Learning the Ropes Together: Assimilation and Friendship ...

HEALTH COMMUNICATION, 17(3), 211–231 Copyright © 2005, Lawrence Erlbaum Associates, Inc.

Learning the Ropes Together: Assimilation and Friendship Development Among First-Year Male Medical Students Theodore E. Zorn Department of Management Communication University of Waikato, Hamilton, New Zealand

Kimberly Weller Gregory Department of Organizational Communication Queens University

This study explores the mutual influences of friendship development and organizational assimilation processes among first-year male medical students. Interviews and observations were used to examine the ways students constructed and enacted their friendships with male classmates during the process of assimilating into medical school. The study also examined how the male friends viewed the influence of their friendships on their assimilation into medical school and how the assimilation process simultaneously influenced their developing friendships. Thematic analysis revealed that although the men perceived their medical school friendships as “not yet close,” the friendships provided them with valuable tangible and socio-emotional support during the rigorous assimilation process and that the assimilation process paradoxically facilitated as well as hindered the development of friendships. Implications for practice and future research are discussed.

Two important challenges facing students entering medical school are assimilating into the medical school culture and managing relationships with fellow students. New entrants have to learn the ropes of medical school at the same time they are meeting, collaborating, and even competing with a large group of mostly new peoRequests for reprints should be sent to Theodore E. Zorn, Department of Management Communication, University of Waikato, Hamilton, New Zealand. E-mail: [email protected]

212

ZORN AND GREGORY

ple. These two processes, assimilation and relationship development—and especially the ways they interact—are the foci of our study. Our goal is to demonstrate the roles that friendships play in assimilation and the ways that assimilation influences friendship formation. Medical school is an incredibly demanding and stressful experience for prospective physicians. Common stress producers include “information overload, test anxiety, sleep deprivation, and a lack of time to devote to family and friend relationships” (Katz, Monnier, Libet, Shaw, & Beach, 2000, p. 343). Research suggests that the transition periods of medical school, such as the beginning of the first year, are particularly stressful (Radcliffe & Lester, 2003) and that one’s ability to cope with stress in the first year is the strongest predictor of mental health in later years of medical training (Guthrie et al., 1995). Thus, increasing our understanding of the first year experience seems essential. Our particular interest is the informal assimilation into the medical student culture and how students cope in the early stages of their experience. Some studies have shown that a sizable portion of medical students turn to alcohol as a means of coping (Tyssen, Vaglum, Aasland, Gronvold, & Ekeberg, 1998). A more constructive potential source of support is the set of friendships formed with classmates who share the medical school experience. Numerous studies demonstrate that social support can reduce the negative effects of stress (e.g., Katz et al., 2000). In fact, one study found that peer support was a significant source of coping with stress for students in the last year of medical school (Radcliffe & Lester, 2003); it would not be surprising to find that the same is true in the first year. The goals of this study were to discover ways in which male newcomers to a medical school constructed and enacted their same-sex organizational friendships and the role they see these friendships playing in the organizational socialization process.1 Conversely, another goal was to explore how the male friends viewed the influence of assimilation on their developing friendships. To achieve these goals, we adopted an interpretive perspective. As Cribb and Bignold (1999) argued, “If we want to understand how students’ basic values and philosophies are shaped by the professional perspectives and cultures of the medical school … we need research approaches which positively explore cultures and subjectivities” (p. 205). Interpretive approaches attempt to do exactly this. As Alvesson and Deetz (2000) explained, in interpretive studies, “the emphasis is on a social … view of organizational activities. … The expressed goal is to show how particular realities are so-

1One of the goals of the initial research from which this article was developed was to explore the role of gender in the construction and enactment of friendships, following research that has demonstrated gender differences in friendship formation (Inman, 1996; Swain, 1989). Thus it was our choice to focus only on men’s friendships with other men. Because our focus for this article is the relation between friendship and assimilation processes, we have intentionally de-emphasized gender issues to have adequate space for our primary focus.

FRIENDSHIP AND ASSIMILATION

213

cially produced and maintained through norms, rites, rituals, and daily activities” (pp. 33–34).

ASSIMILATION INTO MEDICAL SCHOOL Assimilation is the process “by which individuals join, become integrated into, and exit organizations” (Jablin & Krone, 1987. p. 712). It is a two-sided process in which, on the one hand, organizations socialize new members, attempting to create appropriate attitudes, values, and behaviors and, on the other hand, newcomers simultaneously seek to individualize their roles in the organization as they learn organizational norms and values (Jablin, 2001). Thus, we conceptualize assimilation in medical school as a process in which the school attempts to “shape” newcomers in particular ways, and in which newcomers simultaneously strive to shape and make sense of their new situation and roles. Newcomers to medical school gather impressions of their new environment from social interaction with other members of the organization—both established insiders and fellow newcomers—and together create both shared and idiosyncratic meanings for their experiences. Their interactions contribute to the way they symbolically construct their developing organizational identities and relationships. There is relatively little systematic study of the process of initial assimilation into medical school. As Hafferty (1988) explained, “Researchers tend to focus on the clinical rather than the preclinical years of medical training” (p. 344). However, studies from the broader medical socialization literature are fairly consistent in describing the experience as, at best, extremely challenging and, at worst, dehumanizing. Pitkala and Mantyranta (2003) summarized these studies, concluding that “Medical education has been reported to be a stressful …, anxiety-provoking …, and traumatizing experience … which may cause psychic problems” (p. 155). Light (1988) further argued that medical education is characterized by a high level of uncertainty, which is a strong contributor to the anxiety and stress experienced. Furthermore, the uncertainty experienced leads medical students to search for models and methods that help them cope. Although most scholars have pointed to the models and methods offered by medical school faculty—role models and prescribed methods such as emotional distancing of patients—interaction with peers is a relatively unexplored source of influence in assimilation. The preclinical period in medical education—typically, the first 2 years of medical school—is a time in which the most salient task is to master an immense amount of technical information (Conrad, 1988). Yet, numerous scholars have pointed to the importance of the hidden curriculum that operates throughout medical education, in which future physicians learn the values, norms, and expectations of the profession through a more informal process of culture transmission (Cribb & Bignold, 1999; Harter & Krone, 2001; Light, 1988). As Harter and Kirby (2004)

