Family Medicine and the Hidden Curriculum

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Lessons from Medical Variety Night

Last November’s Medical Variety Night provided an impressive peek into the musical and comedic talents of our students.  Andrea Winthrop, Steve Archer and I were asked to serve as a “Judges Panel” to determine the best class skit.  We were all amazed at the poise and creativity on display.

The evening also provided a few lessons for both faculty and students as to how well intentioned humour and satire can appear quite different before a mixed audience not familiar with the contexts employed.  A number of conversations have ensued which I believe have been illuminating and instructive for both students and faculty.  As in the patient care context, “near misses” are opportunities to learn and avert more serious problems in the future, and I believe we have, as a school, availed ourselves of the opportunities this year’s production provided.

A theme that I and others in attendance found particularly troubling related to a number of references to Family Medicine as a less-than-appealing career option.  This perception is hard to fathom given that we a have superb and award winning faculty teaching Family Medicine.  Our Family Medicine training program is widely recognized as one of the best and most sought after programs in the country.  In addition, Family Medicine is, arguably, the most demanding of specialties.  In open and frank discussions with a number of students on this issue, a few underlying causes came to light which I found illuminating and felt would be useful to share with faculty.  They provide superb examples of the “Hidden Curriculum”, a term used to describe unintended influences that affect student learning, and are known to be very powerful shapers of student attitude and behavior.  So, in no particular order:

  1. Engaging Uncertainty.  Students find Family Physicians they encounter to more commonly express uncertainly in their ability to resolve patient presentations.  This is in contrast to other specialists who they find characteristically more definitive in their approach.  Family Physicians more commonly use statements like “we’ll have to look it up”, or “don’t be afraid to say you don’t know”.   With respect to other specialists, the expression “seldom wrong but never uncertain” comes to mind (my quote, not theirs).  Importantly, students do not see this difference as inappropriate or as reflecting any lack of competence, nor are they so naive as to believe other specialists always have the answer.  In fact, the students I met uniformly expressed admiration and respect for Family Physicians they encountered, and their ability to manage a diversity of patient populations and presentations.  However, it’s clear that our students are accustomed to success, and many are not yet comfortable facing uncertainty in their lives, or in their future practices.
  2. Technical/procedural expertise.  Many of our students are technically very savvy and excited by the prospect of being on the “leading edge” of innovation and application of emerging technologies and procedural approaches to various conditions.  Simply stated, they like the “toys” of modern medicine and they’re excited about applying evolving procedures.  They perceive that these exciting new approaches as the exclusive domain of sub-specialists.
  3. Prestige”.  Hospital in-patient services remain at the core of clinical training for our students.  Properly run and supervised, they are superb environments in which the learning of pre-clerkship can be applied to real patients, with appropriate overlays of scholarship, professionalism, advocacy, collaboration and all the intrinsic competencies we have adopted within our curriculum.  Although formal teaching remains valuable during these rotations, we all recognize that the major component of learning occurs through active participation as part of the team, and by observation of “real life medicine”.  With respect to Family Medicine, these rotations are problematic in two important ways.  Firstly, virtually no Family Physicians are involved or even visible during these rotations.  Secondly, and most disturbingly, they often see instances where primary care and primary care providers are disparaged.  A casual reference suggesting that a patient was inadequately cared for prior to admission, or a concern that appropriate care will not be continued after discharge can, in a stroke, undo all prior teaching.  These observations in the clinical setting trump teaching in the pre-clerkship.  Our actions, it would seem, speak more loudly than our words.
  4. Money.  I have become convinced that the single most powerful expression of Hidden Curriculum in our society is the OHIP Fee Schedule.  Students are very aware of the differential reimbursement of physician groups, and the high premium paid for procedural work relative to patient assessments.  This of course, results in two hugely damaging consequences, the equation of financial with professional “value” or “prestige”, and the enticing allure of higher income to students facing increasing debt loads by graduation.

