Hidden Curriculum

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Original Article

Stunting professionalism: The potency and durability of the hidden curriculum within medical education Barret Michaleca,*  and Frederic W. Haffertyb a

Department of Sociology University of Delaware, Newark, DE 19716, USA. Mayo Clinic Rochester, MN 55905, USA.

b

*Corresponding author.

Abstract   Despite an extensive literature within medical education to touting uting the necessity in developing professionalism among future physicians, there is little evidence these ‘

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calls  have thus far had an appreciable effect. Although various researchers have suggested that the hidden curriculum within medical education has a prominent role in stunting the development of professionalism among future physicians, there has been minimal discussion of how the content of the hidden curriculum actually function to this end. In this article, we explore: (i) how the hidden curriculum may function within medical education as a countervailing force to medicine s push for professionalism and (ii) why the hidden curriculum continues to persist within medical training and particular  aspects so dif 󿬁cult to dilute. We conclude by proposing mechanisms to assuage elements of the hidden curriculum, which may, in turn, allow the principles of professionalism to blossom among medical students. Social Theory & Health  (2013)  11,  388–406. doi:10.1057/s doi:10.1057/sth.2013.6; th.2013.6; published online 1 May 2013 ’ 

Keywords:  professionalism; hidden curriculum; medical education

Introduction Calls for a recommitment to principles of professionalism 1 have been widespread within organized medicine since the early 1990s (Hafferty and Levinson, 2008; AAMC, 2011; Boudreau  et al , 2011). Extensive research and policy statements have highlighted the charge for and by medical professionals to renew their ‘social contract’  with the public, express compassion, empathy and connectedness with their patients, promote and practice teamwork within health care delivery, rid themselves of their political and   󿬁nancial drives, and pursue the highest levels of clinical competence and ethical standards (Institute of Medicine, ©

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Professionalism and the hidden curriculum

2003; Arnold and Stern, 2006; Veloski and Hojat, 2006; Cruess and Cruess, 2008; Wynia, 2008; Camp  et al , 2010; Dyrbye  et al , 2010). Evetts (2011) notes that groups can utilize the discourse of professionalism in composing their occupational identity and   ‘…  promoting its image with clients and customers’ (p. 407). In this sense, the clamor for  ‘ professionalism’ within the medical profession can be seen, in part, as a response to shifts in the sociopolitical and economic context of health care with the rise of consumerism, increased commercialism within the medical   󿬁eld in general, the proletarianization of the health care workforce, the rise in available medical information as ushered by the information age and increased specialization leading to fragmentation in the delivery of care (Light and Levine, 1988; Relman, 2003; Hafferty, 2006a,b; 2006 a,b; Wood Woodruff  ruff   eett al , 20 2008 08). ).2 Org Organi anized zed med medici icine, ne, once once touted touted as   the  prototypical profession, has seen its public image battered and bruised, and although many of the spotlighted issues and noxious elements appear to be tied to the arena of clinical practice, remedial calls have targeted medical education as the bat battle tlegro ground und in bringi bringing ng abo about ut a nee needed ded shi shift ft in pro profes fessio sional nal behavi behaviors ors,, duties and attributes. Numerous medical education institutions have implemented various courses, programs and standards designed to provide students with extensive learning opportunit oppor tunities ies steep steeped ed in prom promoting oting profe profession ssionalism alism (Baernstei (Baernstein n   et al , 2009 2009;; Rabow  et al , 2009; Branch, 2010). The Liaison Committee on Medial Education (LCME), the body that accredits the United States and Canadian medical schools, has an accreditation standard (MS-31-A) that requires schools to account for the ‘professional attributes’  of their students. The Accreditation Council of Graduate Medical Education (ACGME) has identi 󿬁ed professionalism as one of its six Core Competencies (along with patient care, medical knowledge, practice-based learning and improvement, interpersonal communication skills and systems-based practice) (Swing, 2007). There are similar efforts in other countries. Parallel reports in both Canada (CanMEDs, The Canadian Federation of Medical Students and so on) and the United Kingdom (the General Medical Council, the Royal College of Physicians and so on) also stand as socio-political testimonies to a broad and sustained effort by organized medicine to re-establish its principles of professionalism (Frank   et al , 1996; GME, 2009; Bridgewater et al , 2011; Mondoux, 2011). At the the prac practi tice ce le leve vel, l, va vari riou ouss me medi dica call sp spec ecia ialt lty y bodi bodies es ha have ve de deve velo lope ped d professionalism codes and charters. For example, the American Board of Internal Medicine Foundation, the American College of Physicians, the American Society of Inte Intern rnal al Me Medi dici cine ne Foun Founda dati tion on an and d th thee Eu Euro rope pean an Fe Fede dera rati tion on of In Inte tern rnal al Medicine have created a physician professionalism charter, now endorsed by overr 125 med ove medica icall org organi anizat zation ionss wor worldw ldwide ide (AB (ABIM IM Founda Foundatio tion, n, ACP-AS ACP-ASIM IM Foundation, and European Federation of Internal Medicine, 2002). Furthermore, the American Board of Medical Specialties, the organization that sets standards ©

