One word that gets batted around in the world of deans and medical school administrators is “the hidden curriculum.” I always found it difficult to glean the exact meaning of the term. It seemed to represent all the qualities that medical schools don’t want to teach to medical students, but end up either modeling or instilling into their students. I am often skeptical of buzz words, but I think the key premise of the hidden curriculum holds valence as we try to train physicians in humanism, amidst the context of an ever more complex system of health care. More straighforwardly stated: we need to ensure doctors are trained in compassion and empathy, even though the number of other domains in which we are requiring mastery is growing exponentially. It becomes a matter of training medical students in compassion and ethics, which is far easier said than done.
Let me give you a concrete example of how powerful the hidden curriculum can be on our medical system. I recently learned of a case where an attending physician was telling a mother to her face that she was incapable of caring for her child, and that the mother should be evaluated by child protective services, the agency responsible for removing children from parents not capable of caring for their children. The child had a flare of a chronic medical disease, and the physician felt that it was neglect to have waited so long to bring the child in to the hospital. A medical student who had been following the family continuously believed instead that the mother was a doting and loving mother, and that it was economic hardship and lack of knowledge that prevented the mother from making the 4 hour drive to bring her child to the hospital earlier.
This is a difficult situation, and an important question is, if you were the medical student what would you do? Would you speak up against the attending physician? How would you do so? This question directly addresses the issue of the “hidden curriculum.” As I was beginning medical school, my answer to that question would be that I would absolutely speak up. I don’t care what official title someone holds; to tell someone that she is essentially a bad mother, when all she has done is try her best to care for and love her child, is horrible. But as I’ve progressed in my medical training, my decision making process around answering this question has become more complicated.
For instance, what if the physician knew something else about the patient’s story that I did not? What if the physician recognized key signs of abuse that I had not recognized? What if this was the fifteenth time this physician saw the mother not bring her child to the doctor soon enough? Thus, lack of certainty becomes a factor in my decision of whether to speak up. For many students, the fact that the physician is also evaluating the student may enter the decision making process, though it did not affect mine. There is also a culture of hierarchy in medicine, and as a low peg on the totem pole, a medical student speaking up contrary to a senior team member could cause problems, in some instances even affecting patient care. As you can see, whether a student speaks up in this circumstance depends on a complex web of factors: authority, power, knowledge, empathy, and courage.
These points underscore how our beliefs become more complex over our medical training (I hate how politicians say their beliefs “evolve” over time so I won’t use that word). Decisions like these of whether to speak up are not decisions isolated to medical students. Rather they are qualities learned during training that we carry with us for the rest of our careers, and these qualities permeate the whole medical system. Here at Stanford, our dean has encouraged us to speak up when we see an injustice. The problem is, it’s always more complicated than black and white. I think the first step in fighting the creep of the “hidden curriculum” is to address it head on, which is happening. We need to talk more about these issues to bring them out of the shadows and into the light, in medical education and in the hospital. We also need to encourage teams and systems centered around the care of the patient, not structured around the hierarchy of professional seniority. The good news: I think it’s happening. More to come, and your thoughts/stories welcome.