Hidden curriculum in family medicine

There is inevitably a hidden curriculum within any form of education and often, this hidden curriculum comes into direct conflict with the formal curriculum propounded by the institution. I am a second-year family medicine resident at University of Toronto. Throughout my medical training both in school and in residency, I have encountered several examples in which the hidden curriculum has come to light. One such example can be found in the resident training program regarding self-care and wellness. The notion that doctors should prioritize their own health and wellness has been drilled into us throughout our medical training. However, time and again throughout my residency in family medicine, I have witnessed burnt-out mentors expressing how overworked they feel and the health consequences from their lack of sleep. From my own experience to date, there is little opportunity for time off from the pressures of residency, leaving little or no time to devote to personal interests such as spending time with friends and family or pursuing personal hobbies. This has led to a disconnect for me. On one hand, I am hearing from mentors that I should take time to care for myself, yet on the other hand I see the long hours demanded of physicians and realize that in practice, there is little time or opportunity for personal care and wellness.

Another area in which I feel that there is a disconnect between what we are taught and what is implicitly expected of us is around professionalism. It is understood that you are never to question your superior because by doing so, you risk being seen as unprofessional or disrespectful. If one sees his or her supervisor do something unethical or wrong, there seems to be an “unwritten rule” that you are not supposed to question or challenge a superior, especially in front of other physicians or patients. This idea comes into direct conflict with the way in which we are formally taught in our medical curriculum. Emphasis is put on ethical decision making and standing up for what is fair and moral. However, in practice, this can sometimes be very difficult to implement. The risk of ruining a professional relationship should not be in direct conflict with speaking up in the face of a moral or ethical dilemma.

Hidden curriculum refers to the unwritten or unintended lessons or perspectives that students gain in an education which are different than those explicitly taught in the curriculum. The use of the term “hidden curriculum” refers to the fact that the lessons are often unacknowledged or unexamined by both the students and the mentors. However, I think that addressing this issue is a big step towards resolving the implicit contradictions that inevitably arise in any type of professional education. Through acknowledgement and discussion of various hidden curriculum issues, we can become more aware of the way that they impact our beliefs and perspectives. The hidden curriculum will always exist; it is an inevitable part of any education, especially in medicine, which is fraught with contradictions between professionalism and emotions. I don’t believe that the goal should be to try to eradicate the hidden curriculum in medical education, but rather, to try to challenge these contradictions by openly discussing the underlying values and beliefs and the inherent conflicts that arise as a result. It is important to make the hidden curriculum an explicit dialogue and encourage frank discussion so that residents do not feel alone in their uncertainties or feel discomfort with the contradictions with which they are often faced. Obviously, one of the biggest challenges with the hidden curriculum is the fact that it is, indeed, hidden. However, if the issues are brought to light and discussed, then they become less “hidden”, and contradictions and paradoxes can be addressed and hopefully resolved.

I think certain steps can be taken to help address the inherent problems of the hidden curriculum. We can have formal lectures or open forum discussions embedded into the residency training curriculum where we can discuss the issues that arise because of the hidden curriculum. If the reference to “hidden” is removed, then the issues surrounding this part of the curriculum would become visible and brought to the forefront. By doing this, I think it would go a long way in making students and mentors realize that these issues and the inherent contradictions are real and affecting everyone. In this way, topics can be overtly discussed openly amongst all medical colleagues. Once the issues and inconsistencies are recognized, everyone can then be more open and forthcoming about their feelings on the issues and perhaps help others experiencing similar difficulties.

This is an original submission. There are no conflicts of interest. There have been no financial or material support.

Dr Allison Hoffman is a second-year family medicine resident at the University of Toronto.