214

ZORN AND GREGORY

explained, “Through the rituals of medical school, students learn … what they must do and demonstrate to be taken as legitimate members of the medical community” (p. 49). Much of the socialization via the hidden curriculum is imparted by structures put in place by medical school faculty and administration (Beagan, 2001). However, an important part of socialization in any organization occurs via informal interaction with peers. For example, Hafferty (1988) demonstrated through an analysis of cadaver stories that informal interaction among medical students in this initial period is important in socializing medical students to (a) the rules regarding the management and display of emotions, (b) the medical gaze that defines acceptable ways to view the body and death, and (c) an identification as an insider in the medical profession. Beyond Hafferty’s study of cadaver stories, however, little is reported in the scholarly literature about the role that peers play in the assimilation process. As mentioned earlier, peers have been found to be important sources of support in the later years of medical school (Radcliffe & Lester, 2003). Thus, it seems likely that peers—particularly those with whom friendships are developed—would be particularly important in the initial assimilation process.

FRIENDSHIPS IN MEDICAL SCHOOL Although there is little research on medical students’ peer friendships, the research on college/university and workplace friendships is informative. Antonio (2004) recently concluded that 30 years of research on university students’ socialization “has continually pointed to the peer group as perhaps the dominant change agent during the college years” (p. 446) and “interpersonal interactions [with peers as] a primary contributor to overall development in college” (p. 448). Of importance, Antonio found evidence that interpersonal interactions with peers served to mediate macro-level influences on socialization. Workplace research suggests that peer friendships in organizations such as medical school are easily formed because members of the same organization tend to share common interests and experiences (Pogrebin, 1987). Such research also suggests several benefits to friendships among peers working together. First, peers have an empathy with each other’s daily concerns that can ameliorate negative experiences because they feel that they are “all in the same boat” (Pogrebin, 1987, p. 230). Second, friends share knowledge and information that can facilitate task accomplishment (Morrison, 1993a, 1993b; Reichers, 1987). Third, peer friends help each other by discussing and making sense of ambiguous organizational phenomena and by building traditions and identities that reduce their uncertainty about the environment (Fine, 1986). Finally, the bonds and resulting sense of identity from friendships may contribute to members’ satisfaction with an organization (Fine, 1986). Research on undergraduate students’ socializa-


215

tion shows that informal involvement with peer friends enhances their academic engagement and social integration and increases their persistence in their studies (Ethington, 2000; Tinto, 1997). Lundberg (2003) provided evidence that, when the friendships are educationally related rather than purely social, they facilitate enhanced learning outcomes for students of all ages. Tinto (1997) argued that student friendships formed in a shared learning situation helped bridge the “academic-social divide” that often exists by meeting both academic and social needs “without having to sacrifice one in order to meet the other” (p. 611). Friendships may be particularly salient in the process of assimilation into medical school. New entrants to medical schools find themselves thrust together into a strange and uncertain environment. They often feel vulnerable and insecure, and friendships may offer support through the process of becoming acclimated to the new environment (Pogrebin, 1987; Van Maanen & Schein, 1979). Friendships may serve also as a source of learning about norms and “occupational rhetoric” (Fine, 1996; Jablin, 2001) and as an audience for trying out the performance of one’s emerging identity as a physician (Radcliffe & Lester, 2003). Just as peer friendships may play a role in assimilation, so too may the process of assimilation influence friendship formation. Maines (1990) found that friendships “take on shape and meaning in terms of the social context in which they are formed and maintained, and that they must be viewed in light of those contexts if they are to be properly understood” (p. 172). Research evidence from studies of “blended” relationships—relationships that have both personal and organizational dimensions—has shown that the organizational context exerts a powerful influence on the particular tensions that must be managed in the relationships (Bridge & Baxter, 1992; Sias & Cahill, 1997; Zorn, 1995). Two studies found that people are influenced in their choice of friends by proximity; that is, they made friends with those who worked near them (Schutte & Light, 1978; Sias & Cahill, 1997). Studies have also shown that peer friendships became closer when people experienced problems at work (Odden & Sias, 1997; Sias & Cahill, 1997; Sias & Jablin, 1995). Although suggestive, the research reviewed earlier sheds little direct light on how friendship development and assimilation are played out in the early stages of medical school. Given the high stress levels of transition periods (Radcliffe & Lester, 2003), the demonstrated consequences of coping in the first year (Guthrie et al., 1995), and the formative influence of informal interaction with peers (Hafferty, 1988), it seems important to understand the nature of relationships formed in the first year. Of particular interest to communication scholars is how friendship and assimilation processes are socially constructed and enacted in the process of creating and shaping meaning. Needed are studies that investigate participants’ sensemaking about their experiences at work and ways that those processes contribute to and are influenced by social interaction. Relationships, such as organizational friendships, are played out and constructed in talk. To address such issues requires an approach that highlights the symbolic interaction that consti-

216

ZORN AND GREGORY

tutes relationships and methods appropriate to surfacing meanings and the subtleties of interaction. The study we conducted focused on male student groups in their first few months as students in a southeastern U.S. medical school. We examined their discussions with and about their peers. By analyzing this talk, we can understand how they developed individual and shared meanings for their developing friendships, their assimilation experiences, and the relation between the two. Specifically, we asked: RQ1: How do male newcomers to medical school symbolically construct and enact their friendships with each other? RQ2: How do male newcomers to medical school symbolically construct the relation between their friendships with each other and assimilation into medical school?

