Perils of the hidden curriculum revisited

Medical Teacher
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage:
Perils of the hidden curriculum revisited
Marcel D’eon, Naomi Lear, Marci Turner & Claire Jones
To cite this article: Marcel D’eon, Naomi Lear, Marci Turner & Claire Jones (2007) Perils of the
hidden curriculum revisited, Medical Teacher, 29:4, 295-296, DOI: 10.1080/01421590701291485
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Published online: 03 Jul 2009.
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2007; 29: 295–296
Perils of the hidden curriculum revisited*
University of Saskatchewan, Canada, 2McGill University, Canada, 3University of Western Ontario, Canada
Medical schools are beginning to better define, teach, and assess professionalism for students. While there are many positive
aspects of medical school training some students encounter poor modeling, unresolved ethical dilemmas, unnecessary and
debilitating academic stresses, and emotional and physical harassment. This may undermine current trend to create programs that
develop professionalism in students.
In Canada and around the world, medical schools are
beginning to better define, teach, and assess professionalism.
The value of doing so for students has recently and
persuasively been argued by Cruess & Cruess (2006). There
is also a growing awareness of the ‘hidden curriculum’
(Hundert et al. 1996; Kassebaum & Cutler 1998; Crook et al.
2004; Caldicott & Faber-Langendoen 2005); that is, the learning
students derive from the ‘‘nature and organizational design [of
a program], as well as from the behaviors and attitudes of
teachers and administrators’’ (Longstreet & Shane 1993, p. 46).
Although we acknowledge that, for the most part, the medicalschool experience is positive, it is the goal of this commentary
to focus on those interactions within the hidden curriculum
that require our earnest attention (Coulehan & Williams 2001).
For instance, students encounter ethical challenges that they
are unable to resolve, due to a lack of guidance or to negative
modeling, and are often left feeling inadequate and unintelligent (Turner et al. 2006; Lear and Tellier 2006a).
Additionally, far too many students do not report adverse
situations and incidents (Department of Medical Education
2004; Sokol 2004). In this commentary, we describe ways in
which certain aspects of the hidden curriculum—specifically,
emotional stress created by exposure to unethical behavior,
unreasonable academic requirements, and harassment by
supervising physicians—subvert the professional behaviors
educators want to teach. We contend that it makes little sense
for medical schools to rigorously teach and evaluate professionalism for students when the destructive elements of the
hidden curriculum are allowed to go unchecked (Kassebaum
& Cutler 1998). The way we treat medical students is
the way they will treat their patients, colleagues, and future
medical students: medical students will do what we do, not
what we say (Kassebaum & Cutler 1998).
Professionalism is threatened when medical students are
forced by attending physicians to choose between the role of
learner and the role of health-care provider (Hicks et al. 2001).
Most ‘professional lapses’ identified by medical students fall
into one of three categories: conflict between education and
patient care; professional responsibility exceeding capability;
and substandard patient care (Hicks et al. 2001). Inspired by
their own experiences of facing ethical dilemmas, a team of
Canadian medical students collected narratives from upperyear students that described experiences where they felt their
duty to learn conflicted with their duty to treat (Turner et al.
2006). They reported a number of troubling situations.
For example, attending physicians sometimes did not obtain
patient consent for student involvement in patient care (often
when patients were under anesthesia), or exaggerated a
student’s competency to obtain such consent. A number of
students described feeling insecure and under-prepared to
assume the tasks assigned to them by their supervisors; this
caused them anxiety about their ability to provide high-quality
patient care, and about the possibility of causing patient harm
while learning new technical procedures. In general, students
were concerned when their involvement in patient care may
have compromised the patient’s dignity, comfort, or convenience, or when patients seemed to be ‘used’ for educational
purposes (even if they had consented to student participation
in their care). Furthermore, students often suppressed
their own opinions about patient care, ethics, and medical
management to avoid the consequences of questioning an
authority figure.