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for the 24 of the 27 approved medical practice specialty boards, has just (as of  2011) established a standing committee on professionalism. Nevertheless, and in the face of all this   ‘progress’, critics have argued that medical school administrators and faculty have been overly eager to advance profes pro fessio sional nalism ism as an edu educat cation ional al ent enterp erpris risee and have have theref therefore ore rushed rushed to conceptualize and operationalize an overly nostalgic version of professionalism (Wear and Kuczewski, 2004; Hafferty, 2006c; Prasad, 2011). Moreover, they argue that this   ‘call to arms’  fails to address the issues related to professionalism present at the systemic and organizational levels both in training and in medical care settings, and suggest that if medical education truly is committed to reform then education and practice leaders will need to address not only factors at the individual level, but also the overarching culture and organizational climate of  medicine that seeps into the teachings of future doctors (Hafferty, 2006d; West and Shanafelt, 2007; Lesser  et al , 2010; Cunningham  et al , 2011). Further complicating this picture, medical students have expressed considerable dismay with and resistance to the ways in which faculty have produced addendums supplements an racter already saturated curriculum in the name of  inculcatin incul cating g and profe profession ssionalism alism   –to  charac cha terizi izing ng suc such h curric cur ricula ularr append app endage agess as pedantic, harassing and even insulting, and thus   ‘turning them off ’  to the whole call for professionalism (Reddy   et al , 2007; Baernstein   et al , 2009; Finn   et al , 2010). Moreover, students consistently have pointed out that they are not seeing the values, behaviors and attributes touted in the classroom being actualized by clinical faculty and supposed role models (Brainard and Brislen, 2007; Leo and Eagen, 2008). In short, medical students do not see these explicit teachings of  professionalism as a useful addition to their training, nor do they see medical school faculty and shadowed physicians as fully practicing what they appear to be preaching. In these respects, critics argue that there is a  ‘ hidden curriculum’ nested within medical training (for example, cultural mores transmitted through formal and informal training processes that re󿬂ect the norms and values upheld by the institution of medicine (Ha󿬂er   et al , 2011)) and that this more invisible and tacitly transmitted curriculum functions as a perpetual culprit in burdening and/ or dam dampen pening ing the cultiv cultivati ation on of pro profes fessio sional nalism ism amo among ng med medica icall studen students ts3 (Chuang  et al , 2010). As Hilton (2004, p. 71) argues,   ‘…  the hidden curriculum …  is probably the most important factor in 󿬂uencing development of professionalism’. Nonetheless, research has yet to dissect  how  and  why  this usual suspect impedes the blossoming of professionalism. Therefore, it is important to better understand the ways in which the hidden curriculum affects the teachings of  profes pro fessio sional nalism ism within within medica medicall edu educat cation ion,, as wel welll as why thi thiss dim dimens ension ion of  medical training continues to persevere despite its   ‘hiding in plain sight’  (Gair and Mullins, 2001; Wear and Skillicorn, 2009). 390

 

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This present article offers a discussion of how the hidden curriculum may function within medical education to stunt the growth of professionalism among medical students. More speci󿬁cally, this article examines how the   ‘teachings’  of  the authority and autonomy (particularly via the   ‘privileged’  nature of medical knowledge) nested within the hidden curriculum actually serve to contradict and counteract explicit formal instruction in the principles of professionalism. Converse ve rsely ly,, al alth thou ough gh th thee hi hidd dden en curri curricu culu lum m can can be vi view ewed ed as detr detrim imen enta tall to students’  professionalism (or at least how professionalism has been discussed in the medical education literature), we suggest that the hidden curriculum also serves as a vehicle for protecting the embattled medical profession by providing subterrestrial lessons in authority and autonomy   –   which have been viewed, both within medicine and by sociology, as markers of any true profession. Put simply, we argue that although elements of the hidden curriculum, such as the teachings of authority and autonomy, may have detrimental impact on students’ development of professionalism, these same elements of the hidden curriculum are actually essential to the perpetuation of medicine’s status as a profession and therefore protected and promotedstrategies by both cultural practiceseducation. within medical and by other-than-formal pedagogical within medical

The Hidden Curriculum and Tenets of Professionalism: An Apparent Contradiction Although the term often is attributed to the education scholar Philip Jackson (1968), the notion that there is a   ‘hidden’  dimension to curricula practices   󿬁rst appeared in the writings of sociologist, Fred Strodtbeck (1964), a student of  Talcot Tal cottt Par Parson sons. s. Fre Freque quentl ntly y ref refere erence nced d in rev review iewss of pri primar mary y and second secondary ary education, the hidden curriculum represents an undercurrent of norms, values and reg regula ulatio tions ns emb embedd edded ed wit within hin the tra traini ining ng pro proces cesss tha thatt studen students ts are to assume and embrace in order to function effectively in a social role (Wren, 1999). Apple (1979) suggests that the internalization of these rules, codes and values actively creates and reinforces the boundaries of institutional legitimacy that students will come to represent in their occupational pursuits. Previous rese resear arch ch on th thee hi hidd dden en cu curr rric icul ulum um ha hass addr addres esse sed d ho how w th thee stru struct ctur uree an and d processes of education perpetuate inequalities, foster ideologies and practices of particular social groups and facilitate individual disempowerment (Giroux, 1985). In turn, professional education has been shown to reproduce hierarchies, degrees of marginalization, ways of thinking and other values of that particular occupatio occu pational nal secto sectorr (Marg (Margolis olis   et al , 2001). These properties and practices of  differential legitimization have been noted to exist in medical training and are argued to be found in customs, rituals and everyday experiences that replicate ©

