S8E13: The Hidden Curriculum in Medical Training

Lilly: I had a Tamagotchi I got from White Elephant, and it lasted seven days before it died.

Laurel: I mean, I haven't played with a Tamagotchi since I was a young child, and I think I killed them pretty much on the daily. So seven days sounds pretty good.

Lilly: Yeah, I thought so too.

Hạ: They're needy. Tamagotchis are needy.

Laurel: They're so needy. I do think it's funny that we're talking about the neediness of Tamagotchi as people who are to some extent either currently or to be responsible for human beings. But I appreciate you all joining me, Lilly and Hạ, to talk about hidden curriculum.

And I want to start by just saying that everything we say is obviously going to be of our own perspectives and does not reflect our employers and current med school and so forth. And that the things we're going to talk about, I think, reflect broader trends and challenges of med school curriculum and residency curriculum overall, as opposed to any particular institution, because I don't think it's an institution-specific problem.

I mean, hidden curriculum is something where it's, I think, a factor pretty much anywhere there's learning, right? Because the whole idea of it is you have what you learn on paper in the books, and then you have what you learn off paper, not written down. And so I would guess that any professional program has that, right?

I've been thinking about the ways that hidden curriculum as a concept is kind of unique in the context of medical training. But I think the fact that there's such a mixture of both what you're meant to know but also what you're meant to do, there's almost this twofold aspect. It's not just the facts you learn in your head, but also how you speak to patients and other healthcare workers and so forth.

Lilly: I think this is a really interesting topic to talk about because it comes up, I think, in medical schools throughout the country and probably in other countries as well, where we talk about this hidden curriculum that you're supposed to learn about. Sometimes we have a lecture on it, sometimes we don't. And it's kind of this enigma that you'll find out when you find out as you're working in the hospital what it looks like.

And for me, I think a lot about role modeling when it comes to the hidden curriculum. So you'll meet your attending, you'll meet your team, you all discuss expectations, goals for the week, things like that. And across the board, people always say, "We want to treat one another with respect, and we want to treat our patients with respect, and we want to have empathy for them."

But then throughout the time on any kind of rotation that you're on, and regardless of who you're kind of working with, you might see this in the dynamics of the team. You might see this in the interdisciplinary groups. You might see this between auxiliary staff, whatever it might be. But there are small things that you pick up on. For example, we want to be respectful of our patients. We want to be mindful of our colleagues.

But then on rotations, especially as a med student when you're kind of observing everyone around you a lot of times and not really giving as much input . . . At least I didn't because I just was scared to say anything, I guess. Even though no one necessarily intimidated me, but everyone seems scary when you're a medical student and you just kind of listen to these interactions.

You tend to pick up on the more passive-aggressive remarks or the odd comments here and there, assumptions about patients, about staff, about other specialties. It's these kind of nitpicking comments or negative attitudes or perspectives from people who may or may not be burnt out by a system and have less tolerance for things that don't necessarily embody the initial goals or expectations that are set out by the team.

And so a lot of times I notice those things, and then I also pay more attention to attendings and others who implement that kind of role-modeling perspective where they call things out and call us in to make sure that we're being mindful of that throughout the service we're on.

Hạ: I feel that you raise a really interesting point, Lilly, because a lot of times, a lot of ways that people phrase the hidden curriculum, it's also like they think more about these tangibles, like the flow of understanding how you're supposed to act within the hierarchy, or this understanding of also what language to use and how to present yourself based on what role you play.

But a lot of times, I feel that conversations, when people think about hidden curriculum, they often forget about how hidden curriculum can lead to biases, which, as you described so wonderfully, Lilly, that can also affect the ways that you interact with other staff members, the ways that you interact with your patients, or even how certain types of patients will then get stereotyped into a certain category, thus leading to people not being as open or really thoughtful with their patient care.

I think about it a lot, because it's so hard as someone who's gone from med school and now nearing the end of residency and having gone through all the different spectrums, I still remember as a third-year med student just seeing the ways that people reacted to things or processed things. It shocked me so much. And I would often go, "It feels so callous."

And then as you go through the more medical training system, you start realizing . . . For me, I've had so many different moments where I'm like, "Oh, these things that as a third-year med student I would cry, or I would be like, 'Oh, this is so serious, and this is so hard.'" Now I see so much that it just becomes kind of the norm.

Unintentionally, if you just treat it like the norm and not realize that for other people outside of you and other learners experiencing things for the first time it's not the norm, it can cultivate a culture in medicine that doesn't make it feel as open to process, doesn't make it feel as open to reflect and to actually recognize how hard the medical system is.

Laurel: Yeah, I think that makes a lot of sense, and it tracks with something I've been reading about when I've been looking through articles on hidden curriculum. There's the challenge of "because it's not written down, it's not explicit, and it's that much more difficult to challenge or to redirect."

