The Hidden and Informal Curriculum During Medical Education

Both the hidden and informal curriculum take place after or next to the theoretical teaching, the formal teaching and has an important part in the shaping of the medical students’ professionalism and professional values. Moreover, these forms of the curriculum have a major impact on the learning potential of med students. Yet little is known about this subject. A lot has been written but only from a theoretical stand point.

The hidden curriculum is the physical and workforce organizational infrastructure in the academic health center that influences the learning
process and the socialization to professional norms and rituals.

The informal curriculum is the student’s immersion in the interpersonal processes in the academic health center, including
interactions between students and their teachers, interactions among the interprofessional participants in medical care processes, and interactions that students experience with patients and their family members.

Recent published research studied the informal and hidden curriculum by using medical students’ critical incident narratives. Medical students were asked during their third year clerkship in internal medicine to report professional critical incidents, events that thought them something about professionalism and professional values or the lack thereof.

reflect on and write about events, either positive or negative, that “taught you something about professionalism and professional values.”

Each students had to write at least two such narratives online in a web based password protected web site. These narratives were printed and discussed anonymous in focus groups, monthly small group reflection sessions. From the 272 experiences described by the students, 63,4% were positive and 29,1% negative. The other stories were not positive nor negative. The main domain about which these narratives were focused were about medical clinical interaction (81,3%) and 18,6% about educational situations.

Most common themes:

• manifesting respect or disrespect in clinical interactions with patients, families, colleagues, and coworkers. For instance face to face contact with patients or conversations about colleagues in their absence
• managing communication challenges with patients and families. Mostly positive stories about the positive amnner in which professionals handled these contacts. Some stories were clumsy in handling sensitive conversations about important topics
• demonstrating responsibility, pride, knowledge, and thoroughness. Role models showing actions that either were poor or exemplary behaviors.
• stories about professionals taking time to understand their patients’ concerns and needs and making certain that patients understood what was being said about their illnesses
• going above and beyond, caring and altruism in taking care of patients and/or family members
• stories concerning communicating and working in teams and about the issue of teamwork
• creating an (un)welcoming environment. This is mostly about teaching and the learning environment. The feeling to be actively taught and cared for is extremely important for students
• The teacher asking questions and providing explanations, using all opportunities to teach values and manners, also an important educational theme for the students.

These themes show how utterly important it is to be a good professional role model to medical students. They focus mainly on interaction and communication. They mostly have their attention on the respectful or lack thereof interactions in teams and towards patients and many others. Obviously med students are very sensitive to these communications and dependent on role models for their future. They observe very closely how their mentors interact with various others, both visible and behind closed doors.

I don’t think negative interactions or incidents will have a negative effect, these things happen. What counts is the way we solve these negative behaviors, how we deal with them. If we succeed to deal with them in a positive manner, these incidents become educational. What do you think?

Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, & Inui TS (2010). Medical students’ professionalism narratives: a window on the informal and hidden curriculum. Academic medicine : journal of the Association of American Medical Colleges, 85 (1), 124-33 PMID: 20042838