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ideologies regarding inequality and strati󿬁ed relationships (Hafferty and Franks, 1994; D’Eon et al , 2007; Chuang  et al , 2010; Manhood, 2011). In medical education, the hidden curriculum re󿬂ects the ethos of medical work and has the pot potent ential ial to rev reverb erbera erate te deg degree reess of sep separa araten teness ess and distin distincti ction on within health-care delivery, thereby fostering distance between doctors-to-be and laypersons (Michalec, 2011a), and further strengthening a status hierarchy among health professionals. This promotion of strati󿬁cation, however, is in clear opposition with the tenets of professionalism cited earlier (for example, team orientation, patient-centeredness, empathy and so on). Yet, despite this apparent contra con tradic dictio tion, n, ele elemen ments ts of the hid hidden den curric curriculu ulum m con contin tinue ue to sub subsis sistt wit within hin medical training. We argue this is in part because lessons embedded within the hidden curriculum also function to support two fundamental/traditional characteristics that are essential to the preservation of medicine ’s professional status: authority and autonomy.

Authority Medicine and Autonomy: Essential Elements of the Profession of  Autonomy and authority are extensively intertwined within the medical profession, and it has been argued that autonomy, or a profession ’s degree of control over its area of work and clientele, stems from its degree of cultural authority, which sprouts from the attainment and promulgation of an esoteric body of  (medical) knowledge. Moreover, and as argued by Freidson (1970a, 2001) and Abbott (1988), medicine maintains professional autonomy not only through its develo dev elopme pment nt and tra transf nsfere erence nce of tha thatt bod body y of clinic clinical al knowle knowledge dge,, but also also thro throug ugh h its its co cont ntro roll ov over er its its ow own n wo work rk,, th thee divi divisi sion on of la labo borr (bou (bound ndar arie iess of  specializations) and new member entry. Similarly, medicine asserts its autonomy and professional control by staving off interference and regulation from outside forces such as other health workers and the government. In addition, and as icing on the cultural authority cake, medicine also controls the work of other healthcare occupations (Freidson, 1970b). In sum, the degree of control and autonomy enjoyed by medicine stems from its ability to control a body of esoteric knowledge, maintain a sense of legitimacy in the public eye, and sustain a certain degree of power granted by governmental entities. According to Latham (2002, p. 367), the physician profession is grounded in the expert authority that accompanies their clinical/medical knowledge. It is this authority that asserts and relates the necessity of their profession. Put simply, ‘They know something that neither their patients nor society at large can know ’. Medical knowledge is perhaps   the  integral   integral element to the role of the physician. Doctors claim the knowledge and mastery of the intricacies of the human body, 392

 

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of particular medical technologies and procedures, as well as the diagnosis and treatm tre atment ent of dis diseas easee (Fa (Fainz inzang ang,, 200 2002), 2), wit with h thi thiss knowle knowledge dge bei being ng gat gather hered ed through years of training. Wear and Castellani (2000) argue that the current cultur cul turee of med medici icine ne re󿬂ect ected ed in the medica medicall school school curric curricula ula touts touts scienc science, e, scienti󿬁c methods and the knowledge gleaned from medical education as the true   ‘knowledge’, an and d th ther eref efor oree so some meth thin ing g mu much ch more more va valu luab able le th than an th thee patient’s knowledge.   ‘…  the existing medical curriculum, aligned as it is almost exclusively with science and its methods, results in doctors, not patients, who are the real  “ knowers”’  (p. 606). According to Parsons (1951), physicians serve as agents of social control, empowered to regulate what behavior is deemed normal (healthy) or deviant (sick (si ck)) be beca caus usee of th thei eirr kn know owle ledg dgee and and ex expe pert rtis ise. e. It sh shou ould ld be ma made de cl clea ear, r, however, that the authority that physicians maintain is not just over laypersons (that is, patients) but involves other health-care workers as well, such as nurses, physical and occupation therapists, psychologists and those involved in holistic care care.. Stud Studie iess ha have ve show shown n th that at a st stat atus us hi hier erar arch chy y exis exists ts in medi medici cine ne th that at is consistently through daily interactions in the2009). health-care setting, and is transferredreinforced through education (Waring and Currie, This hierarchy is based, in part, on differences in medical knowledge and the asymmetrical power granted to those higher up on the medical hierarchy because of this knowledge  – what Friedson (1970b) referred to as   ‘professional dominance’. In the following sections, we address  how authority and autonomy are  ‘ taught’ through the hidden curriculum, and suggest   why  these elements of the hidden curriculum (authority and autonomy) may continue to circulate through the learning environment of medical education. We will   󿬁rst address the   how   by exploring key vehicles and arenas within which the hidden curriculum functions.

The Teachings of Authority and Autonomy within the Hidden Curriculum Explicit technical, medical knowledge is clearly imparted to medical students through a formal curriculum of courses, labs and clinical training. The hidden curriculum, however, provides an excellent context to inculcate the norms and values of separateness, control and power because medical school faculty are constrained from explicitly stating to students in an open classroom or lab setting ‘You are better than PT students.’, or   ‘You don’t need to listen to nurses. ’   A recent rec ent sta statem tement ent from from the Commit Committee tee on Eth Ethics ics of the Ameri American can Colle College ge of  Obstetricians and Gynecologists (2011, p. 401) states,   ‘Inherent in the education of health-care professionals is the problem of disparity in power and authority …’.

