Exploring NOSM’s
Hidden Curriculum
Rachel Ellaway PhD, Lisa Graves MD, Andrew Robinson MD
Conflict of Interest
We have no financial interests,
arrangements, or affiliations that constitute a
direct or indirect conflict of interest in the
context or content of the subject of this
workshop.
Workshop format
15m
10m
10m
10m
5m
10m
10m
10m
10m
What is the hidden curriculum?
Activity: what have you encountered?
Report back
Unpacking the NOSM HCs
What do you do with the HC?
Using the NOSM HC
Activity: how to use the HC
Report back
Next steps and ‘one thing I learned’
Learning objectives
At the end of the session participants will:
• Understand the concept of the hidden
curriculum.
• Appreciate the different ways in which the
hidden curriculum is expressed at NOSM.
• Identify and make best use of hidden
curriculum factors in learning, teaching and
research.
What is the hidden curriculum?
What is the hidden
curriculum?
“a great deal of what is taught – and
most of what is learned – in medical
school takes place not within formal
course offerings but within medicine’s
‘hidden curriculum’”
Hafferty F. (1998) Beyond curriculum reform: confronting medicine’s hidden
curriculum. Academic Medicine 73(4) p403-407
What is the hidden curriculum?
curriculum
What is taught
After: Snyder, B R
(1971). The Hidden
Curriculum. USA,
MIT Press.
What is learned
What is the hidden curriculum?
curriculum
designers
Intended
curriculum
teachers
Curriculum
in use
learners
Received
curriculum
More than ‘hidden’ …
Hafferty, FW (1998)
Beyond curriculum
reform: confronting
medicine’s hidden
curriculum. Academic
Medicine, 73: 403407.
• Null curriculum – that which we do not
teach
• Societal curriculum – that which is
learner by participating in society
• Concomitant curriculum – that which
is learned at home from family
• Rhetorical curriculum – that which is
learned from policymakers, leaders
and politicians
FMEC
The hidden curriculum encompasses
what students learn outside the formal
curriculum.
It is pervasive and complex and can be
deeply instilled in institutional cultures.
In health education, the hidden
curriculum cuts across disciplines within
and outside medicine.
Why is the hidden
curriculum important?
Empathy, cynicism, idealism
“The escalation of cynicism and atrophy of
idealism has long been recognized as part of
students’ socialization in medical school and
their adaptation to a professional role. This
downward trend has also been observed in
the ethical erosion of medical students
during their clinical training”
Hojat M, Vergare M, Maxwell K, Brainard G, Herrine S, Isenberg G, Veloski J,
Gonnella J. (2009) The Devil is in the Third Year: A Longitudinal Study of Erosion of
Empathy in Medical School. Academic Medicine, 84(9);1182-1191.
Positive, negative, both?
• HC conclusions often frame change
negatively
• Is it an erosion and atrophy of idealism as a
downward trend, or is it an escalation of
realism and pragmatism as a positive and
necessary trend?
Buckets get holes
“we come in with a full bucket of empathy,
then we go through the process of
acculturation, the rigors of training, and our
bucket gets holes in it. When you're ready to
become a doctor ... there's not much
empathy left”
J. Kevin Dorsey, MD, PhD. Dean of the Southern Illinois University School of
Medicine. Source: http://www.amaassn.org/amednews/2006/04/24/prsa0424.htm
Learners co-construct the
hidden curriculum
Learners: “must
learn to role-play, and live
their new identities in order to conform to
the image demanded by their profession …
gaining appropriate reputations of being
both competent and trustworthy …”
Haas, J and Shaffir, W (1991). Becoming Doctors: the adoption of a cloak
of competence. Greenwich CT, JAI Press Inc.p109-110
Cloak of competence
“A significant part of professionalization is
an increased ability to perceive and adapt
behaviour to legitimator’s (faculty, staff and
peer) expectations, no matter how variable
or ambiguous they are in nature …”
Haas, J and Shaffir, W (1991). Becoming Doctors: the adoption of a cloak
of competence. Greenwich CT, JAI Press Inc.p52
Cloak of competence
Haas, J and
Shaffir, W
(1991).
Becoming
Doctors: the
adoption of a
cloak of
competence.
Greenwich CT,
JAI Press.p52
“… in this context of ambiguity, students
… accommodate themselves, individually
and collectively to convincing others of
their developing competence by selective
learning and by striving to control the
impressions of others receive of them”
Inevitable? Desirable? Avoidable?
The Emperor Hears the Heart
Sounds (…The Attending
Wears No Clothes)
• Internal survey of internal medicine/family
medicine residents in 2003 at tertiary care
centre
• 70% reported ‘lying’ about hearing S3’s,
S4’s, or murmurs at various points in
training
• Time pressures, fear of failure, reference
letters etc. etc.
Activity 1: your experiences
• Small groups
• Discuss you experiences and encounters with
the hidden curriculum in medical education
• In your own training
• In your teaching
• In others teaching
• Share and discuss
NOSM’s hidden curricula
Local: NOSM’s hidden curricula
• What we see
• What we suspect
• What we investigate:
–
–
–
–
CANOE
SFoF
PHAME
Hometowner
CANOE: hidden curricula
Examined MD program orientation over last 3
years.
Identified seven key hidden curriculum issues:
1. School versus program?
2. Student or community first?
3. What constitutes a community?
4. Learner voices
5. Mature learner perspectives
6. Confused professionalism
7. Limits of learner centredness
CANOE: student vs community?
• Learners start off feeling like the centre of
everything
• The end of a long and arduous journey to be
a medical student
• But when they get to the communities they
find they need to respond to their needs as
well as their own
• ‘practice here?’
