The Hidden Curriculum: What Can We Learn From Third-Year Medical Student Narrative Reflections?

Harvard Medical School, Cambridge Health Alliance, Cambridge, Massachusetts 02139, USA.
Academic medicine: journal of the Association of American Medical Colleges (Impact Factor: 2.93). 09/2010; 85(11):1709-16. DOI: 10.1097/ACM.0b013e3181f57899
Source: PubMed


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.

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    • "Knowledge of when issues pertaining to the hidden and informal curricula arise, as well as knowing the differing viewpoints of various stakeholders, could allow faculties of medicine to focus on interventions to aid in resolving the conflicts trainees may feel when the values of different curricula collide. Examples of such interventions could include having trainees address the hidden curriculum with narratives early on in training (Gaufberg et al. 2010; White et al. 2012), providing evidence against the hidden curriculum (Selva Olid et al. 2012), and promoting patient centered models of patient care early in training, such as integrated clerkships (Ogur et al. 2007; Gaufberg et al. 2008). "
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    ABSTRACT: The hidden and informal curricula refer to learning in response to unarticulated processes and constraints, falling outside the formal medical curriculum. The hidden curriculum has been identified as requiring attention across all levels of learning. We sought to assess the knowledge and perceptions of the hidden and informal curricula across the continuum of learning at a single institution. Focus groups were held with undergraduate and postgraduate learners and faculty to explore knowledge and perceptions relating to the hidden and informal curricula. Thematic analysis was conducted both inductively by research team members and deductively using questions structured by the existing literature. Participants highlighted several themes related to the presence of the hidden and informal curricula in medical training and practice, including: the privileging of some specialties over others; the reinforcement of hierarchies within medicine; and a culture of tolerance towards unprofessional behaviors. Participants acknowledged the importance of role modeling in the development of professional identities and discussed the deterioration in idealism that occurs. Common issues pertaining to the hidden curriculum exist across all levels of learners, including faculty. Increased awareness of these issues could allow for the further development of methods to address learning within the hidden curriculum.
    Medical Teacher 08/2015; DOI:10.3109/0142159X.2015.1073241 · 1.68 Impact Factor
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    • "Such transitions often involve a heightened process of reflective thinking and meaning-making that helps to foster the continuity of learning, as students make connections between previous and novel experiences (Rodgers 2002). Gaufberg et al. (2010) describe the powerful influence of the hidden curriculum in shaping the values, roles, and identity of students who are in the midst of their clinical experience (Gaufberg et al. 2010). Kilminster argues, however, that critical intensive learning periods can occur prior to the actual period of transition (Kilminster et al. 2011). "
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    ABSTRACT: Medical learners face many challenging transitions. We prospectively explored students' perceptions of their upcoming transition to clerkship and their future professional selves. In 2013, 160/165 end-of-second-year medical students wrote narrative reflections and 79/165 completed a questionnaire on their perceptions of their upcoming transition to clerkship. Narratives were separately analyzed by four authors and then discussed to identify a final thematic framework using parsimonious category construction. We identified two overarching themes: (1) "Looking back": experiences which had helped students feel prepared for clerkship with subthemes focused on of patient care, shadowing, classroom teaching and the pre-clerkship years as foundational knowledge, (2) "Looking forward": anticipating the clerkship experience and the journey of becoming a physician with subthemes focused on death and dying, hierarchy, work-life balance, interactions with patients, concerns about competency and career choice. Questionnaire data revealed incongruities around expectations of minimal exposure to death and dying, little need for independent study and limited direct patient responsibility. We confirmed that internal transformations are happening in contemplative time even before clerkship. By prospectively exploring pre-clerkship students' perceptions of the transition to clerkship training we identified expectations and misconceptions that could be addressed with future curricular interventions. While students are aware of and anticipating their learning needs it is not as clear that they realise how much their future learning will depend on their own inner resources. We suggest that more attention be paid to professional identity formation and the development of the physician as a person during these critical transitions.
    Advances in Health Sciences Education 07/2015; DOI:10.1007/s10459-015-9620-2 · 2.12 Impact Factor
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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). "
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    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 · 2.12 Impact Factor
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