Michalec (2011a) found that   󿬁rst- and second-year medical students report ©

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being tau being taught ght tha thatt med medica icall kno knowle wledge dge carrie carriess par partic ticula ularr estee esteemed med qua qualit lities ies.. During his interviews, students spoke not merely of having trouble communicating ing wi with th la layp yper erso sons ns beca becaus usee of di dist stin inct ctiv iven enes esss of what what th they ey were were le lear arni ning ng (medical knowledge), but that according to their instructors, what they were lear learni ning ng wa wass al also so po powe werf rful ul an and d ac acco comp mpan anie ied d by a hi high gh le leve vell of auth author orit ity. y. Furthermore, these preclinical students sensed   ‘teachings’   (during ceremonies such as orientation and the White Coat Ceremony (WCC), as well as with regard to consistent praise and complementation  –  key arenas of the hidden curriculum) of authority nested within their medical training, and that faculty and administration often suggested in both direct and oblique ways that they (students) were superior, smarter and of more social worth than those outside of medicine. What Michalec’s study highlights highlights is that medica medicall stude students nts are being  ‘told’, (repeatedly and tacitly) that they are   ‘special’, a veritable   ‘best and brightest’. Moreover, a variety of structural elements within medical education continuously reinforce these  ‘ teachings’ of authority and autonomy. Several reports have indicated that less curriculum hours are actually allocated to the teaching and learning of medicine the social and as compared with bioscience and 2011b). clinical aspects of and ethical health issues care (Hafferty, 1998, 2000; Michalec, Such disparities in the formal curriculum may lend to less exposure to learning and practice opportunities for medical students in these speci 󿬁c   󿬁elds, thereby show sh owca casi sing ng,, an and d perh perhap apss ev even en enha enhanc ncin ing, g, th thee pr pres esen ence ce and and valu valuee of th thee authority of clinical knowledge over other forms of knowledge. Moreover, in spite of decades of touting the importance of teamwork and team-based practice, medical students experience the overwhelming majority of their training in sole company of   –  other medical students (Michalec, 2011b), with interprofessional tr trai aini ning ng rema remain inin ing g more more of a pe peda dago gogi gica call mira mirage ge th than an an ac acti tive ve prac practi tice ce (Baldwin, 2007). Similarly, Whitehead (2007) explains that because doctors are expected to bear the onus of medical decision making (compared with other health heal th care care prof profes essi sion onal als), s), th thee assu assump mpti tion on of th this is   ‘responsibility’   must must be inco incorp rpor orat ated ed in th thei eirr trai traini ning ng,, an and d it is th thro roug ugh h th this is tr trai aini ning ng (e (exp xpli lici citt and and implic imp licit) it) tha thatt med medica icall stu studen dents ts con󿬁rm th thee le legi giti tima macy cy of   their   autonomous decision-making ability. Much Muc h lik likee cer ceremo emonie nies, s, per persis sisten tentt adu adulat lation ion and cur curric riculu ulum m des design ign,, role role modeling represents yet another medium for conveying the hidden curriculum (of authority and autonomy) as students   ‘learn’  various aspects of physicians’ profes pro fessio sional nal ide identi ntity ty and res respon ponsib sibili ilitie tiess (Reule (Reulerr and Nar Nardon done, e, 1994; 1994; Batlle Batlle,, 2004; Lempp and Seale, 2004).  ‘ Role modeling remains one crucial area  …  where repeated negative learning experiences may adversely impact the development of pro profes fessio sional nalism ism in med medica icall stu studen dents ts and reside residents nts’   (Kenny   et et al , 2003 2003,, p. 1203). Although the role modeling of behaviors, values and ethical standards can len lend d to pos positi itive ve profes professio sional naliza izatio tion n of future future phy physic sician ianss (Wesse (Wessel, l, 2004; 2004; 394

 

