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Navigating the hidden curriculum in medical school

Lindsay Kalter , Special to AAMCNews
July 30, 2019

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From the clinic to the cafeteria, students pick up messages far beyond what they learn in official courses. But what happens when those messages undermine basic tenets of professionalism? Here's how schools are helping future physicians handle those contradictions.

Duane Kim, a second-year student at University of California, Davis, (UC Davis) School of Medicine, was shadowing a preceptor when he encountered one of the most emotionally difficult cases he’d ever seen — a child with metastatic cancer. Kim was understandably shaken, but because medical school culture often emphasizes stoicism, he wasn’t sure if he should or how to express his feelings.

“I think we’re told to mask our emotions when dealing with patients,” Kim says. “It becomes this thing we’re doing for the good of the patient, by remaining neutral.”

That’s when he turned to his coach, a faculty member assigned to help guide him through aspects of medical school that are not in the formal curriculum.

“My coach’s advice was trying to stay true to who I am as an individual and that I didn’t have to become a robot when talking to patients,” Kim says. “It’s a fine line to walk.”

Kim’s experience exemplifies the hidden curriculum, a powerful socialization process that takes place beyond official lessons. Medical sociologist Frederic Hafferty, PhD, who has written extensively on the topic, describes it simply as anything outside of “the formal dimensions of learning.”

“People grow up knowing there’s a posted and formal speed limit and an informal speed limit. There’s how fast the signs say you should drive and how fast you can drive without getting ticketed,” says Hafferty, a professor of medical education at the Mayo Clinic. “The point is we grow up knowing there can be differences between the formal rules whatever they may be, and the way things work.”

Hidden curriculum messages in medicine abound, including notions like surgery is too hard for women, it's okay to talk down to nonphysician staff, certain specialties trump others, and learning how to do a physical exam is more important than learning how to communicate with patients.

“The point is we grow up knowing there can be differences between the formal rules whatever they may be, and the way things work.”

Frederic Hafferty, PhD
Mayo Clinic

Often, the formal curriculum and the hidden curriculum directly contradict each other. In fact, in a 2018 position paper on the hidden curriculum, the American College of Physicians noted that more than half of medical students experienced disconnects between what they were explicitly taught and what they perceived from faculty members' behaviors.

David Muller, MD, dean for medical education at the Icahn School of Medicine at Mount Sinai, points to one common case of mixed messages. “On the one hand, we say we care about your wellness, but at the same time students are surrounded by examples of being overworked and coming in sick,” Muller says. “They’re getting two messages. They’re not sure how to reconcile that.”

In the last few years, though, more medical schools are aiming to shine a light on the hidden curriculum and help students think critically about it — particularly when its messages contradict basic values the school wants to convey.

“Schools are trying to be sensitive to what’s going on in their learning environments,” says Hafferty, “and in effect, trying to reconcile what they are doing formally with what’s actually happening.”

“There’s an attempt to say, ‘Medical schools are responsible for structuring environments that optimize the learning of students, and that’s more than what you formally teach,’” he adds. “It takes place in the student lounge, in the elevator, in a variety of ways.”

Guidance from coaches

UC Davis School of Medicine launched its student coaching program in 2018 with five mentors and is already planning to add 15 more, says Associate Dean of Students Sharad Jain. “Coaching is a really exciting new approach that’s taking hold in medical education,” she says.

The goal of the program is to give students the space to ask questions they may not feel comfortable asking in formal classes.

“How do I balance coursework and extracurricular interests? What’s it like to deal with your first patient who dies? How do you deal with patients who mistreat students?” Jain says. “All of these are things students struggle with.”

Kim says one example of a hidden curriculum issue that coaches address is seeking help for mental health struggles. His coach advised him to talk with the school’s wellness chair and discussed such issues as how confidentiality works in mental health care. He says he appreciated the focus on well-being.

“We talked about making sure we’re taking care of our mental health. Often it can seem like mental health care is shunned by medical professionals,” he says. "It’s very stigmatized.”

