The Hidden Curriculum

In this episode, we discuss the Hidden Curriculum with Dr. Jasmine Smith. Our guest highlights the informal curriculum that many students and resident encounter during their training. Dr. Smith shares powerful personal stories from her own journey and tips on how to navigate a new environment which can be used by professions in any industry.

Transcript

[0:00] Intro

BP: Welcome to the DEI Shift, a podcast focusing on shifting the way we think and talk about diversity, equity, and inclusion  in the medical field.

QY: I’m Dr. Quentin Youmans    

BP: and I am Dr. Britane Parker. 

QY: And we will be your host for today's episode. Today, we are excited to bring you an episode featuring Dr. Jasmine Smith. In this episode, we will be discussing the Hidden Curriculum in medicine. 

[0:39] Introduction to Dr. Smith 

BP: It is my pleasure to introduce Dr. Jasmine Smith. She is a native of California and graduated from Stanford University before heading to Wake Forest University School of Medicine where she completed her medical school education. She also obtained a Masters in Business Administration from the same institution. She completed her residency in internal medicine and pediatrics at the University of Arizona College of Medicine where she served as chief resident in her last year in the pediatric program and was honored with the distinction of Internal Medicine Resident of the Year. Dr. Smith currently practices academic medicine in Los Angeles and is a Clinical Assistant Professor. She has held many roles in her career  including working as a medical director, co-director of recruitment of physicians in her local institution, and has been a strong advocate of early career physicians and students in medicine. She is known for her mentorship and continues to be asked to speak on topics such as business practice in hospital medicine, affective clinical teaching, as well as diversity and inclusion in the medical field. I can think of no one better to invite on the podcast to discuss medical education in the hidden curriculum. Welcome to the show!

[1:52] Dr. Jasmine Smith speaks 

JS: Thank you so much I am really excited to be here and just to have this time to speak with the both of you. So thank you so much for having me. 

QY: Well, we’re so excited to have you here and we’re excited for our show tonight. 

Dr. Smith first of all we’ve been referring to our guests by their first names on our podcasts, is this okay?

JS: That’s perfectly fine 

QY: Okay. Thanks, Jasmine. We look forward to discussing this important topic with you. Before we get started is there anything we missed in your introduction that you’d like to share with the audience? 

JS: I think you guys covered the highlights. I’m passionate about mentorship and passionate about seeing others succeed and i think it's really important that any lessons that I’ve learned that I can pass those along to make things easier for those that are on a similar path that I was. I think that about sums it up. 

QY: Thank you so much, we really appreciate your insights. So, lets transition into our next segment called “ A Step In Your Shoes” 

------------------------------------TRANSITION-------------------------------------------------------------

[3:08] A Step In Your Shoes 

QY: In this segment, we ask our guest to share something about their background that they would like our listeners to learn about. This could be anything from a type of food or drink, a song, genre of music, poem, etc. The goal is to not only to get to know our guests on the show but to also build cultural competency and humility.

QY: With that said, Jasmine, what would you like to share with us today?

[03:34]

JS: Well, something I thought about was what it was an event that inspired me to pursue medicine and as a reflecting on that and reflecting on just the importance of understanding and the importance of just understanding the shoes that other people have walked through, I thought about how I was inspired to enter medicine after going to the Museum of Tolerance as a child. So, the Museum of Tolerance is a museum in the Los Angeles area where you can go and understand better some of the things that happened during the Holocaust. And one of the things that was pretty profound for me was that as you enter the museum, everyone gets a card or a piece of paper that describes a person who lived during that time. And by the end of the tour, you learn what happened to that individual who was on your card or a piece of paper.

JS: And so in this museum tour, you know, you walk through, see the different exhibits, you go through a simulated gas chamber and, you know, there's speakers and you just kind of get a sense of what that might have felt like. You know, I remember having a card that displayed the name of a little girl who was about my age at the time and I remember at the end of the tour learning that she lost her life during the Holocaust.