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 Janssen   et et al , 200 2008; 8; Bae Baerns rnstei tein n   et al , 200 2009; 9; Helmic Helmich h   et al , 2011), 2011), previo previous us research featuring students’  accounts of their training have shown that students do witness physicians openly mock and put down patients, disrespect other health care workers, put patients at risk and blatantly ignore hospital procedures and an d ethi ethica call sta stand ndar ards ds an and d face face no si sign gnii󿬁can cantt sancti sanction on or punish punishmen mentt fro from m within, or outside, their institution (Ginsburg  et al , 2002; Brainard and Brislen, 2007; Michalec, 2012). Feudtner  et al   (1994) presented medical trainees’   observations of physicians overtly exercising their authority over patients, such as sedating a patient with Haldol in order to give them medications intravenously (simply because the patient did not desire to take her medications), and performing unnecessary forceps deliveries   ‘for practice’. Hinze (2004) provides narratives that highlight how the teachings of authority and a rigid status hierarchy are alive and well within medical training especially concerning gender differences in professional medicine, medic ine, offer offering ing   󿬁rst rst-pe -perso rson n acc accoun ounts ts of how mal malee practi practicin cing g phy physic sician ianss expl ex plic icit itly ly an and d im impl plic icit itly ly deme demean an an and d vi viti tiat atee fema female le medi medica call stud studen ents ts and and practicing physiciansofinthe front of medical traineesof without or sanction. Infemale their exploration effects of the teachings hiddenrecourse curriculum in medical education, Lempp and Seale (2004) found that 21 out of 36 students in their study reported numerous instances of humiliation (from practicing physicians) either through observation or through personal experience. The authors suggest sugge st that   ‘On Onee of th thee prin princi cipl plee ways ways in wh whic ich h stud studen ents ts le lear arnt nt abou aboutt th thee importance of hierarchy in medicine is through teaching that involved humiliation.’   (p. (p. 77 771) 1).. Th Thes esee st stud udie ies, s, and and ot othe hers rs,, pr prov ovid idee dire direct ct evid eviden ence ce of how how modeled behavior, as a veritable lecture hall for the   ‘teachings’  of the hidden curric cur riculu ulum, m, ca can n pro projec jectt les lesson sonss in the aut author hority ity (of medica medicall knowle knowledge dge and speci󿬁c stat status us ch char arac acte teri rist stic ics) s) and and auto autono nomy my of th thee me medi dica call pr prof ofes essi sion on in general. Consequentially, these teachings can have detrimental impact on the development of students’  professionalism. Therefore, why would organized medical education turn a blind eye to a mech me chan anis ism m that that has has been been sh show own n to no nott only only be disa disadv dvan anta tage geou ouss to th thee cultivation of acclaimed characteristics among future physicians, but also has been spotlighted by extant research?   Why  do the   ‘teachings’   of authority and autonomy (through the hidden curriculum) persist?

Authority and Autonomy as Elements to Conserve and Protect Authority Author ity and aut autono onomy my not onl only y are out outcom comes/ es/byby-pro produc ducts ts of bec becomi oming ng a profession, but are also viewed within traditionally framed organized medicine as pillars pillars of the profe profession ssion itself (Parsons, 1951; Friedson 1970b 1970b,, 2001). 2001). In these ©

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ways, authority and autonomy are key to preserving medicine’s perception of  itself as a profession. Therefore, these elements that contribute to both the self  image and even its actuality not only must be protected and closely guarded, but their value and importance also must be fostered and passed along to the next generation of those in the profession (medical students). The hidden curriculum serves both of these purposes. In the case of medicine, the same events, movements and challenges that have spawned the call for professionalism (that is, consumerism, proletarianization, complementary and alternative medicine and so on) have threatened medicine and led the embattled profession to question the stability and durability of its author aut hority ity and aut autono onomy my (He (Hess, ss, 200 2004; 4; Coh Cohen, en, 2006; 2006; Lowrey Lowrey and And Anders erson, on, 2006). In addition, whereas medical school faculty and administration have touted a range of attributes such as compassion, teamwork and patient-centeredness in their push for professionalism (Boudreau e  ett al , 2011), the actuality is that in order to sustain medicine’s professional status (and all that comes with it) medicine seek to saf safegu eguard ard its domain domain-ba -based sed aut author hority ity and aut autono onomy. my. As also als o mus must  t   seek di disc scus usse sed d ea earl ier, r, as th this isthe is consi ac acco comp mpli lish shed ed th thro roug ugh h th the hi hidd dden en cu curr icul ulum um bys mechanism mech anisms s rlie such consistent stent reinforce reinforcement ment ofe hierarchic hiera rchical alrric boundarie boun daries betwee bet ween n doc doctor torss and pat patien ients ts and oth other er hea health lth profes professio sional nals, s, differ different entiat iated ed praise for particular behaviors and even a general   ‘talking-up’  of the value and signi󿬁cance of medical knowledge (over other forms and loci of knowing). As Latham (2002, p. 367) states,   ‘The physician’s authority over the patient is thus also authority over the patient’s community. He [sic] must therefore retain the trust of both, or else render his authority suspect and his expertise useless ’. Similarly, when authority is questioned, autonomy and control are threatened and weakened (Abbott, 1988). Hence, despite hiding in plain sight, the hidden curric cur riculu ulum m has yet to be dissol dissolved ved,, and par partic ticula ularr teachi teachings ngs,, such such as those those involving authority and autonomy, have yet to be stymied or hindered. Rather, in highly strategic ways, the hidden curriculum is being nurtured and harbored because it assists in the defense of the traditional medical powers and privileges. Timmermans and Oh (2010) outline how the medical profession has been extremely extre mely resilient and unyieldin unyielding g throughout throughout the past deca decades, des, consi consistentl stently y confronting its challenges. The authors suggest that the medical profession has survived numerous threats to their status and power through strategic takeovers (t (tha hatt is, is, the the ab abso sorp rpti tion on of th thee le leas astt radi radica call feat featur ures es of comp comple leme ment ntar ary y and and alternative medicines (CAM)), tightening their grip on clinical knowledge (that is, their engagem engagement ent with evid evidence ence-base -based d medi medicine cine (EBM)) (EBM)) and establishin establishing g tactical partnerships (that is, their symbiotic relationship with the pharmaceuti tica call indu industr stry) y).. We su sugg gges estt th that at th thee hi hidd dden en curr curric icul ulum um ha hass al also so serv served ed a prominent role in this set of strategic defenses and realignments by protecting and conserving the profession’s core resources (authority and autonomy) and by 396

