The risks of following the informal and hidden curriculums
How following the unwritten rules of medicine can cause professionalism dilemmas and emotional distress
Becoming a doctor is not just about applying the factual knowledge you are taught at medical school, it’s also about learning how to be a professional. This is reflected in the formal curriculums of medical schools, which teach the professional values expected of medical students and doctors by the General Medical Council.
However, much learning occurs outside the lecture theatre—through the informal curriculum—where your professional identity is forged by observing the attitudes, practices, and behaviours of senior doctors on the wards, on placements, and in non-clinical settings such as the doctors’ mess.
There is also the hidden curriculum. This comprises the ideology and values delivered subliminally, and also “the unofficial rules for survival and advancement” at medical school, which are communicated to students through the structures and culture of their learning environment (for example, through the prioritisation of some specialties over others). These unwritten lessons can sometimes create a tension for young doctors, when they see a contradiction between what they are taught in the lecture theatre and what they see in practice.
This article highlights examples of the informal and hidden curriculums, the risks of following them, and how you can raise concerns about behaviours and actions that are damaging to the doctor-patient relationship.
The influence of the hidden curriculum
Lynn Monrouxe, director of the Chang Gung Medical Education Research Centre in Taiwan, has been researching how doctors in the UK and internationally develop their professional identity for over a decade. She says the hidden curriculum is a process of socialisation that is present “in every element of your learning . . . it’s [reflected in] what you see, and in the way that people talk.”
Often, the hidden lessons about professionalism contradict what students are taught formally. Monrouxe gives the example of teaching at the bedside. Students are taught the importance of patient centredness—“Yet in the bedside teaching scenario, the patient is often rendered as a prop,” she says.
Kristen Davies, a fifth year medical student intercalating at Newcastle University, adds, “How senior clinicians treat their patients goes against a lot of what we are taught to do, and a lot of what we are formally examined on with regard to our communication skills.”
Informal types of learning can be more influential than the details of the formal curriculum, as day to day experiences are more memorable than the content of lectures and books.
Impact of mixed messages
As a doctor or medical student, you might tacitly accept or may not even be aware of the mixed messages you are receiving, but the tension between what should happen and what happens in practice can lead to a loss of idealism and ethical erosion.
Davies says that witnessing poor professional conduct contributes to a loss of enthusiasm, lower morale, and cynicism: “I’ve definitely become more cynical the more senior I’ve become. I’ve tried to keep my enthusiasm, but you just see things happening.”
Davies recalls an incident when an obstetrics and gynaecology consultant put pressure on him to carry out an intimate examination on an anaesthetised patient who had not consented. “The medical school was incredibly clear that we cannot perform [intimate] examinations when a patient is under general anaesthetic, even with prior consent,” he says. Davies declined to carry out the examination, but felt uncomfortable.
Had Davies followed the consultant’s instructions, he would have been disregarding the patient’s right to decide what happens to their own body, and also continuing to perpetuate an unhealthy power dynamic between doctors and patients.
According to Monrouxe, the contradictions between the formal, informal, and hidden curriculums can create dilemmas about professionalism for students, resulting in moral distress.
“Students feel angry when they see something contrary to what they have been taught—it’s quite upsetting,” she says.
“[The experience] can be stressful in the moment and then go, or it can be stressful over a long period of time.”
Monrouxe says that longlasting stress arises when students or junior doctors feel powerless to raise a concern or stand up to a senior doctor’s behaviour. “They may worry that if they do [make a stand] they might be subjected to negative behaviour by that person, or that their future career might be at stake,” she says. “But if they don’t act on [their concern], it can cause long term psychological distress, as students end up feeling they have been part of [the problem], rather than feeling they have done something [to fix the situation].”
The hidden curriculum has also been blamed for a reduction in empathy among medical students. However, Monrouxe says that her research challenges the idea that doctors lose their empathy as a result of witnessing poor professionalism. She argues that when students and doctors feel uncomfortable with these professional dilemmas and the tensions they present, this indicates that their morality and concern for patient centred care is intact.
Dealing with the problem
Monrouxe says that if students can resist accepting and absorbing examples of poor professional behaviour in some way, then their negative feelings can be mitigated.
“Our healthcare workforce is inherently a caring workforce, but unfortunately the culture in which they are working, and therefore in which our students are learning, does not always facilitate those behaviours and feelings,” she says.
“Raising concerns and the responsibilities of students [to do so] are becoming more expected, but I think that the culture will take a long time to change. If the GMC is urging change then it will make a massive difference . . . it really has to come from the top.”
The GMC is clear that medical students have a moral responsibility to raise concerns about patient safety, dignity, and comfort. Students should follow their medical school policy on raising concerns.
“If you’re not sure whether you should raise a concern formally, you should ask your medical school or an experienced healthcare professional for advice.”
However, Monrouxe warns that safeguards need to be in place to support students wanting to raise concerns. “Students need institutional support so that they do not feel alone in their endeavours,” she says. “Unless the structures and systems are in place that support [students with concerns] . . . really students need to be very careful.”
Students and junior doctors also need safe spaces for discussion when they experience tensions as a result of the hidden curriculum. David Warriner, a cardiology registrar and clinical fellow at the Academy of Royal Colleges, says that self reflection, peer discussion, and peer support are important ways to help students who experience examples of poor professional conduct.
Encouraging students to develop their own ways of coping with difficult professional situations, and empowering them to speak up about lapses in professionalism, can reduce distress and promote cultural change.
Warriner acknowledges it can be hard to talk about things at the time, but suggests that students should do so afterwards with their peers, parents, or a personal tutor. “I think if someone’s behaviour makes you feel a bit weird, or odd, or unsettled then you have to talk about it,” he says. “Vocalise it and address it out loud rather than taking it on the chin and burying it deep inside and accepting it as normal.”
Davies agrees that students should talk about their experiences of poor professionalism. “I would encourage them to talk about it at the earliest opportunity they feel comfortable, whether with the person who has been unprofessional, or with someone they feel comfortable with, who may take it further,” he says. “We all need to keep aspiring to the best standard.”
Different types of medical school curriculums
- Formal curriculum: what a school formally states—its mission statement, course curriculums, materials, and objectives
- Informal curriculum: unscripted and predominantly ad hoc teaching and learning that occur outside of the formal curriculum—for example, during ward rounds or at the bedside—and which messages that can be consistent or inconsistent with the formal curriculum
- Hidden curriculum: lessons, especially about norms and values, that are embedded in a school’s organisational structure and culture but not explicitly intended to be taught, which might be supportive or contrary to the formal curriculum
- Null curriculum: lessons learned through omission—for example, behaviours or subjects that are not mentioned in class or role modelled on the wards and by default become things that students conclude must not be important
- GMC guidance: Medical students: professionalism and fitness to practise. 2017. www.gmc-uk.org/education/undergraduate/26625.asp
- BMA guidance: Guide to raising concerns. 2017. www.bma.org.uk/advice/employment/raising-concerns/guide-to-raising-concerns
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
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