This article, the ninth in the “To the Point” series that is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, discusses the role of the “hidden curriculum” in shaping the professional identity of doctors in training. The characteristics that distinguish the formal curriculum and hidden curriculum are defined. Specific examples of hidden curricula in clinical environments and the positive and negative impacts that may result are highlighted. Techniques to evaluate clinical training environments and to identify the hidden curriculum are provided and are followed by methods to promote its positive messages and lessen its negative ones.
Each student begins medical school with a perception of what it means to be a doctor. That perception may be based on personal experience, educational observation, or media messages. Once that student crosses the threshold into medical school, that perception is rapidly sculpted by experience. If we reflect on our own journey through medical school and residency into practice, we note that we have learned many intangible skills and attitudes that were not covered in textbooks, lectures, laboratories, or course objectives. Honest reflection probably would reveal that many of these intangibles were not admirable and did not buttress our core values of honesty, integrity, caring, compassion, altruism, and empathy. Instead, they made us more cynical toward patients, teachers, and our profession.
The erosion of physician professional identity impacts society’s impression of our profession. In a 1999 editorial, Jordan J. Cohen, MD, past president of the Association of American Medical Colleges, listed 3 common criticisms of physicians: (1) Doctors do not care enough about their patients. They do not take time to talk to them and understand what is special about each case. (2) Doctors do not know enough to practice the best medicine. They are too narrow-minded and not open to new treatments and new ways of doing things. (3) Doctors do not do enough to maintain the public’s trust. They are more worried about their own bottom line than about the best interests of patients and the public.
All 3 of these complaints are rooted in society’s perception of doctors’ professional values. Although the public blames physicians, these complaints could apply equally to the institutions and to the framework of medical care provision.
No medical school curriculum is designed to erode the professional values of its students, yet this phenomenon occurs. In this article, we define the “hidden curriculum” and discuss its role in shaping the professional identity of doctors in training, with a focus on medical students. We discuss tools to evaluate the clinical learning environment and identify the content of the hidden curriculum. Finally, we describe methods to modify the content of the hidden curriculum to promote the positive and reduce the negative messages that currently are required by the Liaison Committee on Medical Education.
What is the hidden curriculum?
The term hidden curriculum was defined by educator Phillip Jackson as “the crowds, the praise, and the power that combine to give a distinctive flavor to classroom life which each student (and teacher) must master if he is to make his way satisfactorily through school.” Although he was describing a traditional elementary school classroom, his definition applies equally to the complex educational dynamic of medical school. Jackson viewed education as a socialization process. Similarly, Hafferty and Franks postulated that “medical training is also a process of moral enculturation, and that in transmitting normative rules regarding behaviors and emotions to its trainees, the medical (learning environment) functions as a moral community.” Furthermore, Hafferty and Franks acknowledged that only a portion of the “medical culture” is conveyed within the formal curriculum hours. They suggested that most of what medical students accept as the values, attitudes, beliefs, and related behaviors is learned through the hidden curriculum. The hidden curriculum can impart powerful messages about the application of clinical knowledge and skills in the context of real patients, real physicians, real diseases, real resources, and real social limitations.
A simplistic way of viewing the hidden curriculum in the educational arena is to view each attending physician as a role model and each medical student as an impressionable learner. This learner will see the physician’s positive and negative attributes. In any one-on-one interaction, the learner will consciously and unconsciously pick up cues from every word, every action or inaction, every smile, smirk, and roll of the eyes.
What are the effects of the hidden curriculum?
The hidden curriculum encompasses and impacts the entire health care community: patients, students, faculty, residents, and administrative staff. The hidden curriculum can impact the learner’s perception of the patient-physician relationship, interactions with teachers, approaches to disease management, and priorities within the health care setting. Although the hidden curriculum is associated most often with communicating undesirable or negative cultural attributes, it can easily communicate positive and affirming attributes.
Exposure to the hidden curriculum begins in the preclinical learning environment with gradual erosion of professionalism ideals. Unintended messages may be communicated in lectures or other formal teaching. One study analyzed 983 teaching cases that were presented in the preclinical curriculum to identify whether they supported or undermined explicit messages about diverse patient populations. The distribution of gender within the cases was skewed toward men; in most cases, racial and ethnic descriptors were lacking. Sexual orientation and behavior were specified only in the context of a related disease. These findings demonstrated how messages that were found in clinical teaching cases differ from the intended formal multicultural curriculum.