 

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imparting these resources in a range of tacit and often times implicit ways to the next generation of physicians during medical training. Furthermore, perhaps this is why the recent calls for professionalism, as well as the programs and courses that have been established to increase professionalism among trainees, have been referred to as mere window dressing and/or lackluster, and why medical stud studen ents ts co cont ntin inue ue to se seee beha behavi vior or amon among g th thei eirr pr prec ecep epto tors rs and and sh shad adow owed ed physicians that is not in-line with tenets of professionalism   –  behavior that is unprofessional (Reddy  et al , 2007; Baernstein  et al , 2009).

Re-examining the Stalled Promulgation of Professionalism Principles In a 1988 issue of the   Journal of Health and Social Behavior , Samuel Bloom (1988) presented a powerful argument that   ‘…   medical medical education’s manifest humanistic mission is little more than a screen for the research mission which is ’



the major concern of the institution s social structure  (p. 294). Interestingly, 24 years yea rs lat later, er, we are fac faced ed with with sim simila ilarr set of ste stealt alth-r h-rela elated ted act activi ivitie tiess within within medical education   –   a covert push for authority and control while explicitly sounding the call for   ‘professionalism’. However, whereas Bloom was exploring a history of   ‘reform without change’, we are arguing that medicine actually is 󿬁ghting for its professional livelihood, and that the hidden curriculum has been activated as a vital weapon for medicine in this battle. These front- and backstage maneuverings present medicine with a substantial conundrum: In order to maintain its professional status, medicine must sustain some some degr degree ee of au auth thor orit ity y an and d au auto tono nomy my.. Yet, Yet, th thee pr prom omul ulga gati tion on of such such necess nec essiti ities es (th (throu rough gh the hid hidden den cur curric riculu ulum) m) is somew somewhat hat antith antitheti etical cal to this this push pu sh fo forr prof profes essi sion onal alis ism. m. Th Thee no noti tion onss of auth author orit ity y and and au auto tono nomy my with within in medici med icine ne are not nec necess essari arily ly neg negati ative ve sid side-e e-effe ffects cts of medici medicine ne ac achie hievin ving g or maintaini mainta ining ng pro profes fessio sional nal sta status tus.. Rat Rather her,, it is the their ir re󿬂ecti ection on and transl translation ation through the hidden curriculum that appears to lend to the detriment. Hence, whereas a great deal of attention and effort to cultivate principles in professionalism among medical students has been directed toward developing, offering and assessing professionalism-laden programs, we suggest that focus should shift toward the mechanism(s) nested within medical education that appear to be antithetical to these principles and could very well be stunting their development among medical students   –  toward the tempering of the hidden curriculum and the   ‘teachings’  of authority and autonomy. As noted earlier, the hidden curriculum within medical training re 󿬂ects and reinforces hierarchies, status inequalities and overarching differences in health and health care. Therefore, a key to enfeebling aspects of the hidden curriculum ©

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and their effects is by muting the notion that medicine is   the  profession   profession within health care. Although interprofessional training within medical education circles has been somewhat of a straw dog over the past several decades (Baldwin, 2007), there is evidence that medical education institutions are taking signi 󿬁cant strides toward tow ard emp emphas hasizi izing ng a mor moree int interp erprof rofess ession ional, al,   ‘team-oriented’   approa approach ch to heal he alth th care care.. A nu numb mber er of me medi dica call sc scho hool olss have have re rece cent ntly ly cons constr truc ucte ted d an and d implemented elaborate, multi-year Interprofessional Education (IPE), programs aimed at bringing together students from multiple health care disciplines during their years of training to breakdown the hierarchy within health care delivery, increase patient-centeredness from a team approach, and foster communication and respect among the various health professions (Clark, 2004; Thistlethwaite and Moran, 2010). These programs are integrated into preclinical and clinical training agendas for these institutions, but given the novelty of these programs, research is currently underway to assess to what messages and values are being translated to the students of the various disciplines through these programs. These programs are not slated as programs in   ‘professionalism’  per-say, rather they are geared toward bringing together each of the health disciplines under the umbrel umb rella la of imp improv roving ing health health care care del delive ivery, ry, the exp experi erienc ences es of health health care care professionals, and patient outcomes in general. Another important element of  IPE programs is that they often include members of the local patient population/ general public to serve as a guide to the pre-professionals through the illness experience. IPE, with its focus on team-based care, patient-centeredness, and incl inclus usio ion n of the the pu publ blic ic in th thee educ educat atio ion n pr proc oces ess, s, ha hass th thee po pote tent ntia iall to have have signi󿬁cant impact on the hidden curriculum and lay the groundwork for aspects of professionalism to take root. Another manner in which the medical education community can assuage the potentially injurious profession dominating teachings of the hidden curriculum is to transform the WCC. Often held during the   󿬁rst year of medical training, the WCC is a ritual in which students are draped with the quintessential regalia of a physician. The white coat has been described as a   ‘magical cloak’  that protects the medical student and doctor from the suffering of their patients (Druss, 1998), and as a symbol of science and technology, and a re 󿬂ection of life and purity (Blumh (Bl umhage agen, n, 197 1979). 9). Alt Althou hough gh it may seem seem to occ occupy upy a relati relativel vely y neglig negligibl iblee footprint with the overall process of medical education, and while of 󿬁cials within medicine have argued for its bene󿬁ts and appropriateness (as outlined in Branch, 1998 19 98;; Hu Hube ber, r, 20 2003 03), ), othe others rs su such ch as We Wear ar (1 (199 998) 8) an and d Ru Russ ssel elll (2 (200 002) 2),, have have sugg su gges este ted d that that th thee wh whit itee co coat at ac actu tual ally ly fu func ncti tion onss as a sour source ce of th thee hi hidd dden en curriculum and thus transmits messages of power, authority, elitism and the dominance of science that it symbolizes. Whatever the issue, it is important that medical educators be   ‘…  willing and able to step back and assess just what messages are being created by and within 398

