The hidden curriculum is the implicit messages, intended, unintended, positive or negative, about values, norms, and attitudes that are inferred from people's and institutions' actions and inactions.
These actions or inactions are undermining our institutional values of respect, diversity, and inclusivity.
In 2019, a Working Group was established to explore the hidden curriculum as it relates to the professional interactions between medical learners and/or faculty in the School of Medicine at Queen’s University.
For those who are unfamiliar with the term, the ‘hidden curriculum’ refers to the implicit messages, intended and unintended, both positive and negative, about values, norms, and attitudes that are inferred from people’s and institutions’ actions and inactions. These messages, usually about values, norms, and attitudes, when negative can undermine medical education and patient care.
Through the research conducted, it became evident that there is a negative hidden curriculum in the School of Medicine at Queen’s University, and that it impacts medical students, residents, and faculty at all stages of their careers across many fields of medicine. The Working Group examined that hidden curriculum and its roots, the experiences of learners and faculty in relation to it, and made a series of recommendations to address its negative elements.
By taking steps to identify the challenges faced and by proposing achievable solutions, the Working Group hopes to bring about a change in the culture of the School of Medicine. An institution must be created where medical learners and faculty are celebrated, made to feel truly welcome, and are provided with the best possible environment for teaching, learning and patient care. This report is a first step in that process.
An underpinning and noteworthy assumption in this work is that most physicians and learners at Queen’s are well-intentioned and collegial; that education and possible remediation for those engaged in unintended negative hidden curriculum behaviours will positively change their behaviours and beliefs. The Working Group is also grateful to the medical students, residents, and faculty who shared their experiences so freely.
In total, the working group received survey feedback from almost 500 people, evenly split between medical students, residents, and faculty. Their responses clearly demonstrated the existence of a hidden curriculum in the School of Medicine at Queen’s University. While the respondents reported having experienced more positive aspects of the hidden curriculum than negative ones, those negative experiences seemed particularly impactful. The narrative comments from the survey accompanying these results were consistent with this observation.
A large percentage of respondents also reported having witnessed or experienced negative hidden curriculum directed either towards their field, or fields of medicine other than their own. It’s worth noting that these negative experiences were directed towards many disciplines including Family Medicine, Emergency Medicine, Obstetrics and Gynaecology, Pathology, Pediatrics, Psychiatry, Radiology, and Surgery. In areas of medicine with different specialities (e.g. Medicine and Surgery), there was a hierarchy between the different specialities within that one area of medicine.
The survey showed that the Hidden Curriculum, both positive and negative, was experienced in different degrees in a variety of settings including teaching settings, clinical settings, and informal surroundings. In some teaching settings, respondents were more likely to hear positive comments about certain fields of medicine. However, in clinical settings, particularly the ward and emergency department, and in informal surroundings, negative attitudes towards specific fields of medicine were more predominant.
The survey also showed that in general, residents were significantly more likely to experience negative aspects of the Hidden Curriculum than medical students and faculty, especially when the resident was off-service.
Of note was that essentially all respondents viewed themselves as professional, courteous, and collegial. Despite this, negative aspects of the Hidden Curriculum remain embedded in the School of Medicine, often because of the actions and impact of role models.
While there are many examples of the positive Hidden Curriculum at Queen’s, it is the negative experiences that can have the most impact on our learners and faculty, and those effects are widespread and felt by everyone including medical students, residents, faculty members.
The Hidden Curriculum negatively impacts education, career choice and satisfaction, opportunities, morale and patient care. It is felt to have a perpetual, generational cycle.
A substantial number of respondents reported that they are negatively impacted by the negative Hidden Curriculum, with this significantly disproportionately affecting some (medical students, women, and those in Family Medicine) more than others.
Almost a third of medical student respondents had contemplated either changing or concealing their desired field of medicine. These feelings were shared by 11% of residents who, although already committed to a field of medicine, had thought about changing their field due to the negative Hidden Curriculum.
This contemplation of a career change is strongly positively correlated with feelings of being denied opportunities, being treated unfairly, and being given less desirable clinical tasks when in the learning environment. The comments also illustrated the extent to which engagement and motivation suffers when learners experience the negative Hidden Curriculum. They feel as though they are in distress and their emotional well-being is impacted.
Ultimately there is a risk to patient care, a predictable outcome when learning is compromised, people do not feel pride in their career choices, and there is poor morale on health teams.
When reviewing the survey responses, especially to questions featuring open-ended comments, the analysis revealed four overarching themes into which the facilitators that perpetuated the Hidden Curriculum could be grouped: existing culture, human nature, systemic issues, and intersectionality
There was a belief among respondents that the Hidden Curriculum continues to be perpetuated due to a perceived bias towards certain specialties, and that bias was sometimes propagated by society. Role modelling of negative attitudes was also identified as a primary cause, especially during the clerkship phase. Medical students perceived faculty instructors as modelling negative behaviours through the language they used to describe certain specialties.
The visible disparities that already exist, such as resource allocation (or visible leadership positions, were identified as causes of the Hidden Curriculum, as was a lack of accountability. It was believed that repeated unprofessional behaviour was not being addressed.
There is sometimes an ‘us vs. them’ attitude and the camaraderie that should exist between physicians is absent. The need for hierarchy can also play a role in the development of a Hidden Curriculum.
A significant number of respondents believed that people were simply overworked. When those same people are asked to do more, or cannot get the help they’ve requested, the frustration can spill over into disrespectful behaviour. In addition, when physicians perceive there to be poor patient care, they can become easily frustrated with those who provided that perceived poor care.