So what can be done?  A few suggestions, humbly submitted for consideration:

  1. Awareness of these influences, and of the Hidden Curriculum in general.  Hopefully this article is a start.  I hope it will generate some discussion, particularly at department meetings.  Dr. Leslie Flynn is chairing a group of which I’m a member to study and address Hidden Curriculum issues, and I think this may provide some focus for those discussions.  This awareness must extend to physicians of all disciplines who teach and supervise our students, particularly in the practice setting.  Those who attend on these services are, in my experience, largely unaware of the serious impact of casual commentary, and almost never intend to disparage any other specialty.
  2. Within our curriculum, developing strategies to address the “uncertainty principle” in a more open fashion.  This is both an academic and student wellness issue.  Our students require means to cope with the uncertainty that will inevitably develop in their professional and personal lives.
  3. Serious consideration of the troubling question:  To what extent do our admission processes pre-determine career choice?  Medical school admission remains a highly competitive process (applicant to admission ratio 38:1 at our school), and is likely to become even more competitive in the near future.  This environment favours the goal oriented, determined self-starter who is able to engage this single goal with appropriate compromises and sacrifices along the way.  It can be argued that such “survivors” will be naturally attracted to practice environments that provide definitive resolution of problems, technical mastery and perceived prestige.  There is a recognition, even embedded in the Future of Medical Education in Canada initiative, that admission processes should favour resiliency, personal maturity and problem solving, qualities valuable to any physician and not necessarily reflected by academic success.  Our admissions committee has, in fact, been inoculating these considerations into their procedures for the past few years.  However, as for all schools, academic success remains a key component of the application process.  Perhaps it’s time to consider more radical approaches.
  4. Increasing Family Physician presence in the hospital.  Our students perceive that in-hospital care, and the acuity, complexity and technologic innovation that goes with it, is the exclusive domain of sub-specialists, and fail to appreciate the role of Family Physicians in the continuum of care.  They also get little exposure to the in-patient care provided by Family Physicians in smaller communities.  Our Integrated Clerkship and “Week in the Country” programs address this to some extent, but we need to develop and engage initiatives to integrate Family Physicians effectively into the care of our in-patients.
  5. Advice regarding financial planning and practice management.  Although we can’t influence the fee schedule, we can certainly provide our students with sound financial advice to lessen any economic drivers of career choice.

I would like to end this article by thanking the many students who were willing to speak to me candidly about this issue.  I welcome their further commentary and impressions of faculty.  Open discussion is always the first and perhaps most necessary step to improvement.

21 Responses to Family Medicine and the Hidden Curriculum

  1. karen schultz says:

    Hi Tony,
    Thank you for your thoughtful and constructive approach to this. Helping medical students find the area of medicine that best fits for them, which ultimately translates into more effective physicians and excellent health care for Canadians as they move back and forth across the health care continuum, is a goal for everyone involved in medical education I think (or hope anyway!). This involves all choices of medicine being perceived by our medical students as equally viable and attractive. Unfortunately I don’t think we are there yet, for the reasons you have outlined and perhaps a few more. Your solutions are a great start. I look forward to working on this.
    Karen Schultz
    Queen’s Family Medicine Program Director

  2. Joy Wee says:

    Hi Tony,

    Thanks for your words. You identified our longstanding tolerance of large discrepancies within the OHIP fee schedule as a contributing factor. Do we in medicine indeed value equality amongst different specialties? Such remunerative discrepancies may also indirectly impact available services for vulnerable people, despite the intended universality of our Canadian health care system. Ongoing examination of our admission processes to facilitate the mandate of the Canada Health Act is necessary and good stewardship.

    Joy Wee
    Queen’s Physical Medicine & Rehabilitation Undergraduate Director

    • Hello Joy. You rightfully point out the inherent inconsistency between what we teach and the reality of the “marketplace”. Although medical schools aren’t in a position to directly influence this, we can certainly ensure our students are fully informed before encountering inconsistent information as they undertake various placements.

  3. David LeBrun says:

    Thanks for your thoughtful comments Tony. Our undergraduate curriculum based on clinical presentations tends to channel students away from non-clinical specialties, including my own field of pathology. This is detrimental to our goal of presenting our students with a full range of career options and, ultimately, providing Canadians with optimal health care. This problem is tractable, however, and I stand ready to help find solutions.