And so it's something where I think there are a lot of individual moments that are potentially in isolation . . . I don't want to say necessarily understandable because it depends, but again, someone maybe not reacting with the level of emotions you might expect, right? And then that builds up and potentially becomes a systematic thing where people don't engage patients with the empathy maybe that would be desired.

And because what we're saying is one thing of treat all patients with respect, and then what is being taught and what is being learned is something else, I think it's probably difficult to find the disconnects where they exist.

I am curious, as we talk so often about hidden curriculum and the biases that it can bring forth, if y'all could think of cases in which hidden curriculum is useful or productive.

That's something I was trying to figure out in my own experiences. Granted, I think in most cases it's sort of, again, either the biases or the coping strategies that we learn. And at least from my own experience, I wasn't sure of positive examples. But both of you have had a lot more medical training and life experience than me.

Lilly: I don't know about life experience, but I will say one thing that I think about is the hierarchy and authority perspective of the hidden curriculum. Especially more in surgical specialties, there's this kind of understanding that those who cut make the decisions. And when the attending is speaking in the room or in the OR, and I guess this is also in non-surgical specialties, you shouldn't interrupt. You shouldn't question them. You can't disrupt that hierarchical status in the hospital.

Which I think can be really tricky because although others in training and in their careers have more experience and clinical knowledge and other things to their resume, I don't necessarily think that that means they always make the right decisions.

And ultimately, they're the ones who do take the bulk of the responsibility in making these decisions for patients and if there are negative or positive outcomes from them.

As a medical student, I absolutely never really questioned my attending's decisions. I always was like, "Yeah, that makes sense. They have the experience. They understand this very complex patient with a huge differential."

But as a resident, especially a resident who's been in two different specialties now, I think we have a little bit more experience. We're a little bit closer to our medical school training and the things that we learn on our rotations and taking multiple full-day-long exams and things like that to still have good input and knowledge.

And also, I think that we have more exposures to our patients. So we have more information about their background and their history and what brought them in and things like that.

And so one way that I've tried to kind of nudge the needle a little bit in that perspective is if I really don't understand why an attending is making the decision that they are . . . And sometimes our interdisciplinary team may not question those decisions. They're kind of like, "Whatever. The attending really wants to do that. That's fine." But if it's my patient that I'm taking care of and it doesn't sit well with me, I've really tried hard to . . . and I'm still working on this, to try and just question it a little bit more.

I remember one of the feedbacks I got during my first year of residency was, "You need to ask why more." Like, why is a consulting service asking that of us? Or why is that their decision? Why do they have that recommendation?

I would kind of just trust them. I was like, "Well, they're the specialist. They know more than I do." And so I've been working really hard to do that, which I think is a hard habit to break as a previous med student.

And I just say, for my understanding or for my education, and coming from that perspective when you ask the question, it makes it sound a little less interrogative or territorial. So I always say, "Just for my learning or for my understanding, why do you want to do this?" or, "What cases have you seen?" or, "Why wouldn't this option work as well?"

Sometimes I get to the point where I'm like, "I'm really uncomfortable with this plan. Can I talk to you about it?" And I think that kind of triggers them to be like, "Oh, yeah, let's talk."

And sometimes they're able to explain it to me in a way that I'm like, "Okay, I understand the rationale behind your decision, and now I agree with it." Or sometimes I'm actually able to convince them to not move forward with that plan that I don't think is reasonable.

So it's just small things like that, which come from probably building relationships with people when you're working more closely with them when you go from a med student to a resident.

Hạ: I think part of the hidden curriculum is teaching people to build those skill sets that you talk about, Lilly, like thinking about, "I should ask why," and kind of ask a bit more.

One of the things I've been reflecting a lot on as a senior resident is there are so many things that now seem really obvious to me that weren't obvious when I was an intern or when I was a medical student.

And I feel that the power, the good that can come from the hidden curriculum is when people are able to identify what are those things that aren't obvious that will lead a learner to success, like going, "Oh, you should ask why more. Get into the habit of asking why with a decision, because that's going to make you a better clinician."

But instead, I think what ends up happening a lot of times is the things that people focus on with the hidden curriculum and the things that people get more . . .

Laurel: Reinforcement, maybe.

Hạ: Reinforcement. Yeah. That ends up being a lot more of the negative aspects of the hidden curriculum, which is why when we think of the hidden curriculum, we think of the bad a lot more than the potential of good.

But in a way, to identify those good things, it kind of means we have to move away from it being hidden and making it a more open curriculum.

Laurel: Bring it to life. I'm trying to think of what the opposite of hidden is. Shown curriculum. Revealed curriculum.

Lilly: Exposed.

Laurel: Exposed curriculum. Totally.