• OW not explicit about this …
CANOE: what is a community?
• Community visits core to the OW experience
• But this means leaving campuses
• Confusion that the 2 campus communities
are excluded as communities in this model
• Particular concerns from some learners that
they are being manipulated into or only
given a track into rural primary practice
• Absence of host communities continues
afterwards
CANOE: limits of learner
centredness
• The message of learner centredness oftrepeated
• But a tightly scheduled program of events,
most of which are mandatory
• Learners overseen and directed
• Learners move as a pack rather than as an
individual
• Learners concerned about the contradictions
Science fact or fiction
• Learner driven project
• Looking at experiences of learners with and
without a strong science background
• NS learners much higher levels of reported
stress
• S learners concerned that their NS
colleagues cannot reciprocate study support
because demands of science are so much
greater
Science fact or fiction: stress
70.00%
very low
quite low
60.00%
average
quite high
50.00%
very high
40.00%
30.00%
20.00%
10.00%
0.00%
before arrival on arrival in after 1 month after 6 months
in medical medical school in medical
in medical
school
school
school
stress: SCIENCE
before arrival on arrival in after 1 month after 6 months
in medical medical school in medical
in medical
school
school
school
stress: NONSCI
PHAME
• Perceptions and uses of NOSM-issued
mobile devices
• Greater value in clerkship, but …
• Learners cautious about how their use of a
mobile device will be perceived
• Some only use their devices if their preceptor
uses one
• Anxiety about being seen as unprofessional
• Anxiety about not being assessed with the
tools that they practice with
Research
Hidden curriculum as an
organizing principle
Policy: CanMEDS
Policy: FMEC
1. Address Individual and Community
Needs
2. Enhance Admissions Processes
3. Build on the Scientific Basis of
Medicine
4. Promote Prevention and Public
Health
5. Address the Hidden Curriculum
6. Diversify Learning Contexts
7. Value Generalism
8. Advance Inter- and IntraProfessional Practice
9. Adopt a Competency-Based and
Flexible Approach
10. Foster Medical Leadership
Policy: FMEC
The hidden curriculum often supports
hierarchies of clinical domains or gives one
group advantages over another.
It sometimes reinforces the negative elements
of existing reward and recognition systems and
deters students from pursuing certain careers
in medicine, such as family medicine.
For these reasons, revealing and clarifying the
hidden curriculum will be a challenging yet
critical move forward for Canada’s Faculties of
Medicine.
Policy: FMEC
Implementing this recommendation involves
engaging both learners and teachers in
identifying and acknowledging the hidden
curriculum.
It will encourage a process of self-reflection
and self- analysis and will ultimately afford the
opportunity to continually renew and
reinvigorate the culture and value system of
medical education.
Investment: Phoenix Project
Health professionals provide the best care
when they are able to balance human
compassion and technical expertise.
A catalyst for change by making strategic
investments and working with educators,
health professionals, workplaces and other
partners to nurture and sustain education and
workplace environments that support this
balance.
www.theamsphoenix.ca
What can you do with this?
•
•
•
•
Situational awareness
Critical thinking – reflecting on practice
Phronesis – reflecting in practice
Be aware of power imbalances, intimidation,
colonialism, things that get in the way of
humane and respectful care
• Look for positive experiences, record them,
share them (with anonymity), model them
• Conscious, purposeful pursuit of quality
improvement
The active learning
environment
Your learning environments influence you
Consider the influence on your learning of:
• Role models
• Other care givers
• Patients and their families
• and the environment in which care is given
Consider how these factors influence the
quality of care you will render to your patients
The active learning
environment
• Becomes the template for future
interaction
• Without reflection HC messages
become entrenched
• Normalization of deviation
– E.g. Wait times
Activity 2: affirmative action
• Make a note of an example from you own
experiences or from this session
• Identify positive and negative dimensions
• Formulate a response that makes it into a
valuable ‘teaching moment’
• Share and discuss
Wrap up
• Hidden curriculum is everywhere,
including NOSM
• HC makes up a significant part of medical
education
• HC is often disregarded or rendered
invisible
• HC may or may not be benign or negative
in aspect
• HC can be used in many ways to support
good teaching and learning
Next …
• Identify one new thing you will do or one
thing you will do differently going forward
from this workshop
Bibliography
•
•
•
•
•
•
•
Costello C. (2005) Professional Identity Crisis: Race, Class, Gender, and
Success at Professional Schools. Vanderbilt University Press, Nashville TN.
Green, Fryer, Yawn, Lanier, Dovey. (2001) The Ecology of Medical Care
Revisited. N Engl J Med, 344(26)
Haas, J and Shaffir, W (1991). Becoming Doctors: the adoption of a cloak of
competence. Greenwich CT, JAI Press Inc.
Hafferty F. (1998) Beyond curriculum reform: confronting medicine’s hidden
curriculum. Academic Medicine 73(4) p403-407
Haidet, Paul; Kelly, P Adam; Chou, Calvin; The Communication, Curriculum,
and Culture Study Group 2005) Characterizing the Patient-Centeredness of
Hidden Curricula in Medical Schools: Development and Validation of a New
Measure. Academic Medicine. 80(1):44-50
Hojat M, Vergare M, Maxwell K, Brainard G, Herrine S, Isenberg G, Veloski
J, Gonnella J. (2009) The Devil is in the Third Year: A Longitudinal Study of
Erosion of Empathy in Medical School. Academic Medicine, 84(9);11821191.
Waitzkin, H (1989). "A Critical Theory of Medical Discourse: Ideology, Social
Control, and the Processing of Social Context in Medical Encounters."
Journal of Health and Social Behavior 30: pp220-239.