METHOD Research Setting The participants for the study were 14 men who had been enrolled in a large, southeastern medical school for approximately 3 months. Students in this school were assigned to one of five medical laboratories, or labs, with approximately 33 students per lab, in most cases about 18 men and 15 women. The lab is a room in which students keep a desk; store books, supplies, and equipment; use a computer; and hold various lab sessions and meetings. The lab is designed as a comfortable setting in which the students go to study, eat, or sneak breaks between their rigorous classes and schedule. Students typically spend a great deal of time in their labs and remain members of the same lab for their first 2 years of medical school. The 14 men who participated in this study were equally divided between two labs. Life for these first-year medical students was very hectic and emotionally intense. Students minimally were in the medical school building from 8:30 a.m. to 5 p.m., Monday through Friday, and substantially more was not uncommon. Their classes were collective, meaning all 165 students in their cohort group attended lectures together. At times, students broke up into smaller groups for activities such as associated lab exercises and group discussion sessions. Data Collection and Data Analysis The second author conducted in-depth, semistructured, initial interviews with all 14 participants. These interviews took the form of asking participants to “tell the story” of their early months in medical school, focusing particularly on development of friendships and the role they played in adjusting to medical school. This technique


217

led to interviewees providing an extensive narrative of their experiences and perceptions. The interviewer interjected probes as each interviewee narrated his tale, asking for elaboration, examples, and specific dialogue of conversations, with the intention of fully exploring the interviewees’experiences and perceptions of assimilation and relationship development. Interviews ranged from 30 to 60 min, with most lasting about 45 min. The recorded interviews were fully transcribed. In addition, the second author spent more than 30 hr observing participants and taking field notes (during 14 formal observation sessions and numerous informal sessions). This included attending orientation activities to gain an understanding of the setting and the student socialization process. She then observed participants’ interaction with labmates in their respective medical labs (i.e., their shared offices) during times heavy with social interaction, such as lunch and between-class breaks (this also tended to be the time she entered the lab to wait for and meet with interviewees). Finally, she attended and acted as a nonparticipant observer during various lab exercises and small-group case studies and seminars that included some of the participants. To analyze the field notes and interview transcriptions, Owen’s (1984) method of thematic analysis was used. Owen’s three criteria for identifying themes are recurrence of meanings, repetition of words and phrases, and forcefulness (exemplified by vocal inflection, volume, dramatic pause, or linguistic markers). The second author conducted the initial thematic analysis. Next, the initial analysis was shared with the first author; together, the two authors discussed and refined the thematic categorization of the data. The themes identified as major themes were each represented in multiple interviews and/or observations. Finally, the second author conducted follow-up interviews with four participants (two from each lab) to confirm and refine the analysis and interpretations (Tompkins, 1994). In these interviews, she explained the themes identified in our analysis and asked interviewees to comment on our interpretations, especially to explain if they saw things differently.

RESULTS From analysis of the interviews, themes were identified that described the primary ways that participants (a) constructed their friendships with other male medical students, (b) enacted the friendships, (c) constructed the friendships as influencing the socialization process, and (d) perceived the socialization process as shaping their friendships. The first two sets of themes respond to the first research question and the latter two sets of themes respond to the second research question. Table 1 shows the four sets of themes. In the following section, we address each of the research questions, using the themes presented in Table 1.

218

ZORN AND GREGORY

Constructing and Enacting Friendship In general, the participants focused on the fact that (a) the relationships were new and developing; (b) they emerged in the process of pursuing their primary, task-oriented goals (i.e., surviving medical school); and yet (c) they met social needs that all the participants experienced. We discuss each of these three groups of themes in turn.

The early stages of friendship. Perhaps the most prominent way participants constructed their male medical school relationships was as not-yet-close friendships.2 The men repeatedly noted that their male medical school relationships were “not close” compared to some friendships (typically, those long-standing relationships outside of school) and “close” compared to other relationships (typically those relationships with medical school “acquaintances”). However, participants clearly had an optimistic sense that the relationships were developing on a trajectory toward close friendships as time went on. For instance, general descriptions of the relationships included “the developing end of friendships” (Jeff) and “acquaintances becoming friends” (Matt).3 What all participants stated or insinuated was that the friendships constituted their “med school friendships,” implying that they were constructed according to their location and task. Participants continually noted how their medical school relationships almost always started with frequent contact—that is, those individuals with whom they had the most physical contact, either through lab discussion sessions or because their assigned lab desks were near each other’s—were those people with whom they were likely to become friends. This seemed to be a manifestation of the constraints on time imposed by medical school. Their busy schedule allowed only for friendship formation with those who might be physically near them, because it was easy or convenient to have interactions with them. As Matt stated, “The friends that I have here are the friends I’m more likely to see throughout the day. … So it’s kind of, we’re thrown together.” Paradoxically, though, although time was a constraint on friendship formation, it was the element of time that assisted them in making friends with those individuals with whom they had contact. Because the students often spent 12 to 18 hr a day in the labs, they spent an enormous amount of time with those who sat around them or those with whom they had contact in lab sessions or discussion groups, which contributed to friendship formation among the classmates. Matt explained: “These are the people that I see. These are the people that I spend all my time with and I’m with every day—7 days a week, pretty much.” Therefore, as implied by Bridge and Baxter’s (1992) notion of blended relationships, the friendships developed from 2Themes

are italicized throughout the article for easy identification. are used for participants’ names.