I think that's super true, because thinking about my experience, especially being a first-gen undergrad and then first-gen med student, there was a lot of information that I think people around me . . .

Because most of my clinical experience before I made it to medical school was actually my job where I was a pediatric dental assistant. And so not necessarily as much shadowing or sort of the more extracurricular clinical experience. It was grunt work, working with children who kicked, who are also great.

And so something that I really appreciated coming to medical school was when physicians would take the time to explain things to me, right? Maybe it wasn't on the checklist of our clinical exams, but they had learned through their own practice or been taught, and they took the time to explain, "Oh, if you do this, it's more comfortable for the patient," or, "This going to be the more efficient way to balance this kind of schedule."

And I think it's maybe this process of instead of having people pick up things passively that can be potentially insidious, it's bringing things to, "Hey, this is what I've learned and what I know." And kind of like you said, Lilly, using the relationships that are in place to make everyone together a better provider, have a better care experience for patients, and so forth.

Yeah, Hạ, I think it makes a lot of sense to have things be part of this ongoing learning that we are bringing to light rather than you observe an attending do something, and then you're like, "Oh, I have to do it exactly that same way without question."

Lilly: Laurel, you bring up such a good point that I think is such an interesting perspective that we share in different aspects but kind of similar, where it's almost like this bottom-up perspective.

Before I went to medical school, I was a psych tech, and we are in direct contact with patients who are experiencing mania, psychosis, suicidal ideation. We're the first line. We see them, we try and de-escalate, we're putting ourselves in possible risky situations to try and provide care for patients, get their intake, get their vitals, make sure they're being safe.

Having had that perspective in my first job before starting medical school, I feel like it's given me a lot of respect for the staff that we have on our units. If there's a patient who is experiencing combativeness or agitation, I've noticed a lot of times on many different services that it's always the aides, the nurses, other people who are almost the first line, and the doctors are always kind of standing in the back, and then the med students are even farther in the back. No one really knows how to handle it because logically you're like, "Well, the doctor should put in a medication to try and de-escalate."

I think it's really interesting that we expect our other staff to take over that role of being this almost defense, which I think is kind of putting them also in possible harm's way, which isn't fair.

I had a situation with a patient that was altered and confused, and I just noticed that the rest of my team was kind of on the outskirts of the situation. I was like, "This is my patient. I don't want my nurse to be in a dangerous situation while we're waiting for security to come in." And so I stepped in, and I tried to de-escalate.

Maybe that's because I had that experience as a psych tech that I felt comfortable trying to do that. And maybe we don't get enough of that de-escalation training in our training throughout all the different hospital systems. But that's another perspective that we have from the bottom looking up of, "This is how we treat patients and care for patients." It's very head-on, face-to-face interactions.

And so it gave me a lot more respect for the people that I work with. Whereas I think if you only have the perspective of, "I'm the MD, I'm at the top of the list, I'm at the top of the rank," you don't have that much appreciation and that much, I think, familiarity with the rest of your staff. So it's just a really interesting perspective, I think, that we share.

Laurel: Yeah, I really appreciate you sharing that because I didn't know that we shared that background. And I think similarly, I have a lot of, again, face-to-face . . . I have a lot of experience when a child is having a tantrum and is actively screaming. I think it's something that has been useful where I, in a lot of pediatric situations, am very comfortable with children acting out in a way that I think a lot of other trainees around me maybe aren't.

And so I think it goes to this "you can't only look for your training or best practices from the attending, the person in charge." I think we bring our own experiences, and we learn from each other, and in that, maybe we're better positioned to both learn more but also have a bit more context for what we're learning, which I think is really helpful.

Medicine as a field is really guilty of the sort of knee-jerk . . . We learn classical vignettes, right? Like, "You see this, you do this." And I think grounding it a little bit more in the humanity of people around us is probably better for all of us in the long run.

Lilly: Which I think when you think about it from an external perspective looking in, you're like, "Of course that would make sense that explaining my reasoning to the nurse or the aide that's talking to me about a patient situation that they'll understand why I'm thinking that rather than, 'Oh, that provider just blew me off when I tried to share something I was worried about,' or, 'That provider just knee-jerked and put in orders, or, 'I just assumed I need to do this or that.'"

I feel like as a resident, although it takes extra time that we don't always have, I try a little bit . . . I think I still need to work it on a little bit more, but explaining why I don't want to get XYZ, why I don't think we need to scan this, why I don't think we need to page this specialty, why I think the patient is stable so that the rest of my team isn't anxious thinking that I'm dismissing something.

Hạ: All of this also makes me think about how this hidden curriculum is built from different past training systems and different lived realities. Medicine and also our world itself are always changing so rapidly, and there's so much happening that when we try to just center on what is tried and true, or habits, you can say, or beliefs or approaches that have worked in the past, they don't work that well in what medicine is like now.