Other systemic issues included pay inequity across the fields of medicine. Greater value continues to be placed on specialities with higher salaries, suggesting that one speciality is worth more than another. Respondents also believed that existing silos created a lack of understanding about other specialty areas, and a lack of personal relationships with those in other departments. Participants suggested that people direct more negative remarks towards specialties that are less understood by them.
The Hidden Curriculum effects everyone, regardless of age, stage of training, or field of medicine. The reality, however, is that some people are impacted more than others because of intersectionality. In most cases, those most impacted are younger, female, and are pursuing generalist medicine.
Awareness, Communication, and Training
1. Celebrate the work already undertaken to address the “Hidden Curriculum”.
We should celebrate the current commitment of the Faculty of Health Sciences (FHS) and KHSC, and ensure that the results of this survey should be made widely available.
2. Create a communication plan to disseminate the findings of this report to all stakeholders, and create an awareness campaign of mutual respect and no tolerance of disrespect.
Everyone needs to be made aware of the Hidden Curriculum and the negative impact it has on the profession and patient care. Establishing this awareness must include initiatives that help key stakeholders appreciate the need to be part of an EDIIA collaboration to create cultural change that has a positive focus and outcome.
3. Orientation, learning module resources, and faculty development workshops.
All members of the learning environment need to be educated when enrolled or hired, and required to participate in continuing education to regularly reinforce the message that the negative Hidden Curriculum is problematic and unacceptable.
4. Require all leaders in or associated with the learning environment to undergo specific education or training about the Hidden Curriculum and develop skills that allow them to lead by example and role model professionalism.
Leaders who appreciate the outcomes associated with positive and negative impacts of the Hidden Curriculum will be better equipped to change the culture that presently perpetuates it. Those leaders will also be able to create opportunities for collaboration in the working environments of those that they lead.
5. Intentionally create opportunities for all specialties and clinical departments to educate one another about the work they do and to experience firsthand the valuable contributions that each one makes to patient care and to the success of the interprofessional team.
There are many silos and a lack of understanding of specialties or sub-specialties outside of one’s own. These barriers will need to be dismantled if a positive Hidden Curriculum is to prevail. This could be undertaken, for example, through joint and collective case conferences, and grand rounds that include multiple departments.
6. Create opportunities for the Hidden Curriculum and its impacts to be included in the FHS EDIIA action table outcomes.
There should be a liaison between the Working Group and the committee overseeing the Dean’s Action Tables.
7. Address specific Hidden Curriculum-related incidents of unprofessionalism in the learning environment.
Members must be taught how to correctly identify and effectively deal with unprofessional behaviors related to the Hidden Curriculum, and a psychologically safe process for members is needed to report unprofessional behaviors. A clear and transparent process is also needed to manage those individuals who continue to demonstrate those unprofessional behaviours.
8. Review the UGME curriculum
Content and practices that perpetuate the negative Hidden Curriculum around specialty choice must be identified and eradicated, while learning modules must be identified for review. New learning experiences must be incorporated that accurately represent and celebrate the contributions of different fields of medicine, and students must receive balanced information about the different career choices available to them.
Responsibility and Accountability
9. Create educational messaging for all members of the learning environment.
Everyone must know that they are responsible and will be held accountable for their personal conduct, and they are expected to commit to addressing negative hidden curriculum when they encounter it.
10. Develop and implement a safe and effective reporting mechanism to gather, interpret, respond to and track data. Outcome data should be published yearly and included in member and departmental accountability frameworks.
Queen’s must develop a robust assessment and evaluation system, including reliable metrics to effectively measure, demonstrate and support any type of change is important. Mechanisms that assess how well members are adhering to their professional responsibilities and the effectiveness of the associated accountability framework will be critical in creating an EDIIA environment.
11. Incorporate the definition of the Hidden Curriculum and outline expected behaviors into all current, relevant institutional policies.
These policies may include the Code of Conduct and Intimidation & Harassment policies. Relevant policies should be identified and amended.
12. Publicly commit to implementing clear remediation and discipline processes for those members who are not adhering to the policies/code of conduct, etc.
Remediation exercises must be designed with to help members understand the impact and importance of the Hidden Curriculum and motivate them to engage in the necessary behavioral change. Provisions for additional consequences and commitment to follow through on those, especially for repeated patterns of behavior, must be available.
Wellness and Resilience
13. Continue addressing wellness and resilience.
Many faculty and staff are facing burnout, exhaustion and overwork with limited resources, which causes them to say things, react or do things they normally wouldn’t do. Wellness and resilience must be a priority focus.
14. Queen’s University and the Faculty of Health Sciences must visibly address EDIIA
We must promote respectful, supportive learning and clinical care environments, while promoting and documenting role modeling for how a cultural shift can happen. This will require attention to process and sound qualitative research principles, and should be started at the beginning of these endeavors.
15. Addressing the real issues of pay inequity and its link to the perceived value of the specialty.
This has been a long-standing issue and is one of the things that perpetuates the Hidden Curriculum. While ultimately a Provincial domain, the FHS should be advocating, lobbying and/or taking a stand on equity and compensation/relativity. There has been a historic increase in emphasis on acute and/or procedural care, not chronic, often time-based community preventative care and gender gaps. This could include a reflection/policy statement on pay equity for leaders to take forward to the OMA, SEAMO, and the Ministry of Health.