 

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the very structures they have developed and are responsible for ’ (Hafferty, 1998, p. 404). This means thoroughly evaluating the meanings translated in these ceremonies and the differentiations made between medical students and those not within the medical profession, especially given the timing of most WCCs. Even something as celebratory as a WCC may send con 󿬂ating and contradictory messages. In this sense, medical school administrators interested in mitigating impressions of elitism and power, and fostering positive perceptions of interprofessionalism, mutual cooperation and interdependence (among the health professions   –  key elements of professionalism), should look to include professional sio nal rep repres resent entati atives ves fro from m the oth other er hea health lth care-r care-rela elated ted dis discip ciplin lines es (th (that at is, Nursing, Pharmacology, Physical Therapy, Occupational Therapy, Social Work and so on) in the WCC in some fashion other than just guests and/or spectators. Professionals in these other disciplines could serve as speakers, of 󿬁ciates or could even adorn medical students with their white coats, thereby welcoming them to the health care industry. Another manner in which the same directives could be achieved would be to host a   ‘generic’  WCC for students of   all  health   health care disciplines. Each discipline teaches and trains students to heal, why can they nott al no alll jo join in to toge geth ther er to ce cele lebr brat atee th thei eirr co coll llec ecti tive ve in init itia iati tion on in into to th thee he heal alin ing g professions? Such recon󿬁gurations of the WCC could help to dismantle barriers and fences between the health professions and counteract conceptions of a rigid hierarchy within health care delivery, thereby potentially neutralizing certain deleterious effects of the hidden curriculum. 4 Gi Give ven n that that th thee   ‘lessons’   of au auth thor orit ity y an and d au auto tono nomy my th thro roug ugh h th thee hi hidd dden en curriculum have been shown to also be present within the professional domain (along with the educational domain) of medicine, the efforts of dismantling the hierarchies within health care delivery should also be done from within the medical industry and therefore re󿬂ected in the attitudes and actions of practicing physicians. If medicine is truly invested in the promotional of professionalism principles among its future workforce then the medical profession would do well to adopt the motto:   ‘It takes a village’  and acknowledge and embrace the notion that effective health care is delivered through a   ‘team’  of professionals (that is, nurses, medical social workers, doctors, pharmacists, physical and/or occupational therapists and so on), which includes the patient (Lichtenstein  et al , 2004). In stepping down from its crumbling silo, medicine still will maintain a distinct, esoteric body of clinical knowledge, but, in turn, the profession must profess that its   ‘knowledge’  functions best when working in tandem with the knowledge of  other parties/professionals within the health care delivery team   –  which again, must include the patient. By doing so, medicine will relinquish some degree of  cultural authority and control, yet this will assist in ushering in a new   ‘contract’ with the public as well as with other health care professionals   –  what some are calling a   ‘new patient-centered professionalism’  (Irvine and Hafferty, 2011). ©

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Weakening the potency of the hidden curriculum not only entails the practice of dissolving hierarchies within health care, but also courageously and publically purging the   ‘bad apples’  within the profession. If professionalism is to   󿬂ourish, the attention cannot simply be on pedagogical practices, those practicing within the profession must be held accountable as well (Leach   et al , 2006; Hafferty, 2006b). In order to save itself from its current siege, medicine must become more transparent in terms of how it handles ethical violations, poor and out-of-date practices and the adverse pursuits of political and   󿬁nancial endeavors among its own members (Hickson  et al , 2007). Until this point, we have steered clear of any medically oriented analogies or metaphors, yet perhaps one must be used to better capture the manner in which the medical profession must attack or confront certain aspects of the hidden curriculum. Radiation therapies are a popular method of treating cancer. While deconstructing the tumor, radiation simultaneously damages healthy cells and tissue   –   the desired effect being a greater sum of damage to the tumor than healthy tissue. If we consider the hidden curriculum as having a potentially tumorous effect within the soma of medical education, then implementing vetted and evaluated IPE programs within the curriculum, recon󿬁guring WCCs and foster fos tering ing transp transpare arency ncy within within the pro profes fessio sion n in genera generall may in fact fact imp impact act medical medic al train training ing’s   ‘heal healthy thy tissue’   (re-orga (re-organizin nizing g curriculu curriculum m to inclu include de IPE, possibly forfeiting the positive side-effects of the WCC and even sacri󿬁cing some degree of authority and autonomy). Although some tumors may be eradicated and oth others ers   ‘merely’   cont contro roll lled ed,, th thee ov over eral alll effe effect ct is a more more su susta stain ined ed an and d nourishing environment for the seeds of a more modern-day or  ‘ new’ professionalism to be established and   󿬂ourish (Irvine, 1999, 2006; Working Party of the Royal College of Physicians, 2005; Coverdill  et al , 2010).

