EXPLORING THE
HIDDEN CURRICULUM:
A qualitative analysis of medical students’
reflections on professionalism
in surgical clerkship
KITTMER T
PEMBERTON J
HOOGENES J
CAMERON BH
ASE March 22, 2012
MacSERG
McMaster Surgical Education
Research Group
Background I
Clerkship is a unique time in professional
development
Professionalism curricula
 Formal – Professional Competencies1
 Informal – bedside teaching
 Hidden2-4
1Risdon
and Baptiste 2006, 2Stern and Papadakis 2006, 3Karnieli-Miller et al 2011,
4Hicks et al 2001
Background II
Reflective writing in clerkship
• Effective5
• Implemented in various forms5-8
Qualitative professionalism research has been
used to explore the hidden curriculum,7-9 but
never with an explicit focus on surgical
clerkship
5Hill-Sakurai
et al 2008 6Wald and Reis 2010, 7Kaldjian et al 2011, 8Karnieli-Miller 2011,
9Hicks et al 2001
'Professionalism' on PubMed last decade
2500
number of publications
2000
1500
1000
500
0
2001
2
3
Professionalism
4
5
6
+ medical education
7
8
+ surgery
9
2010
Objectives
To identify and explore the main challenges in
ethics and professionalism experienced by
medical students during their surgical
clerkship at McMaster as recorded in their
critical incident reports (CIRs)
To assess for differences between junior and
senior clerks’ CIR topics
Methods I
• Qualitative approach
• Divided CIRs into 2 groups: early and late
• 4 reviewers independently identified and then
collaboratively determined emerging themes
– Created codebook iteratively
– Continued to conceptual saturation
– Data reduction
• 2 reviewers re-read CIRs and recorded concept
frequencies
• Validation
– Data & investigator triangulation, audit trail, member-checking
Methods II
64 reports
available from
class of 2009
39 early group
25 late group
Results
27 themes
in total
Self
(3)
Patient
(14)
Clerk
System
(4)
Team
(6)
Clerk-Self
Patient
Self
"Frustration, exhaustion, helplessness were
only some of the emotions present in
the room as we went through a six hour
procedure, our last chance to make a
difference, but considered by all to be
most likely a futile endeavour to save
the patient's life."
 Stress & emotions
 Resolving ambiguity
 Responding to patient suffering
Clerk
System
Team
Clerk-Patient I
Patient
Self
Clerk
 Ethical Decision-Making
–
–
–
–
–
–
–
–
–
Patient Dignity
Patient Confidentiality
Patient-Centred Care
Provider bias
Do Not Resuscitate (DNR) & Code status
End of life issues
Informed consent (decision making)
Substitute Decision-Maker (decision making)
Patient autonomy
System
Team
“Reacting to stressful situations by revealing
your frustration can only contribute to the
patient's anxiety and possible apprehension,
and I believe in this case his humiliation - if I
had been in his position, I would have felt
like I was burdening the team with my
unfortunate problem.”
Clerk-Patient II
Patient
Self
Clerk
 Communication
–
–
–
–
–
Cultural Competency
Health Literacy
Breaking Bad News
The Difficult Patient
Disclosure of Adverse Event
System
“When the words 'lymph nodes' were spoken, I
saw on the faces of the family members that
they did not understand.”
Team
Clerk-Team
Patient
Self
 Clerk-Team
– Team communication
– Level of responsibility
– Hierarchy
– Interprofessional communication
– Barriers to learning
– Bullying
Clerk
Team
System
“[Verbal abuse] also interferes with our ability to learn [...] I have
overheard several clerks state that they simply don't want to be
in the OR anymore as it isn't worth the abuse.”
Clerk-System
Patient
Self
Clerk
Team
 Clerk-System
–
–
–
–
Patient advocacy
Safety
Healthcare resource management
Medical error
System
“I thought about hospital environment a few days ago. I
believe that our patients (especially in surgery) suffer
enough from their diseases. They came to us looking
for help and relief. And it is our job to make the
hospital environment safe for our patients.”
Discussion I
 Professionalism curriculum well-received
• Positive feedback in clerks’ exit surveys
 Communication and self-care were most
frequent themes
• Learned with practice and experience
• Not always modeled well
 Negative CIRs more common
• Assignment wording bias: “challenges”
• Previous research suggests assignment wording
influences types of issues students discuss7
7Kaldjian
et al 2011
Discussion II
Junior vs. senior clerks:
 Varying levels of clinical experience &
independence
 Those wishing to match to surgery tend to do
core surgery early in clerkship
 Possible burnout later in clerkship
Limitations
Patient
Conclusions
Self
Clerk
• CIRs are a rich source of information
• Clerks face diverse challenges in their
interactions with self, patients, their team and
the healthcare system
• Junior and senior clerks may have different
educational needs
• Clerks are sensitive to the examples of
professionalism they see every day
System
Team
Future Directions
 Addressing the hidden curriculum10-11
 Spreading the information to staff surgeons, residents,
curriculum planners
○ What clerks struggle with most
○ What we can do better
○ Enhance teaching of CanMEDS competencies
 Curriculum development5
 New plans for a longitudinal professionalism
curriculum in clerkship
○ Modeled after surgical rotation
○ CIR/Case + small-group discussion
10Christian
et al 2008, 11Busing et al, 5Hill-Sakurai et al 2008
Acknowledgments
 Small Group Facilitators
 Class of 2009 clerks at the Michael G.
DeGroote School of Medicine
 Funding
• McMaster Surgical Associates
• McMaster Pediatric Surgery Research
Collaborative
References
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Branch W, Pels RJ, Lawrence RS, Arky R. “Becoming a doctor: Critical-Incident reports from third-year
medical students.” NEJM. Oct 1993: 1130-2.
Busing N et al. “Recommendation V: Address the Hidden Curriculum.” The Future of Medical Education in
Canada: A collective vision for MD education. Associations of Faculties of Medicine of Canada Website,
2010. <http://www.afmc.ca/future-of-medical-education-in-canada/medical-doctor-project/index.php>
Christian F, Pitt DF, Bond J, Davison P, Gomes A. “Professionalism – connecting the past and the present
and a blueprint for the Canadian Association of General Surgeons.” Canadian Journal of Surgery.
Hafferty FW. “Beyond curriculum reform: confronting medicine's hidden curriculum.” Academic Medicine.
2008;73(4):403-7.
Hill-Sakurai LE, Lee CA, Schickedanz A, Maa J and Lai CJ. “A professional development course for the
clinical clerkships: developing a student-centered curriculum.” J Gen Intern Med 23(7):964-8.
Kaldjian LC, Rosenbaum, ME,Shinkunas LA, Woodhead JC,Antes LM, Rowat JA,Forman-offman VL.
“Through students’ eyes: ethical and professional issues identified by third-year medical students during
clerkships.” J Med Ethics 2011.
Lempp H, Seale C. “The hidden curriculum in undergraduate medical education: qualitative study of
medical students' perceptions of teaching.” BMJ. 2004 Oct 2;329(7469):770-3.
Reisman AB. “Outing the Hidden Curriculum.” The Hastings Center Report. 2006;36(4):9.
Risdon C and Baptiste S. “Evaluating pre-clerkship professionalism in longitudinal small groups.” Medical
Education 2006. 40: 1130-1.
Wald HS and Reis SP. “Beyond the margins: reflective writing and development of reflective capacity in
medical education.” J Gen Intern Med 25(7):746-9.