    David

    • Thank you David. Our students absolutely need valid information regarding all the various career options available to them. I recognize the curriculum necessarily exposes them more directly to some career choices than others, and that problem is not limited to Family Medicine. Our Observership and Career Counseling programs endeavour to address this discrepancy, and we always welcome involvement of committed faculty like yourself. Peter O’Neill, our Career Counselor, and I would be happy to meet with you to discuss methods by which we might increase the awareness among our students of Pathology as a career option.

  4. Michael Flavin says:

    Hi Tony,
    Intriguing that the content of the performances at MVN triggered this erudite dialogue. The analysis is insightful and much good can come of the discussion. Of course MVN is performance art and not real life. Artists with integrity, regardless of the fact that they are medical students in their other life, should be allowed to speak and express, even when what they say or do is not to our liking. Let’s hope the students don’t feel muzzled for future MVNs. I’m sure there is no such intent.
    Michael.

    • Hello Michael,

      I agree with your sentiment. The challenge we faced with this particular issue was ensuring we understood the underlying message fully and were in a position to go forward in an informed manner. I think, in this instance, the artistic medium served it’s pupose quite well.

  5. Eve Purdy says:

    Great post Dr. Sanfillipo! It seems that this is one of the beauties of MVN, the “hidden curriculum” doesn’t stay so hidden. It is an opportunity for us as students to engage in meaningful and important discussions with faculty and mentors but also (and perhaps more importantly) with each other.

    It is not surprising that Queen’s does not face these questions alone. A recent BMC Medical Education systematic review article ( http://www.biomedcentral.com/1472-6920/12/81 ) addresses the fact that the number of medical students choosing family medicine as a career in OECD countries is on the decline. An exploration by the authors identifies seven key themes of medical students’ attitudes towards family medicine. They are very similar to the perceptions you have identified. The paper goes on to suggest possible ‘interventions’ (greater representation of family medicine in the curriculum, increased ratio of lecturers from family medicine, increased undergraduate clinical exposures to family medicine and more positive attitudes from specialists). A few interesting Canadian articles on the topic too (http://www.cfp.ca/content/49/9/1131.full.pdf and http://www.cfp.ca/content/58/11/e649.full )

    A shout out to the Family Medicine team, who give us our first taste of clinical learning in the first semester of medical school in an amazingly well organized and engaging course. The Family Medicine Interest Group also works hard to promote and expose preclerkship students to Family Medicine. It is well known that this group also has provides the best food….the effects of which I explored in a recent blog post (http://manuetcorde.wordpress.com/2013/02/03/the-importance-of-food-in-medical-school/)

    • Thanks Eve, for this thoughtful posting. I certainly agree that this particular concern and the Hidden Curriculum in general are issues that faculty and students need to engage together. Awareness, I’m convinced, is the beginning and perhaps most important step toward resolution. I’m finding that blogs and other social media are great ways to engage the conversation and I’m continually impressed at how much we can learn from each other, a point you illustrate nicely with your informative comment. Another interesting source would be the University of Calgary which, about 10 years ago, engaged a faculty wide initiative to address concerns about Family Medicine as a career choice. Their extensive review addresses many of the issues you raised and led to rather dramatic changes in their curricular organization and career choices of graduating students.

  6. Michael Sylvester says:

    Dear Tony,

    I am glad to have the opportunity to address the critical issue of a hidden curriculum that harms family medicine. But I agree with Dr. Flavin that MVN skits should be taken for what they are – lighthearted attempts at humour that sometimes fall rather awkwardly. I feel privileged to have taught a wonderfully engaged and intelligent class of 2016 that were very generous in their evaluations of our course in family medicine. That their leaders saw Dr. Wolfrom and I as suitably good-natured targets for a roast, I believe puts us in some fine company.

