Hidden Curriculum | School of Medicine

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.

Watch the Hidden Curriculum presentation, narrated by PGME Associate Dean Dr. Karen (Pinky) Schultz

Introduction

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. When negative these messages can undermine medical education and patient care.

Through the research conducted in the School of Medicine at Queen’s University, it became evident that there is a negative hidden curriculum, 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 it’s impacts, 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 where medical learners and faculty are celebrated, made to feel truly welcome, are treated equitably and provided with the best possible environment for teaching, learning and patient care is the goal

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.

Survey Results

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.

Impacts

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.

Possible Causes

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.

Existing Culture

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.

Human Nature

Many respondents identified that it is human nature to want to be part of a group (“we are a tribal species”). Indeed, there is value in being in a group but why this devolves into an‘us vs. them’ or hierarchical structures with a better and a lesser will be important to understand.

Systemic Issues

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.

Intersectionality

Some respondents felt that where areas of medicine were predominantly provided by female physicians those areas of medicine were less respected.

Recommendations, Actions, and Planned Actions

The following recommendations were made by the working group:

If you are interested in hearing more about this work and/or want to become involved with this work please contact us at pgme@queensu.ca.

Contributing Members

Steering Committee

Dr. Michael Green (Family Medicine)
Dr. Tony Sanfilippo (Cardiology)
Dr. Ross Walker (Surgery)

Implementation Team

Medical School:

Dr. Cherie Jones-Hiscock (Psychiatry)
Dr. Shayna Watson (Family Medicine)

Postgraduate Medical Education:

Dr. Karen Schultz (Family Medicine)
Dr. Laura MacMillan-Jones (Family Medicine)

Faculty:

Dr. John Drover (Surgery, Critical Care Medicine)
Dr. Mala Joneja (Rheumatology)

Hospitals:

Mr. Christopher Gillies (Chief of Medical and Academic Affairs, KHSC)
Ms. Allison Philpot (Executive Director, Medical Affairs, Patient Flow & Research, PCH)

Working Group

Co-Chairs:

Dr. Karen Schultz (Family Medicine)
Dr. Cherie Jones-Hiscock (Psychiatry)

Members:

Dr. Glenn Brown (Family Medicine)
Dr. John Drover (Surgery, Critical Care Medicine)
Dr. Renee Fitzpatrick (Psychiatry)
Mr. Christopher Gillies (Kingston Health Sciences Centre)
Dr. Mala Joneja (Rheumatology)
Dr. Laura MacMillan-Jones (Resident, Family Medicine, and Graduate, Queen’s Medicine)
Ms. Katrina Sajewycz (Queen’s medical student)
Ms. Ramita Verma (Queen’s medical student)
Dr. Shayna Watson (Family Medicine)

New: Living our Values Award & Nomination Form

This award recognizes a resident and a faculty member who embodies and creates, through their words and actions, a positive, respectful, and inclusive learning and working environment. The award will be presented annually at the Postgraduate Convocation ceremony and will consist of a certificate and the addition of the winners’ names to the Living our Values plaque.

Resident and Faculty nominations will be sought from medical students, residents, and/or colleagues from other health professions. Nomination forms are available on the PGME Awards website, through a link on the Hidden Curriculum website, and through an annual request sent by email. The nomination form will ask for a description (250 word limit) of how the person exhibited respectful behaviour, inclusivity, and/or notable collaboration, and how this impacted learners, the learning environment, and/or the clinical environment.

Selections will be made by the School of Medicine Hidden Curriculum Implementation Group based on nominations received. The awards will be granted based on the compelling nature of the nomination and not on the number of nominations received.

The deadline for nominations is April 15.

Nomination Form

Have you been impacted by the hidden curriculum? Confidentially share your experiences, positive or negative, by clicking here