Conclusion We ha have ve po posi site ted d ho how w an and d wh why y th thee prin princi cipl ples es of pr prof ofes essi sion onal alis ism m (a (and nd th thee develo dev elopme pment nt of the these se pri princi nciple pless among among med medica icall studen students) ts) have have strugg struggled led to blossom within the current climate of medical education, and, in turn, how the hidden curriculum has been able to radiate within this climate. In return for protecting aspects of authority (including medical knowledge) and autonomy/ cont co ntro roll ov over er th thee othe otherr he heal alth th prof profes essi sion onss an and d tr tran ansl slat atin ing g th them em to fu futu ture re physic phy sician ians, s, the med medica icall pro profes fessio sion n has nur nurtur tured ed and sustain sustained ed the hid hidden den curriculum curri culum,, speci󿬁call cally y th thee   ‘teachings’   of pow power er differ different ential ials, s, hierar hierarchi chical cal bounda bou ndarie riess and overar overarchi ching ng ine inequa qualit lities ies in hea health lth ca care re del delive ivery. ry. Alt Althou hough gh appreciable research has identi󿬁ed the presence of a hidden curriculum within medical education, argued for its deconstruction and   󿬁ngered it for the sluggish 400

 

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growth of  ‘ ‘ professionalism’ within medical students, this speci󿬁c work highlights how a function of the hidden curriculum is to conserve the medical profession ’s critical resources of autonomy and authority, which purportedly lends to its remarkable perseverance. We agree with other researchers in that professionalism will not thrive until the culture and climate of medicine (which is currently fostered in part by the hi hidd dden en cu curr rric icul ulum um)) is fu full lly y ex expl plor ored ed and and diss dissec ecte ted. d. In or orde derr to do th this is,, we suggest sugge st impl implement ementing ing antianti-hiera hierachic chical al rheto rhetoric ric and structures structures withi within n medical medical training such as IPE programs and the signi 󿬁cant modi󿬁cation of WCCs. We also ar argu guee that that al alte teri ring ng th thee educ educat atio ion n se sett ttin ing g al alon onee wi will ll not not curt curtai aill th thee hi hidd dden en curriculum. Therefore, practicing physicians and the profession itself must not only sacri󿬁ce degrees of authority, but also levels of their autonomy by making their judiciary practices and political and   󿬁nancial endeavors more transparent (Bridgwater  et al , 2011). These mechanisms will usher in a new   ‘contract’   not only between the medical profession and the general public, but also between all health professions.

Notes 1 Throughout Throughout this this work, the authors use the term Professionalism  to refer to the individual-le individual-level vel traits,  behaviors and attitudes similar to those described in the encompassing normative definition offered by Swick (2000). The term Profession , within this work, refers specifically to organized medicine as an occupational entity and in relation to specific qualities of any true profession (that is, authority and autono aut onomy) my).. Finall Finally y, wit within hin this this work, work, the term term Professionalization   refer referss to the the pr proc oces esse sess and and mechanisms by which medical students learn   to become professional health care practitioners. In turn, this work attempts to bridge the importunate cultural divide between the more sociologically oriented discourse on the Profession of medicine and the more medically oriented discourse on medical Professionalism (Hafferty and Castellani, 2010). 2 Althou Although gh there there rem remain ainss some some con consid sidera erable ble opposi oppositio tion n to the claim claim that that physic physician ianss are becomi becoming ng   ‘

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deprofessionalized and/or subordinated to the bureaucratic controls (Pescosolido, 2006; Spalter-Roth, 2007),, medical 2007) medical insiders remain remain quite convinced convinced that physic physicians ians have suffered suffered serious serious erosions erosions of their  clinical autonomy and discretionary decision making (Shanafelt  et   et al , 2002; Zuger, 2004). 3 Althou Although gh writin writings gs on the hidden hidden curriculu curriculum m come come largel largely y from from within within the United United States States,, United United Kingdo Kin gdom m and Can Canadi adian an med medica icall edu educat cation ion litera literatur turee the there re are the beginn beginning ingss of an expand expanding ing international literature on the hidden curriculum. Similarly, although the concept is universal, particular  context may differ enough so that what holds for one country in terms of specific findings about content  of the hidden curriculum or the content of the space between the formal curriculum and the hidden curriculum is particular to place (specific medical education institution). Therefore, although discussions of the hidden curriculum (in the general sense) offered within this work could be applied to more than one national context, given that the authors are relating the role of the hidden curriculum to the current  state of the medical profession in the United States the discussion of the hidden curriculum within in this  particular work is primarily directed toward US medical education. 4 Although Although the inclusion of other health professions professions within within the WCC may have a positive impact impact on the intern internal al status status hierarch hierarchy y among among the health health pro profes fessio sions, ns, it may do little little to add addres resss (and (and may even exacerbate) the status and power divide between health care providers and patients (laypersons). ©

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