Episode Three
Confronting the "hidden curriculum" in medical school
Caroline Gérin‐Lajoie:
Welcome to "Sound Mind," a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gerin‐Lajoie.
The idea of a hidden curriculum is not new. This concept of unspoken expectations around behavior and attitudes within educational systems has been around since the 1960’s. In medical school, the hidden curriculum is now under more scrutiny for the messages it sends students about wellness, the pressures of medicine, and seeking help.
Here's Alexandra Mora, a fourth‐year student at Queen's University Medical School, explaining her experience with the hidden curriculum.
Alexandra Morra:
To me, the hidden curriculum, it's the little things. It's the offside comments made in a lecture. It's the facial reactions when you tell someone that you want to go into family medicine or psychiatry. It's the little digs that you hear on a rotation about, "Well, this was a referral from a family medicine doctor and they should've known better."
I have a specific example. When I was on a paediatrics rotation, a specialty that sees quite a number of patients with mental health problems, and when I told my preceptor that I wanted to go into psychiatry, her reaction was, "Oh, no. You want to work in the loony bin." What do you do in that situation?
I'm lucky, in that I had a little more experience under my belt and that kind of stuff doesn't bother me. I can imagine someone who's 22, 23, no real‐life experience before. That would impact them and could even change their trajectory as to what residency they want to apply to.
I don't think it stops there. I think there's also a hidden curriculum in the sense of trying to breed a certain type of physician with the culture that still goes on - that physicians should be infallible. It breeds this sense that you can't be vulnerable. That's quite frankly a shame, because there's such a beauty, and power, and vulnerability in relating to all of your patients.
I've heard it time and time again of students being so afraid to speak out or ask for help, because they're afraid they're going to get stigmatized. They're afraid it's going to go on their record. Even within the curriculum now, they have integrated wellness. I think it all was made with good intentions, but it still is more of this prescribed, "You need to do X, Y, and Z. You should be doing yoga, and this, and that. If you're not and you're not feeling great, it's your fault." It's a lot of individualism instead of looking at a more systemic approach.
It needs to be more of looking at a systems‐wide issue and seeing how we can debunk that stigma. Normalizing that it's OK to not be OK, that it's OK to have bad days, that it's OK to feel down, and that it happens. It happens to over a third of students, and it's understandable.
You're working long hours, you're not sleeping much, you're not eating properly, and you're being put under very extraneous conditions. I think that's the first thing is normalizing it and opening the conversation, making it a place that's safe to talk about, rather than one that's more, "Put it under the rug and do X, Y, and Z."
With the hidden curriculum, it even goes as far as applications. Earlier this year, like in November, the family medicine residency programs created a standardized reference letter template. Part of that, at the bottom was professionalism. One of the questions was, "Have you seen this student cry before?" or something to that effect.
Thankfully, it created a bit of an outrage, because if that's the kind of attitude that we're putting out there, that physicians can't cry, they can't be vulnerable, then what kind of physicians are we making?
Caroline Gérin‐Lajoie:
Alexandra Mora, a fourth‐year medical student at Queen's University, talking about her experiences of the hidden curriculum. We're now joined by Dr. Genevieve Moineau, president and CEO of the Association of Faculties of Medicine of Canada ‐‐ or AFMC ‐‐about how medical schools are responding to this challenge.
Welcome, Genevieve. When you hear a story like Alexandra's, what's your reaction and response?
Geneviève Moineau:
Thank you very much, Caroline, for asking me to join you. First of all, I'm very thankful that Alexandra came forward to share her story. Takes a lot of courage, as you've heard, for students to speak out and to be part of this conversation.
Unfortunately, I believe that many other students have had similar experiences and could share similar stories. The key points that she brings forward are exactly these areas that need to be addressed.
Caroline Gérin‐Lajoie:
Many people in medicine are using the term hidden curriculum. Can you explain to us what this means?
Geneviève Moineau:
The Association of Faculties of Medicine of Canada identified over a decade ago in the Future of Medical Education in Canada ‐‐ or FMEC report ‐‐ the need to address the hidden curriculum.
In the report, we define hidden curriculum as a set of influences that function at the level of organizational structure and culture, affecting the nature of learning, professional interactions, and clinical practice.
The FMEC report specified that faculties of medicine must ensure that the hidden curriculum is regularly identified and addressed by students, educators, and faculty throughout all stages of learning.
Caroline Gérin‐Lajoie:
You're highlighting that this is an issue that involves all of us?
Geneviève Moineau:
Absolutely.
Caroline Gérin‐Lajoie:
Beyond the examples that Alexandra shared with us related to the hidden curriculum, are there other types of examples that you can share with us?
Geneviève Moineau:
Regardless of your background, you will potentially be in a situation where comments are made, whether it relates to your gender, whether it relates to your cultural background, or whether it relates to where you've come from, and even your socioeconomic status.
These are some other important aspects of the hidden curriculum that must be addressed.
Caroline Gérin‐Lajoie:
What are your thoughts on the impact of hidden curriculum on the medical learners?