At Mayo Clinic Alix School of Medicine, on its campuses in Rochester, Minnesota; Phoenix, Arizona; and Jacksonville, Florida, students are paired with coaches through a program called THRIVE. Students in each year mentor those in the year behind.

“If we’re not deliberate about teaching the hidden curriculum on professionalism, students won’t be trained properly to practice both the art and the science of medicine.”

Alexandra Wolanskyj-Spinner, MD
Mayo Clinic

Participants can ask their coaches for advice like how to debrief from difficult encounters and how to promote teamwork in a competitive environment.

Alexandra Wolanskyj-Spinner, MD, senior associate dean for student affairs at Mayo Clinic, believes such efforts are essential. “If we’re not deliberate about teaching the hidden curriculum on professionalism, students won’t be trained properly to practice both the art and the science of medicine,” she says.

Team dynamics

Other schools push students to form bonds with classmates so they can discuss challenging issues with one another. At the Perelman School of Medicine at the University of Pennsylvania, for example, students join “learning teams” on the first day of their doctoring course and remain with them throughout their education.

“They work together,” says Nadia Bennett, MD, MSED, associate dean of clinical and health system sciences curriculum. “What we’ve seen is they kind of bond there and establish enough comfort with each other to speak freely about some of their concerns.”

Thad Woodard, a rising second-year student, has both offered and received guidance through the program. He says students give each other advice on how to succeed, such as ways to develop professional connections and how many publications a student will need. “I think you can get a lot by sitting in class, but there’s so much more to medical school,” Woodard says.

Many students’ questions relate to the dynamics of working on health care teams, such as how to collaborate with people who have different levels of training. In fact, Bennett notes, Penn leaders are exploring ways to provide clinical experiences earlier so students can encounter real-life situations that often raise challenging issues.

“We are noticing this is such an important part of the medical student experience,” she says. “They come back frequently to their doctoring group in clinical years when the hidden curriculum is more prevalent.”

Addressing discrimination

Formal medical school curricula often espouse the value of equity, yet the hidden curriculum unfortunately sometimes conveys discrimination and unfair treatment, says Michael Devlin, MD, professor of clinical psychiatry at Columbia University Vagelos College of Physicians and Surgeons.

Students sometimes have questions related to implicit bias, like “‘I feel like as a woman I’m not being taken seriously — how do I handle that?’” Devlin says. It’s also important to check in with students from racial minorities and underrepresented backgrounds about the messages they receive, he adds. At Columbia, groups of 11 or 12 students meet with preceptors in small seminars to help guide them through these and other issues.

One way to address the hidden curriculum is to expose it, Devlin notes. That’s why Columbia also provides a system for anonymous reporting that students can use when they experience or witness unfair bias.

Muller says what schools preach is not always what students perceive.

“We talk about the importance of equity, but students see in medical school some students who have lots of advantages and some who don’t,” Muller says. “All of a sudden that level playing field seems disingenuous.”

Students at Mount Sinai are put into small groups where faculty coach them on how to deal with discriminatory behavior. They study examples like what to do if a student witnesses a more senior team member saying something pejorative about a patient.

“I think the biggest challenge with the hidden curriculum is it’s hidden. If you can’t see it, you can’t do anything about it.”

Michael Devlin, MD
Columbia University Vagelos College of Physicians and Surgeons

“What happens often in the hidden curriculum is that you don’t say anything,” Muller explains. “You have no idea if saying something is going to get you in trouble," and a student may be shocked at first, he adds. “What we try to do is prepare students for these types of situations.”

But it may not be possible to prepare students for all such circumstances, Devlin notes. Instead, the primary goal for medical schools is to bring the hidden curriculum out of secrecy and into view so students can begin discussing and grappling with it.

“I think the biggest challenge with the hidden curriculum is it’s hidden. If you can’t see it, you can’t do anything about it,” Devlin says. “The first step is to reveal it.”

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