3Pseudonyms

TABLE 1 Major Themes Constructing Friendship Early stages of friendship Not-yet-close friendships Relationships based on frequent contact Task relationships Task relationships People with shared goals and experiences Reciprocal assistance: Friends who help each other Socio-emotional relationships Comfortable/enjoyable relationships

Enacting Friendship

Friendship → Assimilation

Assimilation → Friendship Facilitating friendship formation Hindering friendship formation

Talking about school Studying together Reciprocal task assistance

Tangibly assisting

Talking socially Joking Sharing activities

Emotionally supporting Making work enjoyable Creating a sense of comfort Creating identity

Encouraging diversity

219

220

ZORN AND GREGORY

initial relationship as classmates and, in many cases, labmates. Blieszner and Adams (1992), from their review of adult friendship development literature, contend that common membership in groups, as well as frequency and breadth of interaction, have all been shown to contribute to adult friendship development; clearly, common membership in the medical school cohort and, more specifically, in labs, along with the frequent interaction these memberships encouraged, contributed to the development of these friendships. Although they constructed the friendships as developing, participants seemed to feel that the relationships were somewhat superficial (i.e., not close), in part because most interactions revolved around talking about school and studying together, as opposed to more personal concerns. Colin suggested that the male friends were somewhat reluctant to discuss personal issues; they were much more apt to “internalize feelings.” David felt that, initially, the setting of medical school, including a sense of competitiveness, might have limited the amount of self-disclosure among male medical students: “You’re always trying to figure out who’s the number one kid. … So you’re always kind of holding back.” However, participants mentioned that there was a growing amount of personal conversation, self-disclosure, and sharing of stories and past experiences. For instance, Bob commented, “Eventually, certain things come out. You share a little bit more. You ask other people questions, or whatever. … And I think it’ll keep happening.” In this way, talking socially added to their sense that, although the relationships were not yet close, they were developing.

Task relationships. Several of the themes revolved around the idea that participants are associated with each other because of their primary task or goal: getting a medical degree (or alternatively framed, “ surviving” medical school). All 14 participants described their male medical school friendships as task relationships. In follow-up interviews, participants were particularly vocal in confirming the accuracy of this theme. Closely related, all 14 participants also constructed their male medical school friends as people with shared goals and experiences. Participants considered a basic reason they were friends with particular classmates was that they shared the common professional goal of becoming physicians. In addition, their new, shared experiences (i.e., in classes and in the adjustment process into medical school) led to a “common bond” (Tim). Don added, “As soon as you’re in medical school, you’re all in it together.” Almost all the participants claimed that, even outside of classes, they enacted friendships by either studying together or talking about school and their tasks. Paul provided an example of the latter: We just got back from a week we spent in the community in doctors’ offices and … everybody had very different experiences and was really excited about it. … Last week everybody was talking about that. “What did you do?


221

Did you do a rectal exam? Did you take a blood pressure? Did you see a baby being born?” That kind of stuff. Because the students spent most of their waking hours either in class or studying, it is not surprising that studying together became an important vehicle by which they formed and enacted friendships. Many of the participants mentioned that the people with whom they had the closest friendships were the people with whom they had a set routine for studying. Rituals included reviewing histology slides on Saturday mornings or review sessions with their anatomy dissection group. As Steve explained, “Most of my life right now is consumed by studying. … And, that’s probably why … people that I spend a lot of time with are the people I study with.” Another important way that the men both constructed and enacted their friendships with other students was through reciprocal assistance. Participants frequently said that their friends were the people who helped them and whom they helped. Ken explained: “We’ll get together and we’ll say, ‘Well, look, Colin, why don’t you go do this, and I’ll do this other thing and we’ll pool our notes together and we’ll share.’” During the second author’s observations of participants’ interactions with their male classmates, at least 20 interactions were observed that were clear examples of reciprocal assistance. These occurred most frequently during histology lab, when the students would continually gather together to talk about the slides and help one another locate the relevant material. Additionally, they often quizzed each other on medical topics whenever they had a free moment (e.g., while waiting to talk to a professor). In short, the friendships described are what Lundberg (2003) labeled “educationally related peer relationships” (p. 667)—not purely social relationships—and thus the kinds of relationships Lundberg and others (Tinto, 1997) suggested are particularly beneficial to facilitating academic achievement.

Socio-emotional relationships. Although the men seemed to construct their medical school friendships primarily as task oriented, several themes suggest that they also thought of and enacted these friendships as social and personal relationships. Most of them talked of at least some of these relationships as comfortable and enjoyable. For example, Kevin said: “I’m sure most of it is the time that you spend, but there is a degree of comfort that you don’t feel with other people.” A manifestation of this enjoyable and comfortable interaction was a high level of joking behavior among the male friends. Consistent with prior research on male friendships (Swain, 1989), almost all participants made frequent mention of the amount of joking and teasing that occurred during their daily interaction. Joking appeared to serve several functions for the male friends, including “blowing off steam” (Colin), relieving boredom, conveying closeness (e.g., through teasing), or diffusing a potentially stressful situation. For instance, Colin talked about how he

222

ZORN AND GREGORY

enjoys “goofing around” to cope with the pressures of school: “Today I was acting like a poor man. I was playing my cup like it was a banjo, and threw a box down there for people to throw coins, and I collected 50 cents! Just from my lab people!” The frequency of joking behavior observed by the second author was particularly striking in anatomy lab. For example, Don’s anatomy lab group, consisting of five men, seemed to exhibit a great deal of joking, including teasing of one another. One of the members said to the second author, “We have a definite pecking order and Don is on the bottom.” The men laughed heartily at his comment. They also gave made-up names (“Homer” and “Grady”) to the cadavers and talked playfully (and often disparagingly) about them. Joking in the lab seemed to be an acknowledged ritual for the students, perhaps helping to buffer the intensity of dealing with death and the cadavers (Hafferty, 1988). As Ed said, “I think we make a joke because here are all those dead bodies, you know.” According to participants, two additional ways in which the social dimension of their friendship was enacted were talking socially and sharing activities. Although their time was severely constrained by the pressures of medical school, participants were able to talk socially about sports, past experiences, social issues, women, classmates, and personal problems. This talk occurred both between and during class activities. These moments of social talk appeared to be important to the men and a sign of their growing friendship. Interestingly, most participants suggested that the amount of time spent talking about school far outweighed the amount of time talking socially, yet this was not consistent with our observations. Jeff, for example, said he believed 85% of their conversation was spent talking about school, with only 15% social talk. However, the men seemed to talk socially more often than they realized or acknowledged. We observed many incidences of social talk, the majority of which took place while the men were working on tasks, often without seeming to notice the multitasking and quick topic switches. For example, during histology lab, the students would continue to look through their microscopes as they talked socially (e.g., about a television program, sports, or an interesting news item). Such multitasking conversations may represent the students’ efforts at circumventing the strict time and task constraints. When they did have free time, the friends valued sharing activities, such as sports, exercising together, and going out to local bars. Again, most participants claimed that school-related activities (e.g., studying and talking about school) consumed most of their friendship interaction. However, although the students perceived that they had little time to engage in activities together due to their time constraints, they still mentioned these activities a great deal, and perhaps participated in shared activities more than they acknowledged. Thus, the participants constructed their relationships as very heavily task- and school-oriented, yet observations suggested that talking socially and sharing activities were quite frequent and prominent. Perhaps the competitiveness of medical


