Hidden Curriculum
Hidden Curriculum
Hidden Curriculum
*Corresponding author.
Abstract Despite an extensive literature within medical education touting the necessity
in developing professionalism among future physicians, there is little evidence these
calls have thus far had an appreciable effect. Although various researchers have suggested that the hidden curriculum within medical education has a prominent role in
stunting the development of professionalism among future physicians, there has been
minimal discussion of how the content of the hidden curriculum actually function to this
end. In this article, we explore: (i) how the hidden curriculum may function within
medical education as a countervailing force to medicines push for professionalism and
(ii) why the hidden curriculum continues to persist within medical training and particular
aspects so difcult to dilute. We conclude by proposing mechanisms to assuage elements
of the hidden curriculum, which may, in turn, allow the principles of professionalism to
blossom among medical students.
Social Theory & Health (2013) 11, 388406. doi:10.1057/sth.2013.6;
published online 1 May 2013
Keywords: professionalism; hidden curriculum; medical education
Introduction
Calls for a recommitment to principles of professionalism1 have been widespread
within organized medicine since the early 1990s (Hafferty and Levinson, 2008;
AAMC, 2011; Boudreau et al, 2011). Extensive research and policy statements
have highlighted the charge for and by medical professionals to renew their
social contract with the public, express compassion, empathy and connectedness with their patients, promote and practice teamwork within health care
delivery, rid themselves of their political and nancial drives, and pursue the
highest levels of clinical competence and ethical standards (Institute of Medicine,
2013 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health
www.palgrave-journals.com/sth/
2003; Arnold and Stern, 2006; Veloski and Hojat, 2006; Cruess and Cruess, 2008;
Wynia, 2008; Camp et al, 2010; Dyrbye et al, 2010).
Evetts (2011) notes that groups can utilize the discourse of professionalism in
composing their occupational identity and promoting its image with clients
and customers (p. 407). In this sense, the clamor for professionalism within the
medical profession can be seen, in part, as a response to shifts in the sociopolitical and economic context of health care with the rise of consumerism,
increased commercialism within the medical eld in general, the proletarianization of the health care workforce, the rise in available medical information as
ushered by the information age and increased specialization leading to fragmentation in the delivery of care (Light and Levine, 1988; Relman, 2003; Hafferty,
2006a,b; Woodruff et al, 2008).2 Organized medicine, once touted as the
prototypical profession, has seen its public image battered and bruised, and
although many of the spotlighted issues and noxious elements appear to be tied
to the arena of clinical practice, remedial calls have targeted medical education as
the battleground in bringing about a needed shift in professional behaviors,
duties and attributes.
Numerous medical education institutions have implemented various courses,
programs and standards designed to provide students with extensive learning
opportunities steeped in promoting professionalism (Baernstein et al, 2009;
Rabow et al, 2009; Branch, 2010). The Liaison Committee on Medial Education
(LCME), the body that accredits the United States and Canadian medical schools,
has an accreditation standard (MS-31-A) that requires schools to account for the
professional attributes of their students. The Accreditation Council of Graduate
Medical Education (ACGME) has identied professionalism as one of its six Core
Competencies (along with patient care, medical knowledge, practice-based learning
and improvement, interpersonal communication skills and systems-based practice)
(Swing, 2007). There are similar efforts in other countries. Parallel reports in both
Canada (CanMEDs, The Canadian Federation of Medical Students and so on) and
the United Kingdom (the General Medical Council, the Royal College of Physicians
and so on) also stand as socio-political testimonies to a broad and sustained effort by
organized medicine to re-establish its principles of professionalism (Frank et al,
1996; GME, 2009; Bridgewater et al, 2011; Mondoux, 2011).
At the practice level, various medical specialty bodies have developed
professionalism codes and charters. For example, the American Board of Internal
Medicine Foundation, the American College of Physicians, the American Society
of Internal Medicine Foundation and the European Federation of Internal
Medicine have created a physician professionalism charter, now endorsed by
over 125 medical organizations worldwide (ABIM Foundation, ACP-ASIM
Foundation, and European Federation of Internal Medicine, 2002). Furthermore,
the American Board of Medical Specialties, the organization that sets standards
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389
for the 24 of the 27 approved medical practice specialty boards, has just (as of
2011) established a standing committee on professionalism.
Nevertheless, and in the face of all this progress, critics have argued that
medical school administrators and faculty have been overly eager to advance
professionalism as an educational enterprise and have therefore rushed to
conceptualize and operationalize an overly nostalgic version of professionalism
(Wear and Kuczewski, 2004; Hafferty, 2006c; Prasad, 2011). Moreover, they
argue that this call to arms fails to address the issues related to professionalism
present at the systemic and organizational levels both in training and in medical
care settings, and suggest that if medical education truly is committed to reform
then education and practice leaders will need to address not only factors at the
individual level, but also the overarching culture and organizational climate of
medicine that seeps into the teachings of future doctors (Hafferty, 2006d; West
and Shanafelt, 2007; Lesser et al, 2010; Cunningham et al, 2011).
