Stunting professionalism: The potency
and durability of the hidden curriculum
within medical education
Barret Michaleca,* and Frederic W. Haffertyb
Department of Sociology University of Delaware, Newark, DE 19716, USA.
Mayo Clinic Rochester, MN 55905, USA.
Abstract Despite an extensive literature within medical education touting the necessity
in developing professionalism among future physicians, there is little evidence these
‘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 difﬁcult 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/sth.2013.6;
published online 1 May 2013
Keywords: professionalism; hidden curriculum; medical education
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
professionalism as an educational enterprise and have therefore 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 and supplements to an already saturated curriculum in the name of
inculcating professionalism – characterizing such curricular appendages 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
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 reﬂect the norms and values upheld by the
institution of medicine (Haﬂer et al, 2011)) and that this more invisible and
tacitly transmitted curriculum functions as a perpetual culprit in burdening and/
or dampening the cultivation of professionalism among medical students3
(Chuang et al, 2010). As Hilton (2004, p. 71) argues, ‘… the hidden curriculum
… is probably the most important factor inﬂuencing 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
professionalism within medical education, as well as why this dimension of
medical training continues to persevere despite its ‘hiding in plain sight’ (Gair
and Mullins, 2001; Wear and Skillicorn, 2009).
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 speciﬁcally, 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. Conversely, although the hidden curriculum can be viewed as detrimental 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 promoted by both cultural practices within medical and
by other-than-formal pedagogical strategies within medical education.
ideologies regarding inequality and stratiﬁed relationships (Hafferty and Franks,
1994; D’Eon et al, 2007; Chuang et al, 2010; Manhood, 2011).
In medical education, the hidden curriculum reﬂects the ethos of medical work
and has the potential to reverberate degrees of separateness and distinction
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 stratiﬁcation, 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
contradiction, elements of the hidden curriculum continue to subsist within
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 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
development and transference of that body of clinical knowledge, but also
through its control over its own work, the division of labor (boundaries 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 element to the role of the physician.
Doctors claim the knowledge and mastery of the intricacies of the human body,
of particular medical technologies and procedures, as well as the diagnosis and
treatment of disease (Fainzang, 2002), with this knowledge being gathered
through years of training. Wear and Castellani (2000) argue that the current
culture of medicine reﬂected in the medical school curricula touts science,
scientiﬁc methods and the knowledge gleaned from medical education as the
true ‘knowledge’, and therefore something much more valuable than the
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) because of their knowledge and expertise. It should be made clear,
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. Studies have shown that a status hierarchy exists in medicine that is
consistently reinforced through daily interactions in the health-care setting, and
is transferred through education (Waring and Currie, 2009). 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 ﬁrst address the how by
exploring key vehicles and arenas within which the hidden curriculum functions.
being taught that medical knowledge carries particular esteemed qualities.
During his interviews, students spoke not merely of having trouble communicating with laypersons because of distinctiveness of what they were learning
(medical knowledge), but that according to their instructors, what they were
learning was also powerful and accompanied by a high level of authority.
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 is that medical students 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 the social and ethical issues as compared with bioscience and clinical
aspects of medicine and health care (Hafferty, 1998, 2000; Michalec, 2011b).
Such disparities in the formal curriculum may lend to less exposure to learning
and practice opportunities for medical students in these speciﬁc ﬁelds, thereby
showcasing, and perhaps even enhancing, the presence and value of the
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
training remaining more of a pedagogical mirage than an active practice
(Baldwin, 2007). Similarly, Whitehead (2007) explains that because doctors are
expected to bear the onus of medical decision making (compared with other
health care professionals), the assumption of this ‘responsibility’ must be
incorporated in their training, and it is through this training (explicit and
implicit) that medical students conﬁrm the legitimacy of their autonomous
Much like ceremonies, persistent adulation and curriculum design, role
modeling represents yet another medium for conveying the hidden curriculum
(of authority and autonomy) as students ‘learn’ various aspects of physicians’
professional identity and responsibilities (Reuler and Nardone, 1994; Batlle,
2004; Lempp and Seale, 2004). ‘Role modeling remains one crucial area … where
repeated negative learning experiences may adversely impact the development
of professionalism in medical students and residents’ (Kenny et al, 2003,
p. 1203). Although the role modeling of behaviors, values and ethical standards
can lend to positive professionalization of future physicians (Wessel, 2004;
Janssen et al, 2008; Baernstein et al, 2009; Helmich et al, 2011), previous
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 ethical standards and face no signiﬁcant sanction or punishment from
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, offering ﬁrst-person accounts of how male practicing physicians
explicitly and implicitly demean and vitiate female medical students and
practicing female physicians in front of medical trainees without recourse or
sanction. In their exploration of the effects of the teachings of hidden 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 that ‘One of the principle ways in which students learnt about the
importance of hierarchy in medicine is through teaching that involved humiliation.’ (p. 771). These studies, and others, provide direct evidence of how
modeled behavior, as a veritable lecture hall for the ‘teachings’ of the hidden
curriculum, can project lessons in the authority (of medical knowledge and
speciﬁc status characteristics) and autonomy of the medical profession 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
mechanism that has been shown to not only be disadvantageous to the
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?
