Using the Hidden Curriculum for Education and Career Development

On the first day of my clinical rotation, I walked anxiously toward my attending’s office. I had been looking forward to meeting him for several weeks. He was widely recognized among my peers and other medical school faculty as a leading clinician and educator, and I had a growing interest in his career path.

After brief introductions, I started into a list of questions I’d prepared. “Dr. Smith*, thank you for your time and willingness to answer some questions about the rotation.” Before I could continue, he softly interjected with a smile.

“Joseph, please call me James*,” he said, holding our eye contact. Sensing my hesitation in the next moments, he reassured me of his preference to use our first names. Over the next 45 minutes, he thoughtfully answered each of my questions. That meeting led to several others over the following weeks in addition to our interactions in the hospital. Even after I had completed the rotation, James was generous with his time and respect for me as an individual.

As a medical student, I learn by watching lectures, working through practice questions, and reviewing flashcards.  I speak with my patients about the circumstances that bring them to the hospital and try to formulate the best possible plan for each. I also learn from observing my attendings and residents: how they communicate with patients, signal through body language or gestures, and interact with one another and other medical staff. These observations help me gauge how receptive they might be to my questions and presence on rounds or in the workroom, and how I ought to interact with those who will ultimately complete my clinical evaluations.

The conclusions I draw from these observations reflect the “hidden curriculum.” As outlined in a recent ACP position paper published in Annals (1), the hidden curriculum refers to teaching that, although not transmitted through explicit courses or activities, is implicitly transmitted through vocabulary, practices, and habits. It is embedded in medical culture and is sometimes hard to identify. However, most learners—whether through positive experiences with upstanding role models or negative experiences with rigid medical hierarchy—have felt the presence of this implicit, unspoken curriculum.

As the article reveals, the hidden curriculum can either positively reinforce values that learners should cultivate or negatively reinforce views and habits that counteract the professional ethics espoused by our profession. These effects can be particularly outsized for medical students. As early entrants into the medical community, we naturally seek role models who contribute not only to our early habits as clinicians and members of clinical teams, but also our interest in different medical specialties. However, we can feel uneasy communicating honestly with attendings and supervisors who wield knowledge, position, and the role of evaluator over us.

This is why I believe efforts such as those that James displayed are so important. Although the use of first names may seem like a small or minor measure, it is in fact a positive example of the hidden curriculum. By proactively removing a barrier created by the inherent power and knowledge asymmetries between us, James was “teaching” me something important about open communication.

In that particular situation, not only did it make for a more meaningful clinical experience, it also empowered me to feel comfortable speaking up, asking questions, and offering my thoughts about any moments or dynamics that I felt were particularly praiseworthy or inappropriate. While thankfully no negative incidents occurred during my clinical rotation with James, the knowledge that I could call him by his first name set a tone and culture that elevated the quality of our communication and increased my engagement as a team member. 

The use of first names is but one of many ways through which clinicians can wield the hidden curriculum to counteract negative aspects of medical education and culture. Medical educators, supervising clinicians, and learners could work together and go beyond this to leverage the positive effects of the hidden curriculum in order to improve medical education and career development.

* Name changed.

Reference

1. Lehmann LS, Sulmasy LS, Desai S; ACP Ethics, Professionalism and Human Rights Committee. Hidden curricula, ethics, and professionalism: optimizing clinical learning environments in becoming and being a physician: a position paper of the American College of Physicians. Ann Intern Med. 2018;168:506-8. [PMID: 29482210] doi:10.7326/M17-2058