Further complicating this picture, medical students have expressed considerable dismay with and resistance to the ways in which faculty have produced
addendums and supplements to an already saturated curriculum in the name of
inculcating professionalism characterizing such curricular appendages as
pedantic, harassing and even insulting, and thus turning them off to the whole
call for professionalism (Reddy et al, 2007; Baernstein et al, 2009; Finn et al,
2010). Moreover, students consistently have pointed out that they are not seeing
the values, behaviors and attributes touted in the classroom being actualized by
clinical faculty and supposed role models (Brainard and Brislen, 2007; Leo and
Eagen, 2008). In short, medical students do not see these explicit teachings of
professionalism as a useful addition to their training, nor do they see medical
school faculty and shadowed physicians as fully practicing what they appear to
be preaching.
In these respects, critics argue that there is a hidden curriculum nested within
medical training (for example, cultural mores transmitted through formal and
informal training processes that reect the norms and values upheld by the
institution of medicine (Haer et al, 2011)) and that this more invisible and
tacitly transmitted curriculum functions as a perpetual culprit in burdening and/
or dampening the cultivation of professionalism among medical students3
(Chuang et al, 2010). As Hilton (2004, p. 71) argues, the hidden curriculum
is probably the most important factor inuencing development of professionalism. Nonetheless, research has yet to dissect how and why this usual suspect
impedes the blossoming of professionalism. Therefore, it is important to better
understand the ways in which the hidden curriculum affects the teachings of
professionalism within medical education, as well as why this dimension of
medical training continues to persevere despite its hiding in plain sight (Gair
and Mullins, 2001; Wear and Skillicorn, 2009).
390
This present article offers a discussion of how the hidden curriculum may
function within medical education to stunt the growth of professionalism among
medical students. More specically, this article examines how the teachings of
the authority and autonomy (particularly via the privileged nature of medical
knowledge) nested within the hidden curriculum actually serve to contradict and
counteract explicit formal instruction in the principles of professionalism. Conversely, although the hidden curriculum can be viewed as detrimental to
students professionalism (or at least how professionalism has been discussed
in the medical education literature), we suggest that the hidden curriculum also
serves as a vehicle for protecting the embattled medical profession by providing
subterrestrial lessons in authority and autonomy which have been viewed,
both within medicine and by sociology, as markers of any true profession. Put
simply, we argue that although elements of the hidden curriculum, such as the
teachings of authority and autonomy, may have detrimental impact on students
development of professionalism, these same elements of the hidden curriculum
are actually essential to the perpetuation of medicines status as a profession and
therefore protected and promoted by both cultural practices within medical and
by other-than-formal pedagogical strategies within medical education.
391
393
Janssen et al, 2008; Baernstein et al, 2009; Helmich et al, 2011), previous
research featuring students accounts of their training have shown that students
do witness physicians openly mock and put down patients, disrespect other
health care workers, put patients at risk and blatantly ignore hospital procedures
and ethical standards and face no signicant sanction or punishment from
within, or outside, their institution (Ginsburg et al, 2002; Brainard and Brislen,
2007; Michalec, 2012).
Feudtner et al (1994) presented medical trainees observations of physicians
overtly exercising their authority over patients, such as sedating a patient with
Haldol in order to give them medications intravenously (simply because the
patient did not desire to take her medications), and performing unnecessary
forceps deliveries for practice. Hinze (2004) provides narratives that highlight
how the teachings of authority and a rigid status hierarchy are alive and well
within medical training especially concerning gender differences in professional
medicine, offering rst-person accounts of how male practicing physicians
explicitly and implicitly demean and vitiate female medical students and
practicing female physicians in front of medical trainees without recourse or
sanction. In their exploration of the effects of the teachings of hidden curriculum
in medical education, Lempp and Seale (2004) found that 21 out of 36 students in
their study reported numerous instances of humiliation (from practicing physicians) either through observation or through personal experience. The authors
suggest that One of the principle ways in which students learnt about the
importance of hierarchy in medicine is through teaching that involved humiliation. (p. 771). These studies, and others, provide direct evidence of how
modeled behavior, as a veritable lecture hall for the teachings of the hidden
curriculum, can project lessons in the authority (of medical knowledge and
specic status characteristics) and autonomy of the medical profession in
general. Consequentially, these teachings can have detrimental impact on the
development of students professionalism.