    There is something about Queen’s School of Medicine that has it ranking lowest in Canada for two years in a row in the percentage of graduates choosing family medicine (and below the national average for 15 of the last 16 years).
    There are schools in regions where family doctors take home less money – that generate more family doctors than we do.
    There are schools that have less family medicine content in their undergraduate curriculum – that generate more family doctors than we do.
    There are large urban medical schools that offer more concentrated tertiary care sub-specialty experiences and fewer rural opportunities – that generate more family doctors than we do.

    Although there are no proven solutions, there is support in the literature for change in admissions. In their thorough 2003 discussion paper on interventions to enhance recruitment and retention in family medicine, Drs Shortt, Green, and Keresztes included a proposal for selecting students who are older, female, from rural backgrounds, with lower income expectations and an orientation to people rather than technology.
    (Short SED, Green ME, Keresztes C: The decline of family practice as a career in Ontario: A discussion paper on interventions to enhance recruitment and retention. Centre of Health Services and Policy Research, Queen’s University; 2003.)

    More recently, Scott et al named 11 variables that predicted whether a student picked family medicine as their top residency choice. Among these were
    being older, having undertaken voluntary work in a developing nation, desire for varied scope of practice, a societal orientation, a lower interest in research, and a desire for short postgraduate training.
    (Scott I, Gowans M, Wright B, Brenneis F, Banner S, Boone J. Determinants of choosing a career in family medicine. CMAJ 2011;183(1):E1-8)
    It will be interesting to follow our graduates’ response to the recent changes in our admissions procedures, although I don’t know if any of these variables were specifically targeted.

    There are several medical schools in Canada that are actively pursuing a 50% match rate to family medicine as part of a socially responsible goal to maintain the efficiencies of Canada’s primary-care-based system. Inevitably, these schools have strategies that include tackling elements of their own hidden curricula by following suggestions such as the ones you propose.

    While we decide how to change our hidden curriculum, however, I believe that Queen’s School of Medicine has a more central duty: to decide whether or not it wants to graduate its share of Canadian family doctors. If not, why not?

    Michael

    • As usual, Mike, you challenge us to confront the elephant in the room. Do we really see this an issue we wish to engage? If so, what is our “share” of graduating family doctors? I think we need to look to you and your colleagues to lead this discussion. I also think your recent appointment to the Admissions Committee is likely to enliven those meetings.

  7. Tony: MVN was an impresive display of humor and talent…(not sure when doctors ebcame so talented-apparently some time after Meds 81). While I agree that the hidden curriculum was “on stage”, I have a different interprtation as to why it made it to the performance stage. There were several other skits, unrelated to Family Medicine, that where uncomfortable (mentioning foibles of specific individuals in a manner which was at best unkind). I believe both the Family Medicine skits and this ad hominem reflect issues relating to maturity and sensitivity. Having been on the MVN stage 100 years ago I remember that Meds 81 was also immature and not particularly sensitive to the impact of our words. I believe the feedback you have already provided the students and some prospective consultation prior to the next MVN (?establishing a faculty advisor for the show) about appropriateness could avoid these problems without requiring heavy handed censorship. This would not detract from rewriting the hidden curriculum…but likely would more directly address the issues of taste at MVN. Stephen Archer

    • Hello Steve, and thanks for this note. We are all, indeed, firmly entrenched in our own glass houses as we comment on the content of MVN. I also have vivid recollections of Meds 81 productions, and no further detail on that subject is required. Finding the delicate balance between unwarranted censorship and instructive commentary to well intentioned performers has been a challenge. I agree the conversations that have occurred have been beneficial and provided some practical steps to ensure that future events avoid potential pitfalls without stifling the artistic license which, paradoxically, was very helpful in providing insights into a sensitive topic that’s difficult to discuss openly.

