1. 
   

   To describe how medical learning environments are composed of a complex interplay of the formal curriculum, informal curriculum, and the hidden curriculum.

   
   
2. 
   

   To explain how the hidden curriculum of a medical school or healthcare organization influences professionalism in trainees and practicing physicians.

   
   
3. 
   

   To demonstrate how to assess and address these hidden rules in a learning environment.

In this example,these two residents are articulating a key message about professionalism they acquired during undergraduate medical education via the hidden curriculum. The residents are describing the gap between what they were taught during their professionalism lectures and what they saw their role models do in practice—the latter of which, they also came to learn, signaled the real lesson. Obviously, faculty members do not intend to undermine the curriculum, and training programs expect the faculty to model the lessons taught in the lectures. So, how has this hidden curriculum evolved, what are the implications, and how can it be improved?

Over the last decades, professionalism has evolved (see Chapter 3, A Brief History of Medicine’s Modern-Day Professionalism Movement). Numerous definitions have been created; curricula, codes, and charters have been developed; and educators have articulated competencies and milestones in professionalism. Despite all of this hard work and good intentions, there is a tension in the teaching of professionalism. Faculty may be impassioned in their commitment to improving student and resident education, but the creation of curricula or assessment tools has taken a path of least resistance. Finding 2 hours during resident orientation is operationally far easier and more readily justifiable (e.g., “See, we are doing something”), than undertaking the extensive work necessary to do the following: (1) change the actual practice behaviors of the physician role models that trainees will encounter during their clinical experiences; and (2) alter the conditions under which these physicians carry out their work. In short, codes and curricula are easier to create than new models of practice. The consequence has been a perfect storm of contradictions experienced by students. Students will receive a morning conflict-of-interest lecture stressing the importance of curbing bias in clinical decision-making, only to later find themselves following a preceptor who will meet with three drug representatives, belong to an industry sponsored speaker’s bureau, and work for a contract research organization to enroll patients in clinical trials—all of which generate revenue for the physician. To make the messages even more confusing for students, this preceptor may explain why his work with pharmaceutical companies is good for patients because the company provides much needed free samples for the clinic and, ultimately, the research will improve patient care.

Today’s trainees are finding themselves exposed to two sets of curricula—a formal and often more ideal “classroom” version, and a more pragmatic “real life” clinical version. In some instances, the messages students receive are synergistic and reinforcing. In other instances, however, trainees hear some set of ideal professionalism messages in class and then see contradictory messages in action.

The term, “hidden curriculum” (HC), is a concept to help understand the potentially conflicting messages of complex medical learning environments. Using the HC, we can biopsy the range of different messages that individuals receive as they go about their daily routines of interacting with faculty, peers, staff, and patients, as well as the organization itself. As is true for social life in general, the messages students receive can be divided into two broad categories—formal and informal. Some of the rules that govern our daily lives are formal in nature. Examples include laws or other types of formally written policies. These more formal rules can be learned by formal training and reinforced by a variety of rewards or punishments. However, we also organize our social and work lives around ways of doing things that are more tacit and informal in nature. These more informal rules are not codified in any formal way, but their power over human and/or organizational behavior can be just as strong. Oftentimes, the only way we learn about their existence is by watching others go about their daily routines—and then being observant when these informal norms are violated.

There are innumerable examples of these informal rules and how they govern our daily lives, with most flying beneath our perceptual radar because of their highly taken-for-granted nature. One example is getting on a bus or train; no formal rules govern such behaviors, but informal rules exist. Consider City A and City B. In City A, bus riders may mill about on a platform waiting for the bus to arrive—each staking out turf where they thought the bus door would open. As the bus arrives, riders surge forward, jockeying for position as they tightly bunch on either side of the bus door, forcing disembarking riders to move through a narrow gauntlet of bodies. The actual boarding is an every-man-for-himself scene. Even people who are naturally timid, and do not like to be pushy, will soon realize that they need to push like others or they will be left behind. In City B, riders form a queue with later arrivals adding themselves to the end of the line. When the bus arrives, debarking is easier for exiting riders, since the line was on only one side of the door. In turn, new riders enter the bus in the order they arrived at the bus stop. City A behaviors in City B would violate City B’s informal rules for bus lines.

Driving an automobile is another example of the intersection of formal and informal “rules of the road.” On the one hand, drivers must be licensed and insured (each by a different type of organization). Your “right” to drive is also subject to a myriad of restrictions. You must pass a driving test, and a thriving industry provides classes to teach you driving skills, as well as the formal rules of the road. Those not followingthese rules are subject to an array of sanctions, including arrest and detainment. Highways are littered with signs telling you how fast you can drive and where you can or cannot turn, and so on. However, drivers also learn that these formal rules of the road are not the entire story. For example, sooner or later, most drivers “figure out” that while there is a posted (i.e., formal) speed limit, the “real” limit is somewhat higher—often you can drive 10 miles per hour faster than the speed limit without getting a ticket. Some formal rules can be broken without consequences.

The same range, and mingling, of messages also is true for medical education. Students come to medical school knowing (and if they do not know, they quickly learn) that much ofwhat transpires in medical school will be determined not by the rules contained in the studenthandbook or in course syllabi, but in the way “things are done around here” at their medical school. Furthermore, they also know that there will be different rules depending on the teacher and/or setting. As such, students spend a considerable amount of time and mental energy “figuring out” the rules governing each new course and/or clinical setting as they transition between and among the hundreds of settings and situations in their medical training journey. In addition to considerable transition costs associated with moving in and out of new learning environments, trainees also encounter significant translation costs as they figure out how the informal rules in their newest class,clinical service, or even specialty area differ from the formal rules (Hirsh, 2013). Students even come to know that individual faculty within a given setting may have different “styles” of communication or informal rules, thus requiring learners to master an even broader range of styles and preferences. Becoming a good medical student is not only about mastering the formal curriculum. It also is about mastering the space between the formal and the more hidden dimensions of student learning (Snyder, 1971).

What do students learn when they master this “other” curriculum? If they are successful navigators of that space between the formal and the hidden curriculum, they learn not only that such a space exists, but, more importantly, that their “survival” is highly dependent on their ability to decode that space. The “best” students are often not the most academically brilliant, but rather the ones who are able to understand the prevailing culture of their current learning environment and act accordingly—and do so regardless of the formal rules. What students learn is to give faculty what faculty expect from good students; the “right” answer to an exam or to attending questions during rounds; the “right” deportment in front of patients versus away from patients, or the right (and wrong) way to log duty hours (Brainard & Brislen, 2007; Prentice, 2012). Students learn to “play the game” and to become experts at what sociologists call “impression management” (Giacalone & Rosenfeld, 1989). Perhaps most insidious, students learn to play knowing that faculty recognize (if only on an implicit level) that gamesmanship is the prevailing order of the day—for faculty too were once students. What students learn, in a most fundamental sense, is the strategic importance of becoming “situational chameleons” (Dalfen, 1999; Hafferty &Hafler, 2011).