Even when I think about it now, over the last few years for pediatrics, it's changed so much thanks to TikTok. And now with also AI being available, I now have families go, "I looked up my child's symptoms with AI, and these were the diagnoses they gave me."

And so all of this is to say if we're thinking about this hidden curriculum and these habits and these behaviors that we're getting taught, they are from people who have come before us who have not experienced . . . Not to discredit, they have experienced a lot of things, but it's a different place and it's a different time. And so that's why having to be collaborative and thinking about, "Where do we take our learning from?" is so important.

Laurel: Yeah, the times, they are a-changin'.

I think about one of the more informative moments I had, and it was super brief, but it was a physician telling me offhandedly after a particular patient, "Oh, yeah, we see these folks that we would otherwise never interact with." And I remember it really surprised me because I was like, "I interact with this community." I was broke. I've been in some rough situations.

And so it was just a really interesting reminder of the . . . I want to be careful with my language, but maybe perhaps the old guard of medicine had . . . or has, as a lot of folks are still practicing . . . a set of experiences. But again, being first-gen, I'm already coming from a different situation than a lot of physicians.

And so it's something where I think, especially as the world is changing, how we care for our patients changes as a result. I think so much about how we communicate with our patients in this world of, again, AI and social media. It's a different beast.

Again, it's really important maybe to bring forward what is being implied and what's being taught by default so we can figure out where it doesn't work and where it maybe . . . I've never actually . . . TikTok has come out since I worked as a pediatric dental assistant, so I actually have not talked about TikTok with the children. But I'm sure there are ways, and Hạ, you probably know them, to engage in this new world.

So yeah, I am grateful to be in a shifting world with y'all, and that we can hopefully make it a little better and brighter with both what we learn and what we teach.

And before we say goodbye and leave this episode out to the world where people can find it wherever podcasts are streaming, I was curious if y'all had any final thoughts on how you will try to . . . I don't know if manage is maybe the right word, but manage the hidden curriculum in your future roles as both a healthcare worker and a healthcare coworker and teacher.

Lilly: Yeah, Laurel, thank you so much for wanting to talk about this topic, because I think it's always changing, and we hear little bits and pieces in school, but it's always nice to kind of reflect on it once we've had a little bit more experience in the real world.

Going back to the start of the episode and talking about role modeling, that's really what I'm hoping to do as I still navigate, obviously being a learner myself, creating an environment where the other staff that I work with . . .

The nurses, the aides, the social workers, everyone that's on our team taking care of a patient, we ultimately have this goal of giving the best care we can to the patient and making sure that we facilitate an environment that they feel comfortable asking questions, knowing that we can hopefully have a meaningful discussion about it.

And when we do have medical students with us or other learners with us, we let them know, "If you have questions, you should ask them. If you have thoughts, you should share them. If there are resources that you're aware about, we want to know about them because you learn about these things outside of just us and these hospital walls."

I think that there are always little gold nuggets and pearls that you can get from anyone on the team. And ultimately, that could maybe improve the patient's outcome a little bit more. So I think continuing to role model as we learn is something I'm hoping to do in my practice.

Hạ: And I think a lot of it is also just continuing to reflect on what is the "curriculum"? I'm waving my hands as quotation marks, but people can't actually see me. But what is the curriculum that is important, and what is the curriculum that I want to impart? And always thinking about, as things shift and things change, how would I modify my approach to things?

And just constantly being willing to be in a state of movement instead of being stagnant, and thinking about, as Lilly beautifully said so much with that role modeling, how in that fluidity instead of that stagnancy . . . How do you pronounce it?

Laurel: Stagnation?

Hạ: Stagnation. How that then also helps with modeling and with helping build more growth in the future instead of just telling people, "This is the way that you have to be to be in medicine," because that's not true.

Laurel: I resonate with that. I think all of us seem to be kind of thinking in the same line of, again, this fluidity, this sort of dynamic responding to things.

Sort of the way that I'm thinking about it is in the future with hidden curriculum, I don't want to be so attached to any one way of doing things that it leads to worse care for my patients.

And so I think maybe for me, how I hope to kind of turn the hidden curriculum into exposed curriculum is to be maybe a lifelong learner and to be, where I can, present and reflective so I can see, "What are we doing, what are we teaching, and how can that potentially be bettered for the better of our patients?"

I think there is no point at which I want to feel like I am done learning, because I think that's how you end up really entrenching these things that get stuck, both with people and practices.

But also, I've just been in school for forever, so I think I don't know how to do anything but learn. So I think it's a hard habit to break, but I think I'll still try and keep that mindset even when I'm no longer technically a student, should that day ever come.

Lilly: It will.

Laurel: I appreciate the time that y'all have spent with me exposing the curriculum. Let us all learn well and teach well, and I will try not to die in Minecraft.