The Hidden Curriculum: What Can We Learn From Third-Year Medical Student Narrative Reflections?
ABSTRACT To probe medical students' narrative essays as a rich source of data on the hidden curriculum, a powerful influence shaping the values, roles, and identity of medical trainees.
In 2008, the authors used grounded theory to conduct a thematic analysis of third-year Harvard Medical School students' reflection papers on the hidden curriculum.
Four overarching concepts were apparent in almost all of the papers: medicine as culture (with distinct subcultures, rules, vocabulary, and customs); the importance of haphazard interactions to learning; role modeling; and the tension between real medicine and prior idealized notions. The authors identified nine discrete "core themes" and coded each paper with up to four core themes based on predominant content. Of the 30 students (91% of essay writers, 20% of class) who consented to the study, 50% focused on power-hierarchy issues in training and patient care; 30% described patient dehumanization; 27%, respectively, detailed some "hidden assessment" of their performance, discussed the suppression of normal emotional responses, mentioned struggling with the limits of medicine, and recognized personal emerging accountability in their medical training; 23% wrote about the elusive search for personal/professional balance and contemplated the sense of "faking it" as a young doctor; and 20% relayed experiences derived from the positive power of human connection.
Students' reflections on the hidden curriculum are a rich resource for gaining a deeper understanding of how the hidden curriculum shapes medical trainees. Ultimately, medical educators may use these results to inform, revise, and humanize clinical medical education.
- SourceAvailable from: Cheryl L Holmes
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- "Thus, students are personally driven to emulate the behaviors of strong clinical mentors who may or may not model desired professional behaviors (Brainard and Brislen 2007; Cohen et al. 2009). Borrowing the language of educators (Jackson 1968), Hafferty (1998) described this transmission of the culture of medicine as the ''hidden curriculum'' which is now recognized by many as a more powerful determinant of medical student behavior than the formal curriculum (Gaufberg et al. 2010; Ginsburg et al. 2003; Hafferty 1998). A formal curriculum, therefore, must include content and instructional methods other than just teaching appropriate professional behaviors to students (Graber 2009). "
ABSTRACT: Changing the culture of medicine through the education of medical students has been proposed as a solution to the intractable problems of our profession. Yet few have explored the issues associated with making students partners in this change. There is a powerful hidden curriculum that perpetuates not only desired attitudes and behaviors but also those that are less than desirable. So, how do we educate medical students to resist adopting unprofessional practices they see modeled by supervisors and mentors in the clinical environment? This paper explores these issues and, informed by the literature, we propose a specific set of reflective competencies for medical students as they transition from classroom curricula to clinical practice in a four-step approach: (1) Priming-students about hidden curriculum in their clinical environment and their motivations to conform or comply with external pressures; (2) Noticing-educating students to be aware of their motivations and actions in situations where they experience pressures to conform to practices that they may view as unprofessional; (3) Processing-guiding students to analyze their experiences in collaborative reflective exercises and finally; (4) Choosing-supporting students in selecting behaviors that validate and reinforce their aspirations to develop their best professional identity.Advances in Health Sciences Education 10/2014; DOI:10.1007/s10459-014-9558-9 · 2.71 Impact Factor
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- "Features of the setting that inform generalizability to other settings Resources, staffing, support, patterns of interaction Supervisor assumes some risk in determining boundaries of trust for new and future situations Tjosvold and Tsao (1989) Opportunities for familiarity with context Understanding of the healthcare system Trainee works collaboratively (teamwork) and effectively within the health care system Hauer et al. (2009), Hirsh et al. (2007), Young et al. (2011) Workload Amount and duration of work and duty hours Excessive work hours decrease performance and promote trainee burnout, both of which diminish supervisor's trust Dyrbye et al. (2010), Kashner et al. (2010), Levine et al. (2010) Timing of observation Time spent on observation and rating Supervisors make valid judgments based on frequent observations and timely ratings Anim et al. (2009) Workplace culture Hidden or enacted/ observed curriculum of clinical practice Culture influences supervisor and trainee behaviors, including understanding of the purpose of assessment Stern and Papadakis (2006), Gaufberg et al. (2010) Trust as an essential element of trainee supervision CINAHL databases for citations by using terms related to trust in the context of supervision , evaluation, assessment, and interpersonal relationships. Additionally, authors manually searched the bibliographies of relevant articles and identified articles from personal knowledge of the field. "
ABSTRACT: Clinical supervision requires that supervisors make decisions about how much independence to allow their trainees for patient care tasks. The simultaneous goals of ensuring quality patient care and affording trainees appropriate and progressively greater responsibility require that the supervising physician trusts the trainee. Trust allows the trainee to experience increasing levels of participation and responsibility in the workplace in a way that builds competence for future practice. The factors influencing a supervisor's trust in a trainee are related to the supervisor, trainee, the supervisor-trainee relationship, task, and context. This literature-based overview of these five factors informs design principles for clinical education that support the granting of entrustment. Entrustable professional activities offer promise as an example of a novel supervision and assessment strategy based on trust. Informed by the design principles offered here, entrustment can support supervisors' accountability for the outcomes of training by maintaining focus on future patient care outcomes.Advances in Health Sciences Education 07/2013; 19(3). DOI:10.1007/s10459-013-9474-4 · 2.71 Impact Factor
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- "Adelman et al., 2007; Eskildsen & Flacker, 2009). While efforts are ongoing to revise medical school formal curricula to improve students' perceptions of and approach to geriatric care, the " hidden " or informal curriculum remains a powerful influence on how physicians-in-training learn to practice medicine and form opinions about different types of patients (e.g., Cribb & Bignold, 1999; Gaufberg et al., 2010; Hafferty & Franks, 1994; Lempp & Seale, 2004). Research has shown the importance of the attitudes and behaviors of senior physicians on shaping how physicians-in-training perceive certain tasks, types of patients, or goals; for example, Diachun et al. found that " teachers' biases regarding the importance of geriatric education can negatively affect students' interest in geriatric course content " (2010: 1222). "
ABSTRACT: This study explores the attitudes of physicians-in-training toward older patients. Specifically, we examine why, despite increasing exposure to geriatrics in medical school curricula, medical students and residents continue to have negative attitudes toward caring for older patients. This study used ethnography, a technique used by anthropologists that includes participant-observation, semi-structured interviews, and facilitated group discussions. Research was conducted at two tertiary-care academic hospitals in urban Northern California, and focused on eliciting the opinions, beliefs, and practices of physicians-in-training toward geriatrics. We found that the majority of physicians-in-training in this study expressed a mix of positive and negative views about caring for older patients. We argue that physicians-in-trainings' attitudes toward older patients are shaped by a number of heterogeneous and frequently conflicting factors, including both the formal and so-called "hidden" curricula in medical education, institutional demands on physicians to encourage speed and efficiency of care, and portrayals of the process of aging as simultaneously as a "problem" of inevitable biological decay and an opportunity for medical intervention. Efforts to educate medical students and residents about appropriate geriatric care tend to reproduce the paradoxes and uncertainties surrounding aging in biomedicine. These ambiguities contribute to the tendency of physicians-in-training to develop moralizing attitudes about older patients and other patient groups labeled "frustrating" or "boring".12/2012; 26(4):476-83. DOI:10.1016/j.jaging.2012.06.007