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What are we really telling our medical students? The story of the Hidden Curriculum

What are we really telling our medical students? The story of the Hidden Curriculum

This blogpost was co-written by Jane Philpott, Tony Sanfilippo and Karen Schultz 

Canadian Resident Matching Service (CaRMS) season is upon us—an exciting if anxiety-laden time of year when medical students finalize their residency program choices. This process is mandatory for medical students who hope to complete their residency in Canada. It involves ranking the specialties and institutions where they wish to complete their training. The programs follow suit with their rankings of each applicant. A match ensues where preferences are optimized against the number of seats and medical students are ranked accordingly.  

In an ideal world, medical students would go into the match feeling that all areas of medicine are equally valued, and their choice would be based solely on interest and aptitude. Unfortunately, it is increasingly clear that students are exposed during medical school to attitudes that suggest medicine is hierarchical, with some disciplines more valued than others. This causes many students to question and even change their intended career paths. 

“Since entering this environment I have felt more of a need to compare myself and have felt that choosing a primary care specialty will be looked down upon…. why is that? I did not come here with that attitude.”  

- medical student  

These subtle and not-so-subtle messages that students infer from actions and inactions of people and institutions, constitute an unfortunate aspect of what has come to be referred to as the “hidden curriculum.” The hidden curriculum is a powerful thing. It can either reinforce or undermine formal curriculum and values. To better understand the impact of the hidden curriculum, the Queen’s School of Medicine recently surveyed its medical students, residents, and faculty members. Although the survey results revealed many examples of positive hidden curriculum, where peoples’ actions reinforced affirmative values, there were too many disturbing examples of negative hidden curriculum undermining core values of our curriculum and our school. These negative actions, because of their disharmony with formal curriculum and institutional values, are particularly impactful and were found to affect people at all stages of their career and in most areas of medicine.  

“Oh, you’re too smart to go into…. [insert any speciality here—many were mentioned as examples in the survey]”  

- multiple survey respondents 

For learners, this negative hidden curriculum is poignant. It impacts educational opportunities, influences career choices, and undermines confidence. It fosters doubt and dissatisfaction with a chosen path and counters the learner-centered teaching we espouse at Queen’s. 

So, what is the root of the problem? What creates the personal and structural climate where these negative biases and value judgements can be spread? Respondents had many ideas: 

“I think that those negative attitudes are first taught and then as we have our own experiences as learners, we are biased by those comments and then it is a self-perpetuating problem as we then pass those biases on to the junior learners who then become seniors and pass it on again”  

- resident 

Siloed working environments foster a lack of understanding each other’s work. Often, we do not know each other, and it is easier to be unprofessional to an unknown person. Other factors include overwork, burnout, and loss of resilience; perceptions driven by payment schedules, length of training, competitiveness to get into some programs; immediacy of outcomes from procedures vs the more intangible impacts of generalism or preventative medicine; and the process for how and who we admit into medical school. 

As an institution that values respect, collegiality, diversity, and inclusion, we need to address these root causes and be a part of the solution. We need to ensure that all areas of medicine are equally appealing to students so they can make their choices based on interest and aptitude. Addressing the hidden curriculum will require a multifaceted approach and an ideological shift within our profession. All of us will need to be committed and involved.  

This work is underway. It will be tied to the Dean’s Action Table on Equity, Diversity, and Inclusion as, in its negative form, the hidden curriculum is another example of (in)equity and (lack of) inclusion. We must flatten hierarchies that corrosively impact clinical care and education. We expect people to be professional and respectful. We must go beyond eliminating the negative hidden curriculum to embrace a positive hidden curriculum that embodies our institutional values.  

Although the hidden curriculum survey was conducted only in the School of Medicine, we are deeply cognizant that there are equally damaging hidden messages that are communicated about the value of other members of the health professional team. We also intend to address this in the Faculty of Health Sciences. We will not achieve equity outside our health teams unless we respect one another within our health teams. 

We went into health care and teaching to be a positive influence—for our patients, for our learners. Reconnecting to that will optimize our educational and clinical impacts. And in this, the CaRMS season, it will support our medical students in making choices that truly resonate.  

“We all need to respect each others’ disciplines and the fact that all of our jobs are difficult in many ways. If we all showed more respect, and just assume our colleagues are doing the best they can, burnout would be less, and patient care improved.”  

-faculty member 

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Duncan Sinclair

Thu, 03/11/2021 - 10:56

It is no comfort but this is a problem not confined to Medicine or the Health Sciences. It applies throughout the University. In my view, it originates in the trend to specialization in all educational applications, begun many years ago and made worse by its application earlier and earlier in the educational process, now even in schools, well before having to choose a "major" in University. In large part it is the result of the exponential growth of knowledge, scientific and otherwise, during the 20th century. As David Naylor once said, learning from the medical literature is like "drinking from a fire-hose"; it is only sensible in such circumstances to split the stream into a trickle one can savour and swallow. But specialization is also reinforced in other ways, including every teacher's propensity to recruit his or her successors whether as resident, graduate student, or whatever and, of course, by the all-too-obvious reward structure, whether measured in income or status, that ranks specialism above generalism, in effect, according greater value to depth of knowledge than to its breadth. I would argue that it is much harder to be an excellent and accomplished generalist, especially in today's world, than an acclaimed specialist regardless of field. Good luck, Sisyphus.

Duncan Sinclair

Duncan - as always, you manage to capture the deeper implications and considerations on any given topic. Thanks for sharing these thoughts about how we got here. We have our work cut out for us - to respect one another and properly value the necessary range of academic pursuits.

Jane Philpott

Leda Raptis

Fri, 03/12/2021 - 11:09

I would like to add that society overall affects attitudes too. Patients may never see the Pathologist, but all cancer treatment often hinges upon a pathology report. Basic science, the kind that figures out pathways that will lead to drugs is not even supposed to be "Medicine" in the eyes of the public in general. All the public knows about is the final application. Research is not the students' first choice.

Leda Raptis

Hi Leda - thanks for highlighting this important point. The critical value of the pathologist is certainly not adequately recognized. It feels like COVID had shone a light on the profound value of research in the basic sciences - but we have a long way to go in supporting our researchers adequately. Let's keep at working at that!

Jane Philpott

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