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).
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
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 – Show Notes
Drive by Daniel Pink “It gives the science behind motivation… Three keys that provide intrinsic motivation: Autonomy, Purpose, and Mastery.”
As a learner: Be open and vulnerable to create a positive learning environment.
As a teacher: Create a safe space to support that environment.
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.
Labelling patients (e.g. “crazy”) can send an unintended message about value to our patients and our colleagues.
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.
Walking by (instead of into) a patient’s room conveys that the first encounter and most important encounter is electronic.
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)
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.
The memories of meaningful interactions will remain with learners. This demonstrates the power of hidden curriculum.
Duty hours and learning prioritization are not mutually exclusive.
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”).
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.
Listeners will consider the ethical and professional values transmitted in the hidden curriculum.
After listening to this episode listeners will…
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
“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
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