Hidden Curriculum at Medical Schools

Ahmed Imran Siddiqi

Hidden Curriculum at Medical Schools

Ahmed Imran Siddiqi^*

Consultant Physician, Department of Internal Medicine, Jersey General Hospital, UK

*Corresponding author: Ahmed Imran Siddiqi, Consultant Physician, Department of Internal Medicine, Jersey General Hospital, Channel Islands, Jersey, UK

Received Date: 01 July, 2020; Accepted Date: 10 July, 2020; Published Date: 18 July, 2020

Citation: Siddiqi AI. (2020) Hidden Curriculum at Medical Schools. Ann Case Rep: 14: 439. DOI: 10.29011/2574-7754.100439

The word curriculum has been taken from Latin word for track or race course. It is now used for track of studies for a specific course or program [1]. Curriculum refers to a set of defined, written and agreed official lessons a student is expected to complete by the end of a course or programme [2]. During the course of completing the curriculum students are exposed to many unintended and unofficial practices, values, behaviours and perspectives [3]. This is what we call hidden curriculum. All the students are expected to follow the same curriculum and expected to achieve a certain pre-defined level of competency by the end of the course or programme. Most courses would use certain assessment tools to ensure sufficient progress of students during the course. Students are offered extra support and help if they are not progressing sufficiently. Hidden curriculum is a complete opposite of this. It’s not pre-defined, not agreed, not written and not assessed [4] during the course yet hidden curriculum is important because students will inevitably learn from these behaviours, practices and attitudes [5]. They are then likely to practice it during rest of their professional lives. We can only work on something once we recognize and appreciate the importance of that factor. I don’t think there is enough awareness of importance of hidden curriculum in developing a professional.

Medical consultants supervise medical students and doctors in their clinics and wards and focus mainly on their clinical curriculum and competencies. Most of us know that students learn not only from their supervising clinician but from the environment of the department and each member of the team. They learn from clinical and non-clinical staff that is directly or indirectly involved in patient care and from general mood of the department.

At medical institutions Hidden curriculum must be addressed and whole learning environment must be inspiring for students to not only improve their clinical skills but also their practices and behaviours. Thinking about hidden curriculum at my work place raised few questions in my mind: How should we approach hidden curriculum? Should we use the same approach we use for standard academic curriculum? Could we write down hidden curriculum competencies like we write down standard curriculum competencies? Can we write down the details of all the members involved in teaching standard and hidden curriculum so that we could discuss the plans with them all? Could we assess hidden curriculum competencies using any kind of assessment tools?

As I went through the literature I managed to find answers of some of my questions. It is important to recognise hidden curriculum as an important entity and every effort should be made so that the staffs involved in teaching is educated about it [6,7]. The staff should then mould the academic curriculum and deliver it using hidden curriculum skills to train students better. Teachers should encourage students to use hidden curriculum skills. The strategy may vary however; one could make arrangements so that students are using at least one skill a day [8]. Once again, this would only be possible once the teachers/facilitators themselves are well aware of hidden curriculum importance. It is important to recognise that one has to strike a fine balance while using hidden curriculum skills in class rooms as some students may take a negative impact from this. Myles et al. have emphasized the importance of using hidden curriculum in teaching children with special needs [9]. Although, this can be challenging in this particular student population but the hidden curriculum remains the best option for such students for teaching social skills. Children with special needs require special attention and their needs are different from others. Some of these children tend to move away from the society because of this difference and may start considering their special needs a hindrance to progress in life. Their hidden curriculum would include this expectation that their teachers/staff looking after them ensure that these children gain confidence to interact with society.

Moving on to answer my remaining questions I was looking for a set of written hidden curriculum skills/competencies. Each discipline has its own rituals and set of attitudes taken as a norm. As expected, different disciplines have enlisted different skills in their hidden curriculum. Being a healthcare professional myself I focused on hidden curriculum in medical education and training. I could not find a list detailing all the desired hidden curriculum competencies but came across interesting studies showing existing hidden curriculum among medical, dental and nursing staff. The prevailing hidden curriculum skills were different for nursing education [10], dental practitioners [11], for junior doctors in training [12] and medical education [13]. Six learning processes of the hidden curriculum of medical education have been identified: loss of idealism, adoption of a “ritualised” professional identity, emotional neutralisation, change of ethical integrity, acceptance of hierarchy, and the learning of less formal aspects of “good doctoring” [3]. This list is clearly not exhaustive but it includes salient prevailing hidden curriculum skills and it was developed based on feedback from professionals working in respective fields. In other words, these are the skills in practice at the moment. Interestingly, these are not the skills you would like to prevail as hidden curriculum in medical, dental and nursing education. This brings me back to my initial question that we could only make a change once we know the nature and magnitude of existing problems. I went through in detail about each of these hidden curriculum aspects and the reasons behind these but here would only write my conclusion that hidden curriculum is not getting enough attention up and down the country in hospitals and universities due to lack of awareness among the teaching staff of importance of hidden curriculum. One could argue that hidden curriculum development is not incentivised as attractively as clinical curriculum and skills. Also, clinical curriculum progress can be assessed by assessment tools and there are lack of tools available to assess hidden curriculum progress. There is no better document to confirm this than the Dearing report of inquiry into higher education [14]. This brings me to my next question about finding the list of desired hidden curriculum skills. Although, this may sound very simple to find such a list but there was not one. I managed to find pieces on different medical websites to start preparing one for myself. [6,15,16] I now plan to apply Kolb’s cycle of reflective learning model to improve awareness and implementation of these hidden curriculum principles [17].

I noticed practices around me at my work place which could be improved. In our daily practice all the teams involved in management of patients in our ward discuss their respective aspects of patients’ management every morning. In addition to senior members of the team the meeting is also attended by students and trainees in their respective fields. We manage a variety of patients and these patients and their relatives have varied expectations. Some of these expectations are sometimes unrealistic and may sound even unreasonable. I have noticed that some members of the team use unacceptable phrases while discussing patients’ and their relatives’ behaviours or expectations. I reflected on the current practice and felt it needed to be reviewed. With the current practice the students and trainees attending these sessions are not only learning the clinical management bits of the discussion but are also learning the mannerism and vocabulary used while discussing these patients. I noticed that the trainees and students also use similar vocabulary when they participate in the discussion. I discussed it with senior members of the team and suggested to reflect individually on the way we had been running this meeting. All these senior members of the team also felt the need to change this practice as trainee doctors and students were learning the wrong things. We then changed our practice and discussed that with students and trainees as well. Now the meeting is run in a much better manner and whatever the expectations and views expressed by a patient or their relative we ensure that we show respect and dignity to those. Now three weeks after this intervention I can see the difference.

We had a formal meeting in department and agreed on using Kolbe’s model of reflective learning to implement our hidden curriculum principles. Once this first reflective learning cycle is completed I reflect again on my initial questions about hidden curriculum. I feel it’s a work in progress.