#125 Hidden Curriculum

November 15, 2018 | By Justin Berk

Check out this audio treasure map to find the hidden curriculum and learn how it can change your practice. Learn how positive teaching spans not just the classroom or bedside but, how we simply talk about patients. Sanjay Desai MD, coauthor of ACP’s Position Paper on Hidden Curriculum and Internal Medicine program director at Johns Hopkins guides us through several cases that illustrate how our institutional norms can shape the practice of medicine…for better or worse. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST).

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Credits

Written and produced by: Sanjay Desai MD; Justin Berk MD, MPH, MBA; Matthew Watto MD

CME questions by: Justin Berk MD

Editors: Chris Chiu MD & Matthew Watto MD

Hosts: Justin Berk MD, MPH, MBA; Matthew Watto MD; Paul Williams MD

Guest: Sanjay Desai MD

Hidden Curriculum Position Paper

Lehmann LS, Sulmasy LS, Desai S, for the ACP Ethics, Professionalism and Human Rights Committee (2018). “Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician: A Position Paper of the American College of Physicians.” Ann Intern Med.

Hidden Curriculum Pearls

1. A “hidden curriculum” exists in how providers interact and refer to patients. This includes both “good”  and “bad” role modeling. Many of the negative behaviors stem from stress. We all play a role whether in private practice or supervising trainees. 
2. The environment in which we practice should include respect, inquiry, and honesty. Everyone should feel academically safe.
3. The leaders of these environments must establish a strong culture to think, discuss, and display positive behaviors.
4. Just as systems can create stress, systems can support humanistic experiences in medicine while still adhering to duty hour restrictions.
5. Memories of meaningful interactions will remain with learners for a long time. This demonstrates the power of hidden curriculum.

Hidden Curriculum – Show Notes

Sanjay’s Book Recommendation

Drive by Daniel Pink “It gives the science behind motivation… Three keys that provide intrinsic motivation: Autonomy, Purpose, and Mastery.”

Sanjay’s pearls of advice

As a learner: Be open and vulnerable to create a positive learning environment.

As a teacher: Create a safe space to support that environment.

Three major takeaways from the article

1. There is a hidden curriculum. It can be good or bad. We all play a role.
2. The environment in which we practice should include respect, inquiry, and honesty. Everyone should feel academically safe.
3. The leaders of these environments must establish a strong culture to think, discuss, and display positive behaviors.  

What is the hidden curriculum?

Formal curriculum – objectives, lectures, and standard classroom learning

Informal curriculum – teachable moments e.g. bedside rounds

Hidden curriculum – Behaviors and actions based on societal norms. The hidden curriculum can be good or bad and represents an opportunity to role model good behaviors.

Case #1

“The Labeled Patient” – A patient with cellulitis and psychiatric co-morbidities

Labelling patients (e.g. “crazy”) can send an unintended message about value to our patients and our colleagues.   

• Terms like “crazy,” “sicklers,” or “shooter with fever” convey values that are not truly meant to be conveyed.
• The terms sends a (hidden) message about physicians. Common pejoratives terms (e.g. “gomer”) are frequently mentioned in House of God.

A resident’s frustration can serve as negative role-modeling. It sends a hidden curriculum message to learners that medicine is NOT enjoyable. Unfortunately, learners may see their role model/leader as NOT empathetic, and conclude that it’s acceptable.

Residents are busy and admissions mean more work. To say “just be better” is naive and ignores what it’s like to be a trainee.

• The resident is not “bad” for using these terms, but faces systemic issues that can lead to burnout and lack of empathy.
• The resident feeling so frustrated by this patient is a sign something is wrong.
• Negative feelings should be normalized, expressed, and addressed. These symptoms (e.g. frustration, helplessness) are normal to feel and must be addressed to help resist “burnout.”
• Instead of scolding the patient, someone should ask, “Are you ok?”

Case #2

The “iPatient” – A patient diagnosed with pulmonary embolism becomes acutely short of breath.  

Walking by (instead of into) a patient’s room conveys that the first encounter and most important encounter is electronic.  

• The message is conveyed to learners, nurses, colleagues, and the patient. It suggests being at the patient’s bedside is less important than electronic data.
• It sends the message that the patient is not at the center of team decision-making.

The “iPatient” term focuses on the inappropriate interfacing with EMR over the patient.  Coined by Abraham Verghese in “Culture Shock — Patient as Icon, Icon as Patient” (NEJM 2008)

Case #3

“Paul the Precious Duckling” – Correcting the Attending or Not Washing Your Hands?

There is power in hierarchy and senior role modeling has enormous influence.

Hierarchy can create an unsafe learning environment if the student does not feel able to speak out. This sends message to learners that patient safety is deprioritized and secondary to hierarchy.

Case #4

“The Role Model PCP” – Addressing End of Life Care and Modeling Positive Behavior

The memories of meaningful interactions will remain with learners. This demonstrates the power of hidden curriculum.

• Simply by showing up, a positive role model can demonstrate the privilege to care for a patient longitudinally, what it means to gain the trust of the patient & family, and models a dedication to medicine.

Case #5

“The Missed Family Meeting” – Reconciling Duty Hours and Humanistic Experiences in Medicine

Duty hours and learning prioritization are not mutually exclusive.

• A clinical learning environment/structure that does not enable duty hour adherence suggests this is not a real priority.
• Duty hours must be a priority across the institution.
• When leaders provide disparaging judgement in decisions related to duty hours, it suggests that duty hours do not matter.

How can one reconcile these competing interests?

• An environment should create space that allows participants to engage/enjoy in humanistic moments while still adhering to duty hours.
• There will always be conflict (with duty hours) because medicine is unpredictable, but meaningful experiences can be prioritized if we are able to create routine structures where people don’t have to worry about duty hours.

iCompare

In the iCompare study, burnout was high in both arms regardless of duty hour flexibility. We must find a way to promote and create restorative moments that represent the reason learners entered the field of medicine in the first place. (cf. The related editorial on “the most precious resource in medicine”).

Take home message

Be aware of the hidden curriculum and how much influence everyone has at all levels of the medical hierarchy. We constantly send messages about norms. Being mindful of these messages will create a positive learning environment.

Goals and Learning Objectives

Goals

Listeners will consider the ethical and professional values transmitted in the hidden curriculum.

Learning objectives

After listening to this episode listeners will…

1. Recognize that the hidden curriculum exists
2. Be cognizant of how ethical and professional values are transmitted in medical education
3. Avoid role modeling negative values and behaviors
4. Recognize opportunities to model positive ethical and professional values and attitudes

Time Stamps

00:00 Disclaimer, Intro and guest bio

04:00 Guest one liner, book recommendations, career advice

10:50 Intro to the hidden curriculum and ACP’s three recommendations

22:00 Case #1: A patient with schizophrenia

32:10 Case #2: The iPatient

38:07 Case #3: Attending forgets to wash their hands

41:10 Case #4: A dying patient’s primary care doctor saves the day

46:26 Case #5: A case of violating duty hours

60:10 Take home points

62:00 Outro

Links from the show

Drive (book) by Daniel Pink

House of God (book) by Samuel Shem

“Culture Shock — Patient as Icon, Icon as Patient” – first use of “iPatient” term

iCompare study on duty hour flexibility

Citation for Guest CV

Desai, Sanjay. Guest expert. “#125 Hidden Curriculum”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com. November 15, 2018. http://thecurbsiders.libsyn.com/125-hidden-curriculum