersion at the fore and explore symbolic concepts pertaining to access, as they are linked to transformative learning experiences for the medical student.