IAMSE Spring 2024 Webcast Audio Series – Week 5 Highlights

Presenter: Megan Brown, Ph.D. Senior Research Associate in Medical Education Newcastle University

[The following blog was generated by Susan Ely and Doug McKell]

Navigating the Hidden Curriculum in Health Professions Education

The Learning Objectives for the fifth Spring 2024 IAMSE Webinar on Teaching and Learning in Medical and Health Professions Education includes the following: First, understand the hidden curriculum in health professions education, including its impact on students’ learning experiences and clinical practice. Second, identify the effect of the hidden curriculum in clinical medicine, highlighting the mismatch between expectations and job requirements. Third, recognize the complexity of the hidden curriculum, the potential adverse effects, and the need to create a safe space for students to voice their concerns. Fourth, identify opportunities for the hidden curriculum to enhance the student educational experience and promote inclusivity.

Dr. Brown began by expanding upon the four objectives of her presentation. 1. Understanding what the hidden curriculum is and is not. 2. Recognizing the hidden curriculum in daily educational practice. 3. Identifying strategies for the hidden curriculum to enhance the impact of teaching. 4. Reviewing resources and helpful hints for working with the hidden curriculum in different health profession environments. Dr. Brown explained that she began her career as a physician and now identifies as someone with a medical background who’s left clinical practice to teach and research in health professions education. Dr. Brown described the impact of the hidden curriculum during her training and when she qualified to practice as a physician. As a disabled person working in clinical practice, she related that she wasn’t prepared for how the hidden curriculum in healthcare impacted communication with and about her and other people like her. This motivated her to obtain a Ph.D. in medical education and to leave clinical practice.

Dr. Brown discussed her research on the hidden curriculum and its relationship to identity development and professionalism. She pointed out a gap between the theoretical knowledge of the hidden curriculum, which is increasingly well-developed in the literature, and a deficit in practice. For example, how does one translate an understanding of the hidden curriculum into practice? How can the hidden curriculum be navigated to support students and learners in ways that challenge some potentially negative impacts? To answer these questions, Dr. Brown focused on understanding educational objectives and the curriculum as a roadmap for education. She invoked a comprehensive plan that outlines the intended aims, objectives, contents, and experiences that form an educational program. It encompasses all methods of learning, teaching feedback, and supervision. Health professions education covers required content and professional identity with greater detail to develop a learner’s knowledge, skills, attitudes, and expertise.

Dr. Brown described how a broader perspective highlights other layers of education beyond this explicit outline. The formal curriculum comprises the tangible, the measurable, the overt components of an educational system and acts as the skeleton on which the body of the learning experience is built. In addition to the formal curriculum, there is an informal curriculum, which tends to occur in workplaces or clinical settings. Dr. Brown stressed that there are differences between the informal and hidden curricula, with the informal curriculum being opportunistic, idiosyncratic, and unplanned. Dr. Brown pointed out that the informal curriculum acts similarly to the formal curriculum by emphasizing what teachers think students should know. She then referred to Hafferty’s (1998) definition of the hidden curriculum as “The unwritten rules, values, and patterns of behavior that students learn and are expected to conform to whilst learning.” It is the unintended, unofficial learning that students absorb through education. She pointed out that the hidden curriculum involves tacit messaging about what is and isn’t important. These messages can influence students both positively and negatively.

Dr. Brown continued to emphasize that educators’ current understanding of the hidden curriculum in the health professions involves appreciating that what is implicitly taught in the hidden curriculum is just as impactful as what is explicitly taught in the formal curriculum. It shapes knowledge and professional identity by reinforcing social norms, values, behaviors, and ethical perspectives. She referred to a scoping review of the hidden curriculum by Sarikhani et al. (2020), which identified four main categories: 1. structural factors, 2. educational factors, 3. cultural factors, and 4. social factors. The structural factors include the organizational frameworks and roles within educational institutions that subtly dictate the expected behaviors and priorities of medical students and educators and educational practices. The educational factors include the way we teach. The cultural factors refer to prevailing attitudes, values, and norms in educational settings that informally influence learners’ perceptions and identities. Social factors influence the dynamics of interpersonal relationships and role models’ choices. Dr. Brown noted that this is an example where the impact of identity and social factors is linked to interpersonal relationships. She also referred to the influence of role models, which significantly affect students’ learning and professional conduct in the healthcare environment.