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
authority and autonomy (Hess, 2004; Cohen, 2006; Lowrey and Anderson,
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 et al, 2011), the actuality is that in order
to sustain medicine’s professional status (and all that comes with it) medicine
also must seek to safeguard its domain-based authority and autonomy. As
discussed earlier, this is accomplished through the hidden curriculum by
mechanisms such as the consistent reinforcement of hierarchical boundaries
between doctors and patients and other health professionals, differentiated
praise for particular behaviors and even a general ‘talking-up’ of the value and
signiﬁcance 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
curriculum has yet to be dissolved, and particular teachings, such as 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 resilient and unyielding throughout the past decades, consistently
confronting its challenges. The authors suggest that the medical profession has
survived numerous threats to their status and power through strategic takeovers
(that is, the absorption of the least radical features of complementary and
alternative medicines (CAM)), tightening their grip on clinical knowledge (that
is, their engagement with evidence-based medicine (EBM)) and establishing
tactical partnerships (that is, their symbiotic relationship with the pharmaceutical industry). We suggest that the hidden curriculum has also served 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
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
students continue to see behavior among their preceptors and shadowed
physicians that is not in-line with tenets of professionalism – behavior that is
unprofessional (Reddy et al, 2007; Baernstein et al, 2009).
and their effects is by muting the notion that medicine is the 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 signiﬁcant strides
toward emphasizing a more interprofessional, ‘team-oriented’ approach to
health care. A number of medical schools have recently constructed and
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
umbrella of improving health care delivery, the experiences of health 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
inclusion of the public in the education process, has the potential to have
signiﬁcant 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 ﬁrst 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 reﬂection of life and purity
(Blumhagen, 1979). Although it may seem to occupy a relatively negligible
footprint with the overall process of medical education, and while ofﬁcials within
medicine have argued for its beneﬁts and appropriateness (as outlined in Branch,
1998; Huber, 2003), others such as Wear (1998) and Russell (2002), have
suggested that the white coat actually functions as a source of the hidden
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
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 ﬂourish,
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 ﬁnancial 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, reconﬁguring WCCs and
fostering transparency within the profession in general may in fact impact
medical training’s ‘healthy tissue’ (re-organizing curriculum to include IPE,
possibly forfeiting the positive side-effects of the WCC and even sacriﬁcing some
degree of authority and autonomy). Although some tumors may be eradicated
and others ‘merely’ controlled, the overall effect is a more sustained and
nourishing environment for the seeds of a more modern-day or ‘new’ professionalism to be established and ﬂourish (Irvine, 1999, 2006; Working Party of the
Royal College of Physicians, 2005; Coverdill et al, 2010).
We have posited how and why the principles of professionalism (and the
development of these principles among medical students) have struggled 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/
control over the other health professions and translating them to future
physicians, the medical profession has nurtured and sustained the hidden
curriculum, speciﬁcally the ‘teachings’ of power differentials, hierarchical
boundaries and overarching inequalities in health care delivery. Although
appreciable research has identiﬁed the presence of a hidden curriculum within
medical education, argued for its deconstruction and ﬁngered it for the sluggish
growth of ‘professionalism’ within medical students, this speciﬁc 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
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
hidden curriculum) is fully explored and dissected. In order to do this, we
suggest implementing anti-hierachical rhetoric and structures within medical
training such as IPE programs and the signiﬁcant modiﬁcation of WCCs. We also
argue that altering the education setting alone will not curtail the hidden
curriculum. Therefore, practicing physicians and the profession itself must not
only sacriﬁce degrees of authority, but also levels of their autonomy by making
their judiciary practices and political and ﬁnancial 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
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