  8. Lawrence Leung says:

    (re-sent with correction of typos, my apology)

    Dear Dr Sanfilippo,

    I am glad that you took the brunt in laying open this controversial topic. Family doctors, aka General Practitioners, have always been, and in fact, still are regarded as 2nd-tier doctors in many developed countries. Why? Because Family Doctors are never regarded as specialists both semantically and conceptually, and we do not have a subject to specialize. What we need to do to turn this detrimental attitude around is to let everybody knows that, the specialty of Family Medicine is NOT to specialize; our specialty is about broadness of scope instead of focused view of any other specialty. Gram for gram, there are many more topics for academic research in Family medicine than our specialists counterparts, as Family Medicine is broad and has no boundary. Here I draw an analogy from camera lens: Family Doctors are like wide angle lens that take in as much scope and view as possible and put everything under consideration; Specialists are like Macro lens that divulge the finest details of the object in focus. Now which lens is better then the others? In my camera bags, I have both, and I use them both. Fact is, my best wide angle lens (8mm ones) costs 3x more than my 105mm macro lens. In a nutshell, we need to revamp the generally mentally of our society to realise that a global wide-angle approach towards health will worth as much, if not more than a specialist’s scope. When I qualified from UK in 1989, 85% of graduates go into general practice (aka Family Medicine) training. I think the stats have not changed much. Here in North America, Family Doctors are still needed and should still be produced in high quality with genuine motivation towards the specialty. As a Physician, it’s not about the size of dough you take home at the end of the day, it’s the degree of connection and level of understanding of another human being that matters, and we family Doctors specialize in that.

    • Hello Lawrence,

      Agree the value and essential role of Family Medicine is well established, both to the profession and society in general. I believe the vast majority of practicing physicians and students share your views. Hearing them stated so emphatically reflects a commitment and passion that will certainly resonate with our learners.

  9. Andrew Geisheimer says:

    Hi Dr. Sanfilippo,

    Thank you for this thoughtful post. I’ve enjoyed reading it and the comments as well. You may remember that my wife did medical school at UBC and it’s been interesting to me to see how our respective curricula differ. I don’t think that UBC had a specific family medicine course but their students had one afternoon per week that they spent in a family doctor’s office through first and second year. 1-2 students would be paired with a preceptor for a term at a time. Furthermore, their clerkship officially started at the end of second year, when students would do a one month rural family medicine rotation as their first core clerkship rotation. I’m not sure what proportion of UBC’s graduating class went on to pursue family medicine.

    My feeling throughout medical school has been that some of the most rewarding aspects of family medicine are difficult to appreciate as a student, where you only spend a relatively short time with a family doctor. For example, it is difficult to appreciate the benefit of either continuity of care or improvement of chronic health conditions when you’re only with a family physician for an evening in after-hours clinic or even for a week during a week in the country. Having the ability to work with the same patient group for a longer period of time might help with this.

    As a student, I also find the broad scope of family medicine quite daunting. On electives I’ve found that my knowledge and proficiency in specialized, acute care areas such as anesthesia can grow over 2-3 weeks, but I’ve noticed that the opposite is true in primary care areas such as emergency medicine. Perhaps this phenomenon alludes to the uncertainty you describe and admissions criteria that Dr. Sylvester discussed. I have noticed that, as a learner, uncertainty within a specialty area feels much more acceptable than uncertainty in primary care, although I’m not sure if that’s a universal experience or not.

    • Hello Andrew, and thanks for the “insider” perspective. As students, you and your wife are ideally positioned to provide commentary as to effectiveness of medical curricula. I think every Canadian school recognizes the importance of providing relevant exposure to Family Medicine, and are increasingly recognizing the value of providing that exposure early. They all go about it differently, based on their particular educational approaches and available teaching resources. At Queen’s, as you know, we have introduced a number of new curricular offerings over the past few years, including the first term Family Medicine course which Dr. Sylvester very capably directs, the First Patient Program, after hours Family Medicine clinic rotations, and Observership opportunities. Recognizing the point you raise regarding continuity, I’ve been very pleased with the development of the Integrated Community Clerkship directed by Dr. VanWylick and supported by Drs. Renee Fitzpatrick and Brent Wolfram, which is entering it’s third year and provides, I believe, an excellent and comprehensive 18 week community based exposure anchored to Family Physicians and health teams that is valuable to all students regardless of their ultimate career direction. The “uncertainty” issue you raise is intriguing and responses to the last blog and this one would suggest it’s a subject of considerable interest among both students and faculty. I believe it merits further thought and could be the subject of a properly structured investigation.

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