223

school that some participants noted made it desirable to portray themselves as remaining focused on study at the expense of socializing. That is, downplaying social talk and social activities and emphasizing task-related activities is a way to convey a role identity (McCall & Simmons, 1978) of a serious and committed future member of the medical profession. The Mutual Influence of Friendship Development and Assimilation The second research question focused on how the men saw the relation between friendship development and assimilation into medical school. To address this question, we look first at how they saw the friendships influencing assimilation, then at the reverse relation.

The influence of friendship development on assimilation. Many participants saw their task-related friendships as essential to their successful assimilation. Nearly all participants identified some form of tangible assistance as a significant way that their male friendships facilitated their adjustment to medical school life. This type of assistance often involved helping each other with the academic workload by studying together or sharing lecture notes. For example, Bob commented, If I have questions [in histology lab], I’ll usually get Pat to show me a slide, or one of these guys to show me a slide … and that’s a routine. … We’re always real willing to go for the other one to help them out in answering questions or whatever. Of course, their construction of medical school friendships as enjoyable, comfortable relationships also played a role in the men’s organizational socialization process. Most participants mentioned that their friendships helped them with their adjustment to medical school because they made the work enjoyable. As Bob explained: “It’s a little group. … We have fun. I like that. I don’t mind looking at slides and stuff because it’s kind of fun.… It makes me enjoy coming to class more.” The men also experienced a sense of comfort in their new surroundings that was created from their developing friendships. Most of them perceived that their male friendships helped them feel comfortable or at ease in medical school and, thus, helped them with their adjustment. For example, David noted, “If you had to come to med school and you tried to do everything on your own, and not make friends, it would be a lot harder. So [the friendships] have facilitated it. Just for comfort.” Steve noted that this comfort level led him to conceive of his lab as somewhat of a “home away from home.” The friendships, then, appeared to help the men feel

224

ZORN AND GREGORY

more comfortable in their new environment and contributed to them wanting to spend more time there. Participants also perceived that their friendships helped them with their assimilation into medical school by providing them with a sense of identity or “fit” (Tim). For instance, many participants (as well as a medical school administrator) mentioned that the significant amount of time the first-year students spend in their labs makes them feel as if their lab has its own identity or personality. Roger explained: To be able to identify with the 32 people in their lab. … It’s important because it kind of separates them from the 160 people and makes them special and different. And everyone wants to feel that. And [each lab] likes to say, “Our lab’s the best ’cause we have more fun or we’re closer to each other or we do better in grades.” Feeling that they had an identity within the labs, then, contributed to the men getting a sense of their identity within the program—a feeling that they belonged. The participants also perceived that the male friends helped each other adjust to medical school through an exchange of emotional support. Although help with school-related tasks was one form of reciprocal assistance shared by the male students, as described earlier, the mutual help often also took the form of emotional support. In fact, nearly all participants stated in one way or another that their male medical school friends had helped them with the emotionality of adjusting to medical school. Emotional support took many forms. For instance, the men reported helping each other emotionally by “complaining” together or “venting frustrations” (Jeff). For many, the relationships helped to reduce stress by allowing the men to commiserate over their difficult adjustment, including their unmet expectations and problems. Participants mentioned that it helped them to know others shared their same fears and doubts. Often, this sort of sharing signified to the men that they were friends. For example, Colin told a story of how his labmate (and desk partner), Matt, helped him to get through a rough adjustment period. He saw me in the library; I think it was the first week of class. He came up to me and I was … about to cry. I was just so overwhelmed.… And it was Matt who came up and just … kind of talked to me for about five minutes, and that was real nice. And so, right now, we’ve probably got a pretty good friendship … that’s developed. Colin later described the reciprocal nature of the assistance, “These interactions with my classmates help soften the blow. It helps to say, ‘Hey, they’re having problems just like I am. Hey, this person needs help. Matt needs help. Help him out. He helped you. You help him.’”


225

For Ken, however, the emotional support and stress relief his friends gave him came from the stress reduction and camaraderie of sports activities. He said, “Well, you need support. You need a support system. Medical school’s a lot of work; it’s a lot of stress. For example, my support system has to do with guys going out and relieving stress by playing sports.” Other ways the men assisted one another with their emotional adjustment was by helping them deal with their emerging identity as physicians (e.g., talking about the strange sensation of putting on a white lab coat and being called “Doctor”) and helping them to get along with their diverse group of labmates. Through these various ways, participants’ male friendships served to make the men feel more comfortable and less alone in their new context and roles and helped them through the difficult adjustment process. Litwak (1989) argued that friendships play an important role in modern industrialized societies; friends, because of similarity in age, lifestyle, and experience, are often better than kinship or formal organizational relationships at helping individuals adjust to many of life’s challenges. Of particular relevance to our study, he argued that friends are better than bureaucracies at helping people through nontechnical tasks, such as adjusting to new situations. Our findings support Litwak’s contentions; however, we found that friends not only were instrumental in the nontechnical tasks, but through studying together and reciprocal assistance, also helped each other master technical tasks as well. They receive a dual benefit that Tinto (1997) described in which both social and academic needs are met simultaneously. There is an efficiency in this dual benefit that seemed important given the time pressures that the medical students faced.