In addition to presenting ethical dilemmas, the hidden
curriculum may undermine the teaching of professionalism by
unintentionally undermining feelings of self-efficacy and
decreasing the value of the patient–physician relationship
(Pololi & Price 2000). One of the authors of this article
encounters two or three medical students per year who seek
him out for advice regarding academic difficulty. These
students were typically very successful in their earlier
academic pursuits and continue to work diligently, yet perform
poorly because of their lack of preparation for the sciences.
These students seriously question their abilities. As they chose
pre-medical courses and programs other than the basic
medical sciences, these students struggle to learn in medical
school the content that is expected of them, some of which is
Correspondence: Marcel D’Eon, Educational Support and Development, B103 Health Sciences Building, 107 Wiggins Road, Saskatoon, SK, S7J156.
Email: [email protected]
*This commentary is provided by the Canadian Association of Medical Education (CAME).
ISSN 0142–159X print/ISSN 1466–187X online/07/040295–2 ß 2007 Informa UK Ltd.
DOI: 10.1080/01421590701291485
D’Eon et al.
not relevant or helpful for future practice (D’Eon & Crawford
2005). These students wonder if they are less capable than
their peers, and they worry that they will not be ‘good doctors’
when they finish medical school. We need to recognize the toll
that an overcrowded curriculum and a lack of support takes on
our students. When students’ strengths are not emphasized,
and students are belittled for their lack of knowledge (Lear &
Tellier 2006a), their self-esteem and motivation to learn are
affected (Lear 2006), with far-reaching consequences.
To correct this situation, we suggest that students should be
trained to recognize their own negative thought patterns,
identify sources of academic difficulty, and use academic and
psychological strategies to study more effectively and to deal
with lower-than-desired assessment results. Faculty, for its
part, needs to adopt an approach that focuses more on student
learning: it should identify the sources of academic challenges,
make changes to courses based on sound pedagogical
principles (including, but not limited to, managing the
amount of content), and develop ways to recognize and
build on the strengths of the individual students in their
We know that negative experiences of professional
behavior, unnecessary academic stress, and the harassment
of students are all prevalent, with significant consequences for
both students and patients (Department of Medical Education
2004). When students do not bring their concerns forward,
they risk excusing unethical and inappropriate practice in the
future (Satterwhite et al. 2000; Goldie 2004). Despite this, less
than a third of American medical students report harassment to
administrators who are empowered to respond to such
complaints (Department of Medical Education 2004). It was
for this reason that a Canadian undergraduate medical student
surveyed clinical clerks about their experiences of harassment
during medical training. In this qualitative pilot project,
students described incidents of mistreatment they had
experienced, barriers they encountered in reporting this
harassment, and factors they believed would facilitate reporting (Lear & Tellier 2006b).
Examples of harmful incidents reported by those students
include the misuse of power, inadequate preparation for
procedures, discrimination, and assault. Barriers to reporting
mistreatment included the belief that harassment is an
expected part of medical training, a lack of education on the
part of students and faculty about what constitutes harassment
and about the mechanisms available for responding to it, and a
fear of retaliation, associated with the lack of an anonymous
reporting process. The students suggested several strategies
to combat harassment: increasing awareness among students
and staff about the role of medical students and the
responsibilities for personal conduct; creating student support
groups; developing multiple options for reporting; and
providing protections for ‘whistle-blowers’. Turner et al.
(2006) recommend that clinical instructors be aware of moral
teaching practice guidelines that relate to specific ethical
challenges faced by medical students, particularly those
situations in which their professional responsibilities are in
Although there are many positive aspects of the early
clinical experiences (Dornan & Bundy 2004) and academic
training of medical students, this article has highlighted some
areas of the hidden curriculum which must be addressed.
As described above, some Canadian students encounter poor
modeling, unresolved ethical dilemmas, unnecessary and
debilitating academic stress, and emotional and physical
harassment. A lack of attention to these problems undermines
the current trend in medical education of creating programs
that develop professionalism in students (Cruess & Cruess
2006; Kassebaum & Cutler 1998). In the same way that we are
becoming more sophisticated in formally and consciously
teaching and evaluating professionalism for students, we must
become more serious about neutralizing and reversing the
pernicious elements of the hidden curriculum.
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