The hidden curriculum

“The real voyage of discovery consists of not in seeking new landscapes but in having new eyes.”

The hidden curriculum (HC) is a theoretical construct for exploring the continuities and disconnects of educational life. At its most basic level, HC theory highlights the potential for conflicts between what faculty intended to deliver (the formal curriculum) and what learners take away from those formal lessons; all operating within a system’s framework that emphasizes context and the interconnections and interdependencies of system elements. Examples of key influences include pedagogical context (the ‘what’ of what is being taught), the relational context (interactions among faculty and students, including factors such as power and hierarchy), physical context (space, layout, noise) and the context of organizational culture and group values. Building on this conceptual foundation, HC theory also recognizes that much of social life, including what happens in educational settings, takes place ‘beneath the radar’ because of its essentially routinized and everyday nature. Fundamental to the idea of a HC is the notion that becoming a physician involves a process of professional socialization within the culture and subcultures of medicine and medical practice.

“We (faculty) are teaching far more than we know. Every word we speak, every action we perform, every time we choose not to speak or act, every smile, every curse, every sigh is a lesson in the hidden curriculum.”

Gofton & Regehr 2006

Any attempt to penetrate and ultimately to exert an influence on the HC begins by dissecting the formal curriculum, and thus what is supposed to be going on, at least according to those in power. With this as our foundation, we then proceed to explore ‘what else might be happening.’ The space between the official and unofficial, the formal and the informal, the intended and the perceived, then becomes our primary workspace. In doing this work, it is important to remember that the HC is not a ‘thing’ that one finds, fixes and then puts aside. There always is a hidden counterpart to the formal and intended curriculum. Context always exerts an influence. There always are unseen, unrecognized and un- or underappreciated factors that influence social life, and there always are things that become so routine and taken for granted that they become invisible over time. Purposeful inquiry may uncover and intentionally address pieces of these influences, but no discovery is ever complete and no discovery is ever permanent. There is a constant cycling and recycling between the formal and other-than-formal aspects of social life. Furthermore, the HC system’s perspective requires us to acknowledge that any change in context and situation generates a new set of dynamics and thus new sets of influences which, in turn, help to construct new (overall) sets of relationships between the formal and hidden dimensions of social life.

We begin the chapter by tracing the historical roots of the HC within both sociology and education and how it came to surface within medical education during the 1990s. Next, we will explore how the concept has been used within healthcare and medical education over the past twenty-odd years. We also will note how this framework can be used to link many of the concepts and themes covered in other chapters of this book (e.g. assessment, role modelling, faculty development).

From there, we will turn to applications of HC theory to particular settings within medical education. We will highlight several domains of learning (e.g. classroom, rounds) as we become more specific about things to think about as we (as faculty) create learning opportunities for our students. This will be the most ‘hands-on’ section of the chapter as we introduce examples for decoding the HC at both the student and faculty levels.

Relevance

HC theory has deep conceptual roots within two academic disciplines: sociology and education. Philosopher and educational reformer John Dewey, for example, wrote on the importance of ‘collateral learning’ and the prevailing importance of indirect versus direct classroom instruction (Dewey 1938). For Dewey, the incidental learning that accompanies school and classroom life has an even more profound effect on learners than the formal or intended lesson plan. Dewey may not have used the term ‘hidden,’ but he clearly was concerned with the unintended, unnoticed and unconscious dimensions of learning.

Sociology, in turn, has had its own set of conceptual precursors, particularly its long tradition of differentiating between the formal and the informal aspects of social life. For example, sociology differentiates between social norms, which often function on an informal level, and laws, which are codified. Furthermore, sociology recognizes that there are many examples where norms have a more profound effect on social practices than laws: think highway speed limits and the difference between the posted speed limit (formal) and the more informal limits that govern the actions of both drivers and law enforcement. Sociology is joined by the academic literatures of business and management studies with its own rich history of differentiating between the formal and informal aspects of work and how tacit learning is a critical part of learning ‘on the job.’

Since the 1990s, there has been a steady stream of articles in medical education literature drawing on the HC as a conceptual tool for examining medical training. Topics have included work on professionalism, ethics instruction, faculty development, gender issues, examination policies, identity formation and socialization, summative assessment, reflection, resource allocation, cultural competency, the impact of block rotations on student development, longitudinal training, messages conveyed in case studies, the training of international medical graduates, relations among specialty groups, the HC of scientific research and tools to measure the HC. The concept has been used to explore issues in palliative medicine, emergency medicine, orthopaedics and psychotherapy as well as in undergraduate courses such as anatomy and physiology, in residency training, and in continuing medical education. The HC has been examined in countries including the United States, UK, Australia, Canada, New Zealand, Europe and Scandinavia, Japan, India, Saudi Arabia, Sri Lanka and Qatar.

There also is a ‘hidden’ HC literature. There are many studies that draw upon the conceptual framework of HC theory without ever using key terms such as ‘hidden’ or ‘informal’. These articles will not be identified using keyword searches in databases such as PubMed or ISI Web of Science. One example is Campbell and colleagues’ examination of physician values regarding professionalism (largely quite positive and affirming) and the gulf that exists between these values and physician behaviours (Campbell et al 2007). The authors never reference the HC, but their article clearly highlights the difference that can exist between what physicians say and what they do and thus indirectly how students may be subjected to countervailing messages during their socialization into the physician’s role.

Definitions and metaphors

“Lessons from the hidden curriculum are taught implicitly, through role models, institutional leadership, peers, or during the course of practice….”

Fryer-Edwards 2002

In spite of a rather extensive literature on the HC, and in some cases because of this literature, there continues to be some confusion about what does, and does not, fall under the HC marquee. A few examples appear in Table 7.1, where they are roughly dichotomized into the formal (column one) and the other-than-formal (column two) dimensions of trainee and faculty learning.

Table 7.1

Terms and concepts

In this table, we can see the variety of terms that denote the formal (e.g. ‘official’, ‘stated’) and the other-than-formal (e.g. ‘actual’, ‘experienced’) curriculum. It is, however, important to note that the terms in column one essentially are treated as equivalent within the medical education literature. The same is not true for the other-than-formal list. These terms are similar only in that they stand in some contrast to the formal curriculum. As we will see shortly, there are some important differences here.

Definitions

The formal curriculum is the stated and the intended curriculum. This is what the school or the teacher says is being taught. As you will note in Table 7.1, the formal curriculum has at least two dimensions. The first is that it is stated: be that in writing (course catalogue, website, course syllabus) or orally by a teacher. A second dimension is intentionality. What does the instructor intend to teach or convey to students?

Working ‘outward’ from the formal, we quickly enter a myriad of distinctions and derivations within the other-than-formal aspects of social learning. These dimensions may be tacit, indirect, informal, unintended or otherwise invisible to the participants. What they share in common is that they are neither formally announced nor intended.

Educators often employ a simple dichotomy to differentiate between the formal curriculum and everything else that may be going on within the educational environment. In doing so, some use the terms ‘hidden’ or ‘informal’ as synonyms. There is nothing intrinsically wrong with such an approach just so long as everyone (investigators, subjects and readers) understands that what is being shoehorned into this latter category often can be quite different in terms of structural properties and impact. For example, the null curriculum covers what students learn via what is not taught, highlighted or presented. A literary analogy from a famous Sherlock Homes case is of the behaviour of a dog on the night of a murder.