The influences of organizational assimilation on friendships. Paradoxically, participants perceived that the ways in which they were socialized into medical school both facilitated and hindered friendship formation. For instance, the men felt that the manner in which the medical school administration structured the first-year medical student experience facilitated friendship formation in that the structure encouraged frequent contact among the students (via studying and time spent in class and in lab) and shared experiences. As Ed described it, Medical school definitely has affected it [the friendships]—by simply how it’s designed. It kind of forces people together. ’Cause we tend to hang out—our groups are basically established by the time that we have and how we organize our time. Similarly, participants felt that their common experiences with their classmates, through their collective, structured socialization process, contributed to friendship formation. As Bob noted, “Med school definitely forces you into certain subgroups and then, by necessity, you have to make friends out of those groups.” Some

226

ZORN AND GREGORY

participants mentioned that they believed it was the difficulty of these common experiences that made the students closer; Roger used the analogy of fraternity pledging to explain this phenomenon. So, frequent contact and shared experiences created a bond among the men and a sense of comfort that facilitated friendship formation and made each man feel more secure in his new roles of student and friend. However, the men felt that the structure of the curriculum simultaneously hindered friendship formation and caused it to be a slower, more difficult process in that the heavy academic workload and resulting time constraints left little time for purely social interaction. As Bob explained, “It takes a long time … because classes and studying and medicine take so much time.… It takes a lot longer to make really good friends.” Similarly, Tim talked about how the setting limited the amount of social talk: Our conversations … always turn to med school, and I think that’s just because you can just tell that med school’s always weighing on you. … It’s almost like … when you make a friend, you’ve got med school sitting on your shoulders and you can’t really get it off. It’s always there. The construction of their relationships as task relationships also both hindered and facilitated friendship development. It facilitated in that the tasks were a common bond and a reason to interact, yet it hindered in that interacting because of the task seemed antithetical to many people’s notions of friendship. The final way that participants felt their male medical school friendships were affected by their assimilation experiences is that they felt these experiences encouraged diversity in their friendships; that is, the men found it noteworthy that they developed relationships with people dissimilar to themselves. What made this diversity significant for the men was that they claimed to form friendships usually with men who were similar to themselves and, thus, this diversity was a new experience for them. Kevin stated, “All of a sudden we’re thrown in with a bunch of people who, none of us are like each other—except for the fact that we’re in medical school.” Many other participants echoed Kevin’s sentiments that the common experience of medical school and the common goal of wanting to become physicians were the bases for these diverse friendships. Research on adult friendships has repeatedly noted the tendency toward homogeneity on dimensions such as ethnicity, age, marital status, and religion (for a review, see Blieszner & Adams, 1992). Thus, it is not surprising that developing relatively close friendships in heterogeneous groups was remarkable to the men. Participants appeared to enjoy this diversity, however, seeming to find it interesting as well as good training for their future profession, one that requires them to “deal with different types of people” (Tim).


227

DISCUSSION It is important to study informal interaction in medical school, as we have done, in part because of the consistent theme that medical students undergo an ethical and emotional transformation via the hidden curriculum (Cribb & Bignold, 1999; Harter & Kirby, 2004; Light, 1988). Medical school has been described by numerous scholars as transforming doctors-in-training by instilling a medical gaze (Good & Good, 1989) through which people are objectified, which has negative consequences for patient care and for the physicians themselves (Conrad, 1988; Cribb & Bignold, 1999; Gordon, 1996). Critics charge that relationships with people are transformed through medical training in mostly antisocial ways (Christakis & Feudtner, 1997). So, it makes sense to study the informal interaction and relationships that develop alongside medical training, both to understand more deeply the ways the education experience affects medical students as well as to understand medical students’ coping responses. If we want physicians to treat patients holistically, we need to study physicians-in-training as whole people, with lives and relationships outside of, and alongside of, formal medical education. However, even though scholars and administrators agree that there is a strong tension between objectifying and humanizing elements of medical training and that socialization in the formative, preclinical years is critical to how that tension plays out, with the exception of Hafferty’s (1988) study of cadaver stories, we could not find a single empirical study that focused on informal relationships in the preclinical years nor a single study that explored students’ qualitative perceptions of socialization in the early years.4 Because we know from socialization literature more broadly that informal interactions are hugely influential, qualitative exploration of the informal socialization process, such as this study reports, seems vital. Our participants depicted their peer friendships as vital to assimilation into medical school. Although administrators in many types of organizations have no doubt recognized intuitively the value of these bonds in organizational assimilation, this is the first study we are aware of that systematically investigates newcomers’constructions of the role of cohort friendships in the assimilation process. Of importance, although previous research has found that friends were particularly important in helping individuals adjust to nontechnical aspects of new environments (Litwak, 1989), the men in our study helped in both the technical and nontechnical arenas. That is, through studying together and reciprocal assistance, they helped each other master technical tasks in addition to offering nontechnical help such as emotional support. However, most of the ways that the students saw friendship as aiding assimilation 4Note that Harter and Krone’s (2001) study of socialization in osteopathic medical schools could also be considered an exception here. But there are significant differences between the osteopathic and “mainstream” medical school experiences, as Harter and Krone made clear.

