The hidden curriculum of medicine


Think all the way back to your grade school years. Did you know that your personality traits were starting to be honed for the work you do today? Let me give you some examples about myself and see if you can relate.

I remember the praise and exhilaration of being the only kid in the class to get a 100 percent on an extremely difficult second-grade spelling test.  My teacher told me about how proud of me she was and put the biggest sticker she could find on my paper.

As a second grader, I internalized those emotions and that experience to “If I do perfect work, my teacher will be proud of me.” In my mind, the opposite also became true: “If I don’t do 100 percent perfect work, she will no longer be proud of me.” I already had perfectionist tendencies but these early academic years most certainly fed into them. This was through no fault of my teacher, but set a pattern that would continue throughout my schooling.

Conditioning takes place during our medical education training as well. As a medical student, as you were being shaped into your professional identity like it or not. While on rotations, you started to observe “good doctoring” vs. “bad doctoring.” Dr. Anthony Montgomery, PhD terms this the “hidden curriculum.”

Formal learning objectives focused more on technical skills and factual learning rather than interpersonal interactions, coping skills and communication. Organizations talked about “professionalism.”

Here are some of the behaviors I saw modeled on my rotations:

  • A fellow resident came to work with a 100-degree fever; our attending physician called her dedicated. Lesson: The work comes first, in front of your needs, health or illness.
  • Don’t show emotions because that’s weakness. Lesson: There’s no crying in medicine.
  • Being the best lands you the best chance for further advancement. Lesson: Do everything you can to be number one even if it means hiding.
  • A medical school professor told us that all patients lie. Lesson: Don’t trust anyone; find out the truth on your own.
  • You’re going to be the doctor soon, so you better start learning/making the absolute right decision. Lesson: Even though there are no absolutes in medicine, you must always be right
  • You are the clinical leader. (where was my leadership training though?)
  • The older the practitioner, the more they know. Lesson: Be quiet and listen even if you know new guidelines say otherwise.
  • Publish or you are irrelevant. Lesson: My worth is based on what I do.

This hidden curriculum is ingrained into our tradition of medical training, and I could go on and on about underlying messaging students receive during MS3/MS4. But what about residency and/or fellowship training? I believe the lessons that began in medical school are simply more deeply installed and reinforced.

But enough about my experience; I want you to think of your own. Think in depth about situations or cases that still leave a lasting impression on you.

Take some time and write about your medical training experience:

Where did you experience some of the hidden curriculum of medicine?

Where in your life and your practice have you realized that some of the medical programming was just wrong for you?

One physician shared this with me: “I felt I was taught not to cry over bad outcomes. Now I realize that it is essential that I have those emotions and experience my feelings. If I need to cry, then I need to find a safe place and cry instead of suppressing it. I’m healthier this way. I feel like a person again. I mean, I don’t have to break in front of the patient, but I need to be vulnerable at some point.”

For anyone participating in medical education, I would ask you additional questions:

Where have you trained a student, resident or fellow in some hidden curriculum because it was how you were taught? Was this helpful? Why or why not?

I strongly believe that just because the hidden curriculum was a part of our training doesn’t preclude us from teaching our younger colleagues in a more appropriate manner.

This change starts with each of us working through our own experiences, empowering others around us to change and then actively changing the culture of medical education.

  • Instead of pimping a medical student with a harsh line of questions, try teaching from a place of exploratory learning by asking questions like, “Tell me more about this” or “What else?” or “What information would be helpful in this particular case?”
  • Instead of expecting a learner to stay long hours even after the work of the day is done to “show they are interested,” try asking them, “what is the best use of your time? Why is that important?” This way you can see where their interests, anxieties and where the focus lies. Your clinical objectives may be different from theirs. Better to explore both sides to make it an enjoyable experience for all.
  • Instead of openly criticizing a learner for a shortcoming or mistake, take the time to mentor and give assessments as a learning opportunity not clouded in shame. Also sharing an experience where you were involved with a less than desirable outcome can show vulnerability and a sense of caring which fostered the learning you are trying to portray.

With all of these, make sure to stop, listen and process the answers you are given.

Great doctors are not determined by scores, honors or hours of suffering but instead by who that person is under the white coat. Let’s work to keep ourselves and our learners as whole as possible through the entire journey.

Errin Weisman is a family physician and founder, Truth Prescriptions.

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