The impact of the hidden curriculum on learning experience

Within medical education, the hidden curriculum (HC) refers to a set of cultural and structural influences that convey unofficial, and sometimes unintended messages to medical learners that may shape their perspectives and values. As students, we are constantly surrounded and influenced by the HC. It has the power to shape our learning and perpetuate the culture of medicine often without our conscious awareness. In order to better understand the impact of the HC on resident learning experience, we looked at written reflections from family medicine residents about the HC that was collected as part of University of Toronto’s 12-month progress review.

In over 100 reflections, the perceived prevalence of HC varied among residents, from being “ever-present” to having little impact. Many felt that the HC positively impacted their learning, while fewer had an entirely negative experience. Interestingly, misconceptions about HC were common, including assumptions that HC involves a lack of transparency or discussing components of the informal curriculum instead. Three main themes emerged:

1) Prioritization of Wellness was Inconsistent

When wellness was prioritized, the residents commented on alignment of HC with the formal curriculum and positive role models. Conversely, some observed the normalization of poor wellness in the “culture” of medicine and discrepancy between the formal and hidden curriculum.

2) Positive Role Modeling was Prevalent

Role modeling by preceptors was a prominent theme, including the modelling of effective communication strategies, their interactions with patients and co-workers, and their attitudes towards their careers. They were impacted by the availability of support and the way staff provided them feedback. Residents reflected that lessons learned from positive role modeling were empowering and more likely to be implemented in future practice.

3) Mixed Messaging about Family Medicine as a Specialty

A notable, but unsurprising, finding was the HC surrounding family practice as a career choice (https://cfppodcast.libsyn.com/defining-the-specialist-generalist). While residents themselves are often satisfied with their choice to pursue family medicine, they received mixed messaging from others. Particularly in their off-service rotations, they observe attitudes and behaviours from others suggesting their lack of knowledge, inferior skill, or choice of having an “easy” job and lifestyle. Perhaps, in part, due to this negative messaging, some residents report the pressure of requiring additional training.

Through the reflections, we learned that many residents are unaware of or have a misconception about the HC. Being attuned to the HC is the first step to critically reflecting on whether there is a discrepancy between the formal curriculum and what we learn. To add a layer of complexity, messages conveyed through the HC can be inconsistent and are often site-specific, rotation-specific, and highly preceptor dependent. Moreover, as medical students, we are reflecting on and making decisions about our future careers. Receiving mixed messaging regarding family medicine as a specialty choice can make this process challenging. Collecting reflections about the HC is an important and effective method to allow students to reflect on their learning, identify areas of improvement for teaching the HC in the formal curriculum, and propose site and rotation-specific interventions.

Grace Huang, Catherine Meng, and Shamini Vijaya Kumar are medical students at the University of Toronto.

Milena Forte is a family physician at Mount Sinai Hospital and an Associate professor in the Department of Family and Community Medicine at the University of Toronto.

Fok-Han Leung is a family physician at St. Michael’s Hospital and the Associate Director of the Family Medicine Postgraduate program at the University of Toronto.