228

ZORN AND GREGORY

were in meeting socio-emotional needs: emotional support, making work enjoyable, creating a sense of comfort, and creating a sense of identity. Thus, friendships provided the sorts of resources needed to buffer the negative effects of stress and the “bruising experience” (Light, 1988) of medical school. Medical schools have for some years been attempting to deal with the tension between objectifying and humanizing elements of medical training. As Cribb and Bignold (1999) argued, “Many curricular reforms are designed to counteract this tendency, to keep medicine ‘human’” (p. 195), yet the curriculum and interaction with faculty have led most observers to conclude there is still an imbalance toward objectifying (Conrad, 1988) and, in general, antisocial behavior. Pitkala and Mantyranta (2003) recently concluded from their research that, “The old learning culture emphasizing authoritarian teachers and humiliation still retains its hold within medical schools” (p. 159). However, assimilation is a dual process (Jablin, 2001) in which newcomers have the opportunity to push back at the socializing pressures through their own attempts to shape their experience. Students tend to start medical school with humanistic ideals (Pitkala & Mantyranta, 2003) and likely find idealistic allies among their peer friendships. As Christakis and Feudtner (1997) argued, the “social and cultural forces [of medical training institutions] are … modified by the quality of interaction that trainees have with other members of their medical community” (p. 739). Certainly the many helpful, caring behaviors described by our interviewees, such as tangible assistance, emotional support, and sharing activities, suggest the potential for friendships to have a counterbalancing humanizing influence. However, we would not argue that all friendship interaction serves a humanizing function. Medical students learn and likely practice their occupational rhetoric and identities (Fine, 1996) with each other, which likely include the display of values such as task focus and objectifying. As suggestive evidence, our participants constructed their relationships as very heavily task and school oriented, yet observations suggested that talking socially and sharing activities were frequent and prominent. The seeming inconsistency between what they said and what we overheard in observation suggests that identity goals may prompt students to downplay the social aspects of their interactions. Spending time in social talk and social activity may be inconsistent with the identity the men want to convey, as serious, committed future physicians. These students, already immersed in the occupational discourse of physicians and the organizational discourse of medical school, seem to emphasize accounts that portray them as totally dedicated to the work of becoming physicians. However, even though there seem to be multiple dimensions to students’ friendships, administrators with a humanizing agenda would do well to encourage and nurture the caring side of students’ interactions with peers. Although we are hesitant to recommend formal mechanisms to manage friendship development, certainly knowledge regarding (a) its role in assimilation, and (b) the ways medical students’ friendships develop can help administrators and the students themselves in nurturing such relationships. As Christakis and Feudtner (1997) argued, “If we


229

desire to improve ethical behavior, we must … search for ways to rectify students’ and residents’ daily lives and strive to promote the ‘relationships’ that they have with all the people who should matter to them” (p. 743). For example, administrators might discuss friendship and assimilation issues in orientation programs or design orientation processes to encourage bonding (Tichy, 2001) and they might monitor developing networks of friends, being on the lookout for isolates and destructive forms of conflict, and intervening as appropriate to encourage their humanistic behaviors. Future research should explore, perhaps through action research methods (Zuber-Skerritt, 1996), ways of encouraging the formation and development of peer group support and friendships. Facilitating such initiatives may be informed by the ways that our participants suggest their medical school friendships develop. That is, if the patterns that we identified prove generalizable, peer friendship support systems may be facilitated by encouraging frequent contact, shared activities, and enabling space for conversations in which participants can talk socially alongside their more task-focused conversations. CONCLUSION There are clearly limitations to our study. The study was conducted with male participants only at one medical school in a brief time period and with a small sample. So, we must be cautious in generalizing any claims. Certainly additional research with larger samples that include female participants and multiple medical schools would be valuable. However, as Hafferty (1988) argued, there has been a neglect of the “formatively important” (p. 344) preclinical stages of the socialization process in medical education. Our research represents a small step toward understanding the assimilation process in this vital period. Based on our findings and related research (Gersick, Bartunek, & Dutton, 2000; Radcliffe & Lester, 2003; Sias & Cahill, 1997), it seems safe to conclude that friendships play an important part in the assimilation process of first-year medical students. Friends provide tangible, instrumental support to each other along with vital socio-emotional resources that enable students to cope with the difficult transition into medical school. One of the likely reasons that research has generally ignored friendships in organizations is an assumption that friendships do not play an important role in organizational functioning (Zorn, 1995). However, as this study shows, these relationships were eminently functional. They helped these men adjust to a new, uncertain, and often overwhelming work situation. ACKNOWLEDGMENT The authors thank Kandi Walker for her comments on an earlier version of this manuscript.

