The Hidden Curriculum

CanMEDS Professional

The Hidden Curriculum

In education there exists a formal, explicit clearly acknowledged curriculum that is evident to all. There also exists a shadow curriculum, known as the hidden curriculum. The hidden curriculum includes what is implicitly learned, not explicitly taught and can be positive or negative in nature. Hidden curriculum reflects the values and culture of the institution one is part of, the unofficial rules for survival and advancement. It refers to what residents and students learn by watching their preceptor when explicit teaching is not taking place. In fact, it may be that some of the more difficult issues in medicine, showing empathy or resource management, are only learned through the hidden curriculum.

Clinical encounters are often the places where the "hidden curriculum" is learned. Review the following clinical scenarios and comment on the behaviours of the various people involved. What is professional and what is unprofessional?

You are going on rounds with your attending staff. Your "team" consists of 2 medical students, a junior and senior resident. The charge nurse is also rounding with you.

The staff physician enters a patient room (one with 4 beds). He walks in with the chart and asks the patient a few questions about her medical condition (COPD). The team walks in and listens as the attending questions the patient. The attending then asks the medical student to listen to the patient's lungs. The attending then asks the junior resident to listen to the lungs as well as the medical student heard crackles all over.

The team then walks out of the room and stands by the door discussing the orders that have to be written on this patient.

You are a junior resident and working in the urology clinic. This is a followup clinic and you are asked to see patients who are coming for followup of BPH. You go in and start asking the LUTS questions. The attending comes in while you are still getting a history and states that you are taking too long. She takes over the history taking and then very quickly states she wants to do a physical. She asks the patient to undress while you are both in the room and then does a rectal exam to assess his prostate with no draping. She then increases his medication dose and leaves the room, leaving you behind. You say goodbye to the patient and rush out after the attending staff.

You are doing a rotation in the family medicine clinic. You have a patient who has been struggling with depression and was recently placed on medication. The patient states she would like to see the attending physician rather than a resident. The patient's family doctor is at a conference and you explain this to her. She starts to cry stating that she has tried to see the family doctor three times now and would really like to speak with her. You go to the covering attending physician and explain the situation to him. He states the patient cannot expect to be seen by their family doctor, this is a teaching practice and the patient is going to have to realize that they may not see their family doctor at their visits. You go back and relay this information and the patient leaves upset and angry.

By being aware of the hidden curriculum you can choose to learn the positive things being taught and guard yourself against the negative.

A recent study showed that medical students were powerfully affected by clinical encounters and the learning environment. Students’ perception of the profession’s values are very much influenced by the informal and hidden curriculum.

A mentor is someone who takes an active interest in you and your career and guides and supports your professional development. In this section we are thinking about the less formalized influences.

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