Shifting priorities in academic medicine and the shaping of institutional culture.

Little attention has been given to questions of how the culture of institutions change and the role individuals play in that change. From a theoretical framework based in social interactionism (Berger and Luckmann, 1967), notions that ideas carry cultural power (Lukes, 1978; Latour, 1986) are explored through the observation of a curriculum review project at a state-supported medical school. The participant-observer case study encompassed two years. Conflict between the educational needs of medical students and the needs of an institution organized around research and specialty interests were suggested in the data. Public demand for more primary care practitioners was identified as a principal source of that conflict. Primary care appeared to be regarded by many academicians as a "nonscience" endeavor, which does not bear easy integration into the institution's specialist culture. Inductive diagnostic protocols reportedly used by most generalist physicians are not well supported by the deductive research traditions of positivist-reductionist science nor by the didactic teaching methods commonly employed in classroom-based instruction. Many faculty members invoked the symbols and myths of academic science as a defense against ideas promoted through the public's desire to enhance primary care instruction. Assumptions, traditions, and economic forces derived from the scientific-based culture of the medical academy contribute to inhibit a committed response to population-based health care needs, and suggest the continuing maintenance of social stratification within the profession. Some faculty members grew to accept the call to address public needs, even though that meant challenging their own cultural traditions. The response of these faculty implied that a shift of the institution's culture may be underway, but no evidence suggested the changes would be lasting. Implications of the findings as they relate to issues of social diversity in higher education are discussed from critical and social reproduction perspectives. The culture of science is identified as serving as a social mechanism that reduces social diversity within the profession. The findings suggest that similar studies may identify analogous cultural barriers in entrance and advancement requirements of higher education in general. Additional research into the relationship of science to the general practice of medicine is urged