Therefore, why would organized medical education turn a blind eye to a
mechanism that has been shown to not only be disadvantageous to the
cultivation of acclaimed characteristics among future physicians, but also has
been spotlighted by extant research? Why do the teachings of authority and
autonomy (through the hidden curriculum) persist?
395
imparting these resources in a range of tacit and often times implicit ways to the
next generation of physicians during medical training. Furthermore, perhaps this
is why the recent calls for professionalism, as well as the programs and courses
that have been established to increase professionalism among trainees, have
been referred to as mere window dressing and/or lackluster, and why medical
students continue to see behavior among their preceptors and shadowed
physicians that is not in-line with tenets of professionalism behavior that is
unprofessional (Reddy et al, 2007; Baernstein et al, 2009).
397
and their effects is by muting the notion that medicine is the profession within
health care. Although interprofessional training within medical education circles
has been somewhat of a straw dog over the past several decades (Baldwin, 2007),
there is evidence that medical education institutions are taking signicant strides
toward emphasizing a more interprofessional, team-oriented approach to
health care. A number of medical schools have recently constructed and
implemented elaborate, multi-year Interprofessional Education (IPE), programs
aimed at bringing together students from multiple health care disciplines during
their years of training to breakdown the hierarchy within health care delivery,
increase patient-centeredness from a team approach, and foster communication
and respect among the various health professions (Clark, 2004; Thistlethwaite
and Moran, 2010). These programs are integrated into preclinical and clinical
training agendas for these institutions, but given the novelty of these programs,
research is currently underway to assess to what messages and values are being
translated to the students of the various disciplines through these programs.
These programs are not slated as programs in professionalism per-say, rather
they are geared toward bringing together each of the health disciplines under the
umbrella of improving health care delivery, the experiences of health care
professionals, and patient outcomes in general. Another important element of
IPE programs is that they often include members of the local patient population/
general public to serve as a guide to the pre-professionals through the illness
experience. IPE, with its focus on team-based care, patient-centeredness, and
inclusion of the public in the education process, has the potential to have
signicant impact on the hidden curriculum and lay the groundwork for aspects
of professionalism to take root.
Another manner in which the medical education community can assuage the
potentially injurious profession dominating teachings of the hidden curriculum is
to transform the WCC. Often held during the rst year of medical training, the
WCC is a ritual in which students are draped with the quintessential regalia of a
physician. The white coat has been described as a magical cloak that protects
the medical student and doctor from the suffering of their patients (Druss, 1998),
and as a symbol of science and technology, and a reection of life and purity
(Blumhagen, 1979). Although it may seem to occupy a relatively negligible
footprint with the overall process of medical education, and while ofcials within
medicine have argued for its benets and appropriateness (as outlined in Branch,
1998; Huber, 2003), others such as Wear (1998) and Russell (2002), have
suggested that the white coat actually functions as a source of the hidden
curriculum and thus transmits messages of power, authority, elitism and the
dominance of science that it symbolizes.
Whatever the issue, it is important that medical educators be willing and
able to step back and assess just what messages are being created by and within
398
the very structures they have developed and are responsible for (Hafferty, 1998,
p. 404). This means thoroughly evaluating the meanings translated in these
ceremonies and the differentiations made between medical students and those
not within the medical profession, especially given the timing of most WCCs.
Even something as celebratory as a WCC may send conating and contradictory
messages. In this sense, medical school administrators interested in mitigating
impressions of elitism and power, and fostering positive perceptions of interprofessionalism, mutual cooperation and interdependence (among the health
professions key elements of professionalism), should look to include professional representatives from the other health care-related disciplines (that is,
Nursing, Pharmacology, Physical Therapy, Occupational Therapy, Social Work
and so on) in the WCC in some fashion other than just guests and/or spectators.
Professionals in these other disciplines could serve as speakers, ofciates or
could even adorn medical students with their white coats, thereby welcoming
them to the health care industry. Another manner in which the same directives
could be achieved would be to host a generic WCC for students of all health
care disciplines. Each discipline teaches and trains students to heal, why can they
not all join together to celebrate their collective initiation into the healing
professions? Such recongurations of the WCC could help to dismantle barriers
and fences between the health professions and counteract conceptions of a rigid
hierarchy within health care delivery, thereby potentially neutralizing certain
deleterious effects of the hidden curriculum.4
Given that the lessons of authority and autonomy through the hidden
curriculum have been shown to also be present within the professional domain
(along with the educational domain) of medicine, the efforts of dismantling the
hierarchies within health care delivery should also be done from within the
medical industry and therefore reected in the attitudes and actions of practicing
physicians. If medicine is truly invested in the promotional of professionalism
principles among its future workforce then the medical profession would do well
to adopt the motto: It takes a village and acknowledge and embrace the notion
that effective health care is delivered through a team of professionals (that is,
nurses, medical social workers, doctors, pharmacists, physical and/or occupational therapists and so on), which includes the patient (Lichtenstein et al, 2004).