The strongest impact of the hidden curriculum generally is found in the clinical learning environment. Many students face a professional identity conflict when the simple algorithms for patient interaction and disease management that were learned in the classroom fail to apply to the complex clinical environment. They are disheartened when many chronic illnesses are treatable, but a cure is unattainable because of the patient’s socioeconomic context. The hidden messages that they may receive on the wards create a cognitive dissonance with their expectations. In addition, students must fulfill 4 often conflicting educational goals: teamwork, patient care, clinical performance, and satisfactory grades, while pressed for time and feeling powerless.
Examples of the types of ethical challenges that are encountered by learners in clinical settings can be found in an excellent exposition by Christakis and Feudtner. These examples suggest that students may question the value of a formal curriculum that is inconsistent with their experiences in clinical care. Beyond influencing the ethics and integrity of the student, negative messages in the hidden curriculum can deter students from choosing a specialty on hearing complaints about the challenges of night call or lack of reimbursement.
Further, the hidden curriculum can have a negative impact at an institutional level. If a medical center gives important leadership roles to individuals who do not exemplify humanistic care, students may conclude that humanism is less valued than medical knowledge or technical competence, regardless of explicit statements to the contrary. Such messages can demoralize and discourage medical students and lead to cynicism and the inadvertent propagation of unprofessional behavior. Evidence suggests that such a hidden curriculum may inhibit, rather than facilitate, the development of moral reasoning during medical school.
How can the hidden curriculum be identified?
The first step in taking charge of the hidden curriculum is to acknowledge its existence and identify its characteristics. Unfortunately, the hidden curriculum is often difficult to locate and study. Because every member of the learning environment participates in and contributes to the hidden curriculum, it encompasses individuals, departments, and institutions.
We can investigate the hidden curriculum by listening to ourselves for a week. Such introspection can provide answers to the following questions: Do you complain about work hours, patient load, particular patients, insurance, nursing staff, and general stress? Do you voice satisfaction with helping patients, lifestyle, research and publication successes, and the educational mission?
We can ask our learners. Small group sessions focused on ethical dilemmas effectively identify recurring themes in a hidden curriculum. These sessions are conducted in a nonthreatening environment by facilitators who do not evaluate the students’ clinical performance and include unstructured discussions of specific scenarios that have been encountered by students. Anonymous summary reports help to disseminate information to all teachers who are involved. Student reflective essays produce similar information.
Lempp and Seale used semistructured interviews to examine students’ educational environment. These interviews were analyzed systematically for content and validity. Recurring elements of the hidden curriculum included negative influences such as poorly organized didactics, the primacy of hierarchy, and advancement by competition, with positive influences such as encouragement. Students interpreted faculty tardiness to lectures as a lack of commitment to education. Students felt humiliated by senior level faculty and even nursing staff, which emphasized the hierarchy of the medical community. By observing others at work, students concluded that “one-upping” was common and acceptable.
One approach to characterizing the hidden curriculum within a department is the multidisciplinary “Ethics Rounds.” This monthly discussion of ethical issues of pedagogy may include the difficulty in determining course requirements, procedures for grading, or misconduct policies for administrators. Other possible topics include ethical and clinical relations with peers and the conflicting demands of teaching, research, and patient care for faculty.
Few tools exist to assess the hidden curriculum objectively from an institutional perspective. The C3 Instrument is a validated questionnaire that measures an institution’s emphasis on patient-centered care, particularly in 3 areas: role modeling on clerkships, degree of perceived support that students’ own patient-centered behaviors, and student clinical experiences. The instrument was applied in a multicentered study at 9 medical schools. Each school demonstrated a unique learning environment that emphasized the need for institutional-specific assessment.
A focus on the detection of unprofessional behaviors may be more important than the characterization of appropriate professionalism. Unprofessional behavior can be elicited by querying patients and their families. These relatively objective data regarding the hidden curriculum may be collected internally or by a third party.
No single strategy can characterize the hidden curriculum effectively. Therefore, we propose a 5-step process that includes both qualitative and quantitative approaches to the evaluation and improvement of the hidden curriculum in the clinical setting:
- 1
Reflect on your own personal interactions with learners. Assess whether these interactions model patient-centered care.
- 2
Identify all parties who are involved in medical student education and identify key relationships between these parties and the learners. The parties include patients, administrators, physicians, residents, other learners, nurses, unit coordinators, other health professionals, and the media.
- 3
Systematically collect data about interactions between the learner and these parties through personal observations, learner observations, and reflections from surveys or focus groups.
- 4
Analyze and organize these data and identify key themes, positive and negative influences, and specific problems.
- 5
Share these findings with the parties who are involved. Similar to continuous quality improvement strategies, this cycle should be repeated to evaluate for improvement and progress.
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