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.