Geneviève Moineau:
Our learners are most impacted by what they experience. There's what you hear in the classroom, and then there's what you live. That lived experience is the behaviors that you observe, the words that you hear that come from your teachers, your supervisors, your preceptors, and all those in your environment.
Students are particularly impacted by what they hear and see from people in positions of influence.
Caroline Gérin‐Lajoie:
Like many other professions, medicine has some cultural issues. How does the hidden curriculum carry over into the culture of the profession?
Geneviève Moineau:
The hidden curriculum becomes the culture. Students aspire to their role models. As a result, take on the same behaviours that they observe and experience in hopes of becoming who they admire. This becomes a cycle that must be broken.
We need to be reminded that we are those role models and we are being watched and imitated all the time. We need to understand the impact of our words and behaviours on the wellness of our learners.
Caroline Gérin‐Lajoie:
In your opinion, Genevieve, what is the impact of this on practicing physicians further down in their careers? Are they more at risk of exhibiting disruptive behaviors, for example?
Geneviève Moineau:
Absolutely, Caroline. This is the cycle in fact, and so our students and our residents become what they have observed. They perpetuate this hidden curriculum.
Caroline Gérin‐Lajoie:
Let's switch gears to talk about breaking that cycle or to talk about culture change. What role can medical schools play in changing this?
Geneviève Moineau:
Medical schools have a fundamental role in ensuring that teaching and learning environments are respectful. It's our responsibility to ensure that these environments are positive. We need to engage with our colleagues in all health professions, the hospital staff, the learners, the patients themselves, who each may contribute to these issues.
We need to create environments that are open to communication and complaint reporting. We need to be raising awareness of inappropriate behavior through conversations and communications at all levels within medical schools and across the continuum of education. We also need to highlight and reward exemplary conduct.
Caroline Gérin‐Lajoie:
I have also read about initiatives related to mentoring or peer support as an attempt to try to support the medical learners. Is this something that you've heard of or that you've seen?
Geneviève Moineau:
Absolutely. Across our medical schools, there are mentoring programs that have been established that try to address these issues as well.
Caroline Gérin‐Lajoie:
We would hope that leveraging mentorship and peer support may help to create that safer place, as Alexandra mentioned in her story. There has been a lot of discussion about the just culture model as a path to change in medical culture. Can you talk about this model a little bit and how it could work?
Geneviève Moineau:
Just culture is a philosophy that supports an environment where everyone feels safe and there's a shared responsibility over actions. It's a culture that holds organizations accountable for the systems they design and for how they respond to behaviours fairly and justly.
This is a model that is being used to a certain extent in our faculties and that is well‐suited to manage issues of hidden curriculum in the learning environment.
Caroline Gérin‐Lajoie:
We know that cultural change takes time and can be hard to shift. What positive changes have you seen over the span of your career?
Geneviève Moineau:
I won't dare to let anyone know how many years I've been practicing and teaching in medicine, but there have been some significant changes. I do think that there are fewer extreme, egregious issues in medicine compared to a generation ago.
However, we still have much work to do. Our structures have been enabled by our accreditation system, for example, where there are some very specific standards that require faculties to set up processes, procedures, policies, and offices that help support our students so that they can be in that better environment.
This has helped a significant amount, but we still need to be looking at what I would call the micro-aggressions. The experiences that Alexandra, again, described so eloquently of the day‐to‐day, the comments made, the specific behaviours, the behaviours that individuals are continuing to exhibit that lead to these negative environments.
That is the challenge moving forward - to focus on how we ensure that everyone in our health education and healthcare environments do have those respectful behaviours and respectful conversations at all times with our learners. In effect, eliminating the hidden curriculum.
Caroline Gérin‐Lajoie:
Dr. Genevieve Moineau, are you optimistic that within the next 10 years, we will be able to help improve the medical culture?
Geneviève Moineau:
I am optimistic. I do think that at this moment in time in healthcare, we are in a difficult situation. We are in the midst of a very challenging health crisis with the pandemic. Prior to
that, our system was already stressed. We have clinicians who are dealing with new electronic medical records who are now required to have much more accountability than we did years ago.
We are a stressed system, so we do need to recognize that. Yet, we do need to appreciate that we have to move forward so that our learners live and train in a positive work environment, despite all these stresses. If we can do that, and if we can make positive change in this realm, we will have a very, very important positive impact on healthcare in the future.
I'm very thankful that the Canadian Medical Association is focused on the area of wellness and is challenging us to work on the culture of medicine. I look forward to working with the CMA and our other national organizations to address this in a significant way.
Caroline Gérin‐Lajoie:
You've been listening to Sound Mind, a podcast about physician wellness and medical culture. It's produced by the Canadian Medical Association in collaboration with Podcraft Productions.
If you are looking for resources, tools, and research on the topics covered today, please visit the CMA Physician Wellness Hub at cma.ca.
I'm Dr. Caroline Gérin‐Lajoie. See you next time.Transcription by CastingWords