In stepping down from its crumbling silo, medicine still will maintain a distinct,
esoteric body of clinical knowledge, but, in turn, the profession must profess that
its knowledge functions best when working in tandem with the knowledge of
other parties/professionals within the health care delivery team which again,
must include the patient. By doing so, medicine will relinquish some degree of
cultural authority and control, yet this will assist in ushering in a new contract
with the public as well as with other health care professionals what some are
calling a new patient-centered professionalism (Irvine and Hafferty, 2011).
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Weakening the potency of the hidden curriculum not only entails the practice
of dissolving hierarchies within health care, but also courageously and publically
purging the bad apples within the profession. If professionalism is to ourish,
the attention cannot simply be on pedagogical practices, those practicing within
the profession must be held accountable as well (Leach et al, 2006; Hafferty,
2006b). In order to save itself from its current siege, medicine must become more
transparent in terms of how it handles ethical violations, poor and out-of-date
practices and the adverse pursuits of political and nancial endeavors among its
own members (Hickson et al, 2007).
Until this point, we have steered clear of any medically oriented analogies or
metaphors, yet perhaps one must be used to better capture the manner in which
the medical profession must attack or confront certain aspects of the hidden
curriculum. Radiation therapies are a popular method of treating cancer. While
deconstructing the tumor, radiation simultaneously damages healthy cells and
tissue the desired effect being a greater sum of damage to the tumor than
healthy tissue. If we consider the hidden curriculum as having a potentially
tumorous effect within the soma of medical education, then implementing vetted
and evaluated IPE programs within the curriculum, reconguring WCCs and
fostering transparency within the profession in general may in fact impact
medical trainings healthy tissue (re-organizing curriculum to include IPE,
possibly forfeiting the positive side-effects of the WCC and even sacricing some
degree of authority and autonomy). Although some tumors may be eradicated
and others merely controlled, the overall effect is a more sustained and
nourishing environment for the seeds of a more modern-day or new professionalism to be established and ourish (Irvine, 1999, 2006; Working Party of the
Royal College of Physicians, 2005; Coverdill et al, 2010).
Conclusion
We have posited how and why the principles of professionalism (and the
development of these principles among medical students) have struggled to
blossom within the current climate of medical education, and, in turn, how the
hidden curriculum has been able to radiate within this climate. In return for
protecting aspects of authority (including medical knowledge) and autonomy/
control over the other health professions and translating them to future
physicians, the medical profession has nurtured and sustained the hidden
curriculum, specically the teachings of power differentials, hierarchical
boundaries and overarching inequalities in health care delivery. Although
appreciable research has identied the presence of a hidden curriculum within
medical education, argued for its deconstruction and ngered it for the sluggish
400
Notes
1 Throughout this work, the authors use the term Professionalism to refer to the individual-level traits,
behaviors and attitudes similar to those described in the encompassing normative definition offered by
Swick (2000). The term Profession, within this work, refers specifically to organized medicine as an
occupational entity and in relation to specific qualities of any true profession (that is, authority and
autonomy). Finally, within this work, the term Professionalization refers to the processes and
mechanisms by which medical students learn to become professional health care practitioners. In
turn, this work attempts to bridge the importunate cultural divide between the more sociologically
oriented discourse on the Profession of medicine and the more medically oriented discourse on medical
Professionalism (Hafferty and Castellani, 2010).
2 Although there remains some considerable opposition to the claim that physicians are becoming
deprofessionalized and/or subordinated to the bureaucratic controls (Pescosolido, 2006; Spalter-Roth,
2007), medical insiders remain quite convinced that physicians have suffered serious erosions of their
clinical autonomy and discretionary decision making (Shanafelt et al, 2002; Zuger, 2004).
3 Although writings on the hidden curriculum come largely from within the United States, United
Kingdom and Canadian medical education literature there are the beginnings of an expanding
international literature on the hidden curriculum. Similarly, although the concept is universal, particular
context may differ enough so that what holds for one country in terms of specific findings about content
of the hidden curriculum or the content of the space between the formal curriculum and the hidden
curriculum is particular to place (specific medical education institution). Therefore, although discussions
of the hidden curriculum (in the general sense) offered within this work could be applied to more than
one national context, given that the authors are relating the role of the hidden curriculum to the current
state of the medical profession in the United States the discussion of the hidden curriculum within in this
particular work is primarily directed toward US medical education.
4 Although the inclusion of other health professions within the WCC may have a positive impact on the
internal status hierarchy among the health professions, it may do little to address (and may even
exacerbate) the status and power divide between health care providers and patients (laypersons).
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401
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