230

ZORN AND GREGORY

REFERENCES Alvesson, M., & Deetz, S. (2000). Doing critical management research. London: Sage. Antonio, A. L. (2004). The influence of friendship groups on intellectual self-confidence and educational aspirations in college. The Journal of Higher Education, 75, 446–471. Beagan, B. L. (2001). Even if I don’t know what I’m doing I can make it look like I know what I’m doing: Becoming a doctor in the 1990s. The Canadian Review of Sociology and Anthropology, 38, 275–297. Blieszner, R., & Adams, R. G. (1992). Adult friendship. Newbury Park, CA: Sage. Bridge, K., & Baxter, L. A. (1992). Blended relationships: Friends as work associates. Western Journal of Communication, 56, 200–225. Christakis, D., & Feudtner, C. (1997, September 3). Temporary matters: The ethical consequences of transient social relationships in medical training. Journal of the American Medical Association, 278, 739–743. Conrad, P. (1988). Learning to doctor: Reflections on recent accounts of the medical school years. Journal of Health and Social Behavior, 29, 323–332. Cribb, A., & Bignold, S. (1999). Towards the reflexive medical school: The hidden curriculum and medical education research. Studies in Higher Education, 24, 195–209. Ethington, C. A. (2000). Influences of the normative environment of peer groups on community college students’ perceptions of growth and development. Research in Higher Education, 41, 703–722. Fine, G. A. (1986). Friendships in the workplace. In V. J. Derlega & B. A. Winstead (Eds.), Friendship and social interaction (pp. 185–206). New York: Springer-Verlag. Fine, G. A. (1996). Justifying work: Occupational rhetorics as resources in restaurant kitchens. Administration Sciences Quarterly, 41, 90–115. Gersick, C. J. G., Bartunek, J. M., & Dutton, J. E. (2000). Learning from academia: The importance of relationships in professional life. Academy of Management Journal, 43, 1026–1044. Good, M. D., & Good, B. J. (1989). Disabling practitioners: Hazards of learning to be a doctor in American medical education. American Journal of Orthopsychiatry, 59, 303–309. Gordon, L. E. (1996, Spring). Mental health of medical students: The culture of objectivity in medicine. The Pharos, 2–10. Guthrie, E. A., Black, D., Shaw, C. M., Hamilton, J., Creed, F. H., & Tomenson, B. (1995). Embarking upon a medical career: Psychological morbidity of first year medical students. Medical Education, 29, 337–341. Hafferty, F. W. (1988). Cadaver stories and the emotional socialization of medical students. Journal of Health and Social Behavior, 29, 344–356. Harter, L. M., & Kirby, E. L. (2004). Socializing medical students in an era of managed care: The ideological significance of standardized and virtual patients. Communication Studies, 55, 48–67. Harter, L. M., & Krone, K. J. (2001). Exploring the emergent identities of future physicians: Toward an understanding of the ideological socialization of osteopathic medical students. Southern Communication Journal, 67, 66–83. Inman, C. C. (1996). Friendships among men: Closeness in the doing. In J. T. Wood (Ed.), Gendered relationships (pp. 95–110). Mountain View, CA: Mayfield. Jablin, F. M. (2001). Organizational entry, assimilation, and disengagement/exit. In F. M. Jablin & L. L. Putnam (Eds.), The new handbook of organizational communication: Advances in theory, research, and methods (pp. 732–818). Thousand Oaks, CA: Sage. Jablin, F. M., & Krone, K. J. (1987). Organizational assimilation. In C. R. Berger & S. H. Chaffee (Eds.), Handbook of communication science (pp. 711–746). Newbury Park: Sage. Katz, J., Monnier, J., Libet, J., Shaw, D., & Beach, S. R. H. (2000). Individual and crossover effects of stress on adjustment in medical students’ marriages. Journal of Marital and Family Therapy, 26, 341–351.


231

Light, D. W. (1988). Toward a new sociology of medical education. Journal of Health and Social Behavior, 29, 307–322. Litwak, E. (1989). Forms of friendships among older people in an industrial society. In R. G. Adams & R. Blieszner (Eds.), Older adult friendships (pp. 65–88). Newbury Park, CA: Sage. Lundberg, C. A. (2003). The influence of time-limitations, faculty, and peer relationships on adult student learning: A causal model. Journal of Higher Education, 74, 665–688. Maines, D. R. (1990). The organization and career contexts of friendship among doctoral students. In H. Z. Lopata & D. R. Maines (Eds.), Friendship in context (pp. 171–195). Greenwich, CT: JAI. McCall, G. J., & Simmons, J. L. (1978). Identities and interaction: An examination of human associations in everyday life (Rev. ed.). New York: Free Press. Morrison, E. W. (1993a). Longitudinal study of the effects of information seeking on newcomer socialization. Journal of Applied Psychology, 78, 173–183. Morrison, E. W. (1993b). Newcomer information seeking: Exploration types, modes, sources, and outcomes. Academy of Management Journal, 36, 557–589. Odden, C. M., & Sias, P. M. (1997). Peer communication relationships and psychological climate. Communication Quarterly, 45, 153–166. Owen, W. F. (1984). Interpretive themes in relational communication. Quarterly Journal of Speech, 70, 274–287. Pitkala, K. H., & Mantyranta, T. (2003). Professional socialization revised: Medical students’ own conceptions related to adoption of the future physician’s role—A qualitative study. Medical Teacher, 25, 155–160. Pogrebin, L. C. (1987). Among friends: Who we like, why we like them, and what we do with them. New York: McGraw-Hill. Radcliffe, C., & Lester, H. (2003). Perceived stress during undergraduate medical training: A qualitative study. Medical Education, 37, 32–38. Reichers, A. E. (1987). An interactionist perspective on newcomer socialization rates. Academy of Management Review, 12, 278–287. Schutte, J. G., & Light, J. M. (1978). The relative importance of proximity and status for friendship choices in social hierarchies. Social Psychology, 41, 260–264. Sias, P. M., & Cahill, D. J. (1997). From coworkers to friends: The development of peer friendships in the workplace. Western Journal of Communication, 62, 273–299. Sias, P. M., & Jablin, F. M. (1995). Differential superior–subordinate relations, perceptions of fairness, and coworker communication. Human Communication Research, 22, 5–38. Swain, S. (1989). Covert intimacy: Closeness in men’s friendships. In B. J. Risman & P. Schwartz (Eds.), Gender in intimate relationships: A microstructural approach (pp. 71–86). Belmont, CA: Wadsworth. Tichy, N. M. (2001). No ordinary boot camp. Harvard Business Review, 79(4), 63–70. Tinto, V. (1997). Classrooms as communities. The Journal of Higher Education, 68, 599–623. Tompkins, P. K. (1994). Principles of rigor for assessing evidence in “qualitative” communication research. Western Journal of Communication, 58, 44–50. Tyssen, R., Vaglum, P., Aasland, O. G., Gronvold, N. T., & Ekeberg, O. (1998). Use of alcohol to cope with tension, and its relation to gender, years in medical school and hazardous drinking: A study of two nationwide Norwegian samples of medical students. Addiction, 93, 1341–1349. Van Maanen, J., & Schein, E. H. (1979). Toward a theory of organizational socialization. Research in Organizational Behavior, 1, 209–264. Zorn, T. E. (1995). Bosses and buddies: A constructive/dramaturgical analysis of simultaneously close and hierarchical relationships in organizations. In J. T. Wood & S. Duck (Eds.), Under-studied relationships: Off the beaten track (pp. 122–147). Newbury Park, CA: Sage. Zuber-Skerritt, O. (Ed.). (1996). New directions in action research. London: Falmer.