Do What I Say, Not What I Do! Understanding the Power of the Hidden Curriculum

4-5 Minute Read

Authors: Becky Jayakumar, PharmD, BCIDP, BCPA and Judy Hanrahan, JD, MA

Purpose

Discuss the hidden curriculum in medical education, its power to teach professionalism, and the attributes of a positive role model to enable clinical educators to improve their clinical teaching.

Learning Objectives

1. Define “hidden curriculum;”

2. Describe how the hidden curriculum impacts the behaviors, values, and norms of trainees; and

3. Identify three attributes of a positive role model.

Before professionalism was formally included in the medical school curriculum, medical students learned how to be doctors by watching their attendings practice in hospitals and clinics (for more on this see From Trickle Up Professionalism Education to Professional Identity Formation). Professionalism continues to be taught through the hidden curriculum; the difference now is that the professionalism curriculum taught outside of the clinical setting is either reinforced or contradicted through clinical role modeling.(1) 

Hidden Curriculum: What educators teach and impart to students through role modeling, interpersonal interactions, and the established culture of the learning environment. Includes imparting the beliefs, values, and norms of the discipline/profession.

Phillip Jackson first introduced the concept of the hidden curriculum in his 1968 book Life in Classrooms to describe secondary socialization in education. Secondary socialization is the process through which individuals learn socially expected behaviors, values, and norms outside of their family.(2) Classroom learning rarely approximates the actual practice of medicine, law, engineering, or any other profession; therefore, observation, modeling and imitation play pivotal roles in how and why people learn especially in professional schools.(3)

Do What I Say, Not What I Do

During law school a friend of mine (Ms. Hanrahan) was interning at a law practice over the summer. When he asked for a day off to take the Multi-State Professional Responsibilities Exam (MPRE), a test required to practice law in every jurisdiction except Wisconsin and Puerto Rico, one of the law partners noted “just ignore everything you’ve seen working here.”

As a young law student, I found this story alarming. After all you can probably pass the MPRE by knowing just three rules: don’t comingle money, don’t take clients on two sides of the same transaction, and don’t miss court deadlines. The lawyer seemed to be implying a lack of professionalism at the firm.

Now as a bioethics and health law professor, I see the response differently. Legal practice, like medical practice, is more nuanced than can easily be captured on a multiple-choice exam, and learners are often unaware of the whole context of a particular case or situation. As good educators, we try not to overwhelm students with every aspect of a case, focusing instead on high-yield material that students will build upon throughout their careers. Rather than a declaration of rampant unprofessionalism at the law firm, the lawyer’s comment could have been a nod to the fact that what a second-year law student sees during an internship is not the whole picture.

This leads to an important insight. Students pick up on everything they see, so even if you don’t intend to be a role model, you are one. Every encounter is an opportunity to teach students how to treat patients and colleagues, how to care for one’s own well-being, and/or how to navigate the healthcare system. Clinical encounters and collegial interactions that go poorly are particularly ripe for discussion with students on one of these dimensions.

The Power of Role-Modeling

More than half of the 2023 medical school graduates said they experienced “disconnects between what [they were] taught about professional behaviors/attitudes and what [they saw] being demonstrated by faculty.(4) In my (Dr. Jayakumar) clinical practice as a clinical pharmacist, I have witnessed multiple examples of positive and negative role modeling from physicians. While I have witnessed a myriad of positive examples, the negative examples are imprinted in my memory including instances where physicians disparaged other specialties and patients, shamed and degraded trainees, and even charted on patients that weren’t physically examined. The lessons trainees learn from witnessing this kind of behavior can be subtle, profound, and are likely long-lasting.

Role modeling has been shown to be an effective and crucial strategy to instill professionalism and promote cognitive skills in medical students and residents.(5-9) In a recent survey, medical students identified role modeling as the single most important aspect of professionalism.(10) It is important to remember, however, that negative experiences are more easily remembered than positive ones.(11) This so-called “negativitity bias” describes how people “attend to, learn from, and use negative information far more than positive information.”(11) While we cannot insulate students form negative experiences, we can provide context and reflection; consider also, the characteristics of effecitve role-models outlined below.

Characteristics of an Effective Role-Model

In a review of 39 studies, positive role models exhibited three main attribute domains:  clinical competence, teaching skills, and personal qualities.(8)

Clinical Competence

The clinical attributes identified as being characteristic of a role model includes strong clinical competency and utilizing a patient-centered approach with humanistic behavior.  

Teaching Skills

The teaching skills identified as essential for role models included establishing rapport with learners, creating a positive and supportive educational environment, being committed to the growth of learners, and providing students with ample patient interaction. 

Personal Qualities

Finally, the personal qualities that trainees identified as main characteristics of a role model include effective interpersonal skills, a positive outlook, integrity, good leadership skills, a commitment to excellence, dedication, honesty, politeness, enthusiasm, and inspirating their students.(8) ■

References

(1) Wayne SJ, Fortner SA, Kitzes, JA, Timm C, Kalishman S.  Cause or effect?  The relationship between student perception of medical school learning environment and academic performance on USMLE step 1. Med Teach. 2013;35:376380.

(2) Jackson PW. Life In Classrooms. Holt, Rinehart and Wilson;1968.

(3) Mcleod S. Albert Bandura’s Social Learning Theory. SimplyPsychology. Updated February 1, 2024.  Accessed on June 19, 2024. https://www.simplypsychology.org/bandura.html

(4) Association of American Medical Colleges. 2023 Medical School Graduation Questionnaire. July 2023.  Accessed at on June 19, 2024. https://www.aamc.org/data-reports/students-residents/report/graduation-questionnaire-gq

(5) Gruppen LD, Irby DM, Durning, SJ, Maggio, LA. Conceptualizing Learning Environments in the Health Professions. Acad Med.  2019; 94(7):969-974.

(6) Genn JM. AMEE Medical Education Guide No.23 (Part 1): Curriculum environment, climate, quality and change in medical education – a unifying perspective. Med Teach. 2001; 23(4): 337-344.

(7) Dyrbye LN, Thomas MR, Massie FS, et al.  Burnout and suicidal ideation among U.S. medical students. Ann Int Med. 2008; 149:334341.

(8) Passi V, Johnson N. The impact of positive doctor role modeling. Med Teach. 2016; 38(11): 1139-1145.

(9) Yong HKE, Kee KK, Renganathan Y, Krishna L.  Role modelling in professional identity formation: A systematic scoping review. BMC Med Ed. 2023;194:  https://doi.org/10.1186/s12909-023-04144-0

(10) Byszewski A, Hendelman W, McGuinty C, Moineau G. Wanted: role models – medical studens perceptions of professionalism. BMC Medical Education. 2012; 12(115).

(11) Vaish A, Grossmann T, & Woodward A. Not all emotions are created equal: the negativity bias in social-emotional development. Psych Bulletin. 2008;134(3), 383–403.