Dr. Brown then asked that the hidden curriculum be considered in four ways: 1. What happens in corridor conversations (what is said and not said)? 2. How do organizations behave when confronted with controversy? 3. What types of direct and indirect stereotyping exist? 4. What is being accessed as valuable faculty and student performance? She stated that the hidden curriculum must be navigated in a very intentional manner. She gave examples of the design of anatomy labs that reinforce learning silos, the lack of age, sex, and racial diversity represented in printed material, and the gender and body type bias in clinical training for physical examinations. Dr. Brown stressed that this lack of diversity sends strong messages within medicine and healthcare, thus perpetuating this under-representation. In her experience, the hidden curriculum can perpetuate traditional hierarchies and intimidate students from questioning authority or contributing valuable input. Eventually, this can lead to burnout and stress, especially when the hidden curriculum emphasizes overwork and the expectation of constant availability. Furthermore, there can often be unintended bias and discrimination. The hidden curriculum reinforces resistance to change, can discourage innovation, and can promote adherence to outdated practices if not identified and addressed.

Dr. Brown also pointed out some positive aspects of the hidden curriculum. For example, positive role modeling and informal mentorship play a big part in making the experiences of the hidden curriculum constructive. It can instill empathy and sell compassion to students, which is crucial for patient-centered care. She then highlighted four ways to identify the hidden curriculum. These are to observe, reflect, seek, and review. She indicated that it is imperative to carefully observe signs that represent the hidden curriculum. Dr. Brown strongly suggested we should become very aware of the language used, recognize nonverbal cues, and identify the reward or discourage behavior in the work environment. Do these observations align with or contradict the formally taught curriculum? This line of questioning can reveal much about the implicit values being communicated. She challenged educators to critically reflect on what’s being conveyed as necessary by the formal curriculum and examine their priorities in their teaching and student interactions. Similarly, she stressed carefully evaluating discrepancies between what’s being said and what’s being done. Finally, Dr. Brown encouraged the promotion of an open dialogue through anonymous feedback mechanisms, reflective assignments, focus groups, or other formats that can be included in teaching. The last step, the review of the hidden curriculum, is completing a formal critical look at institutional policies and procedures. She encouraged introspection about the language used with students and the procedures students are asked to perform. What messages do these send? Does the institution have policies that inadvertently place certain student groups at a disadvantage? Dr. Brown suggested that awareness and understanding of those elements can aid in identifying areas that will help align those hidden and implicit messages with the institution’s educational goals.

Dr. Brown asked the audience to reflect on their engagement with the hidden curriculum. How do the actions of educators influence learners? Are educators demonstrating the conduct that they articulate How are any discrepancies revealed by these reflections addressed? Lastly, Dr. Brown asked the audience to consider what lessons students might be learning from their faculty’s positive and negative conduct. Once these reflections have been considered, educators can consider the root causes of what has been discovered and seek to address or change those lessons. In summarizing, Dr. Brown listed four actions to address the challenge of the hidden curriculum. These were to integrate reflective practice, support critical consciousness development, support inclusivity, and foster a culture of feedback because, as she pointed out in her final slide, … “What is taught is not learned, and what is learned is not
taught…sometimes [the Hidden Curriculum] is hiding in plain sight.”

Dewey, J. (1938). Experience and Education. New York, NY: Macmillan.
Hafferty, F. W., & Franks, R. (1994). The Hidden Curriculum, Ethics Teaching, And The Structure Of
Medical Education. Academic Medicine, 69(11), 861-871.
Hafferty, F. W. (1998). Beyond curriculum reform: Confronting medicine’s hidden curriculum. Academic
Medicine, 73,403–407.
Jackson, P. (1974). Life in Classrooms. New York, NY: Holt, Rinehart & Winston.
Landreman, L.M., Rasmussen, C.J., King, P.M. and Jiang, C.X., 2007. A phenomenological study of the
development of university educators’ critical consciousness. Journal of College Student Development,
48(3), pp.275-296.
Lempp, H., & Seale, C. (2004). The hidden curriculum in undergraduate medical education: A qualitative
study of medical students’ perceptions of teaching. BMJ, 329, 770–773.
Martin J., R. (1994). What should we do with a hidden curriculum when we find one? In: Martin J., R.
Ed. Changing the Educational Landscape: Philosophy, Women, and Curriculum. New York, NY: Routledge Sarikhani, Y., Shojaei, P., Rafiee, M. et al. Analyzing the interaction of main components of the hidden
curriculum in medical education using interpretive structural modeling method. BMC Med Educ 20, 176
(2020). https://doi.org/10.1186/s12909-020-02094-5
Wear, D., & Skillicorn, J. (2009). Hidden in Plain Sight: The Formal, Informal and Hidden Curricula of a
Psychiatry Clerkship. Academic Medicine, 84(4), 451-458.