JS: And I remember being there and thinking about how that girl didn't get to live her life. As I've reflected as I've gotten older, you know, she didn't get to pursue all of the dreams that she had and maybe walk out some of the hopes and dreams that her family had for her. I remember thinking about how important it was to make my life mean something. I think that was one of the earliest influences for me on  pursuing medicine and pursuing what I felt like it was a career that would allow me to leave an impact. So it was that experience, that one time experience in the Museum of Tolerance that was one of the major inspirations for me to enter the field of medicine. And I think reflecting back, thinking about how a population could be targeted and the things that group of people went through just for existing and understanding how people might have felt hopeless and helpless.

[06:40]

JS: And I think sometimes, right now, especially, we see reflections of that in our society and wanting to be in a position where you can advocate and make effective changes. There's something that's always been important to me. During these last couple weeks, I've just had some time to reflect on things that have impacted me. And just remembering that experience about seeing a group of people being targeted for something that they were born with and wanting to make sure that I lived a life of purpose and advocacy as well.

[07:21]

BP: That's really powerful, Jasmine. And I don't think I've ever heard of an experience like that where a museum had such interactive activity where you actually were able to get a card with the person's name, walk through, learn about the experience and find out what has happened to them. Who else went with you?

[07:43]

JS: It was part of a school trip and I was somewhere between, I want to say, maybe around third or fourth grade. So I was pretty young. And so I even know some of my family members are like, why are you thinking so deep at that age? You know, it's like, I don't know if that's that read through my head. But it was part of a school field trip and it was something that was part of the curriculum that we did every year. And I don't recall a ton

of reflection that we had as a group afterwards, but I knew that it was something that I reflected on for a while after kind of walking through there. You know, on my own or  kind of talking about it a little bit with my parents. So it was definitely a profound moment and something I haven't ever forgotten.

[08:34]

QY: That's really powerful. I think it makes me think about one of the things in society, one of the issues is this empathy gap that's really pervasive when it's really hard a lot of time for people to put themselves in other people's shoes. And I think this experience that you describe is really powerful because it forces you during this time to really think like and live, and imagine living like someone else.

JS: Right.

QY: And I think often times when we do that and when we have experiences like that, we literally do kind of think about walking in someone else's shoes. We can see how injustices and things like that that you're mentioning can really affect people emotionally, their psyches and and then even in this little girl's life, her hopes and dreams. So, thank you for sharing that, that's really powerful.

JS: Yeah, I just think it's important. Especially right now, as we see a lot of people hurting intentionally, try to think about what it is to walk in someone else's shoes and to try to at least empathize, even if you feel like you can't understand someone else's perspective.

--------------------------------Transition to discussion-------------------------------------------------

[9:57] Transition to Hidden Curriculum discussion 

BP: Well, let's jump into our discussion. So, Jasmine, we brought you here because we wanted to talk more about the hidden curriculum in medicine and I was hoping that you could give our audience your definition of what that is.

Defining the Hidden Curriculum

 JS: Yeah I think you are so I think the hidden curriculum as a concept has been described even in other fields and even in the context of medicine. I was referencing earlier to a position statement that came from the ACP specifically about the hidden curriculum that came out a few years ago. But basically, the hidden curriculum, in medicine, I would say, refers to unwritten and unofficial rules, behaviors, knowledge base and expectations within the field that not everyone has access to. I think it's clear that those who have gained that knowledge and expertise over the hidden curriculum and  those who have mastered it, clearly seemed to have an advantage over those who don't have experience with it or those who have not mastered it. I think that much of the preclinical years in medical school is really focused on knowledge retention. I remember medical school being described as a water hose of knowledge, and so you drink up as much as you can, and you hope that the pieces that you initially missed kind of haven't evaporated into the environment when you go searching for them during that two days that the hose was turned off, so you can breathe after a test. I think this is something that most people are used to coming out of college or maybe not being that far removed from college.

JS: Really, in those preclinical years, your focus is on reading and you study, you retain, you perform, and then you repeat that cycle over and over. Then when you transition into the clinical years, you're supposed to take that knowledge and apply it to a clinical setting and I think there's a formal curriculum that talks about, disease recognition and disease management, etc. But there are a lot of things that lead to success and lead to you making a positive impression during those years that aren't overtly shared. 

JS: So, I can think of the first time I feel like my eyes were opened to this hidden curriculum. It was during early in my clinical years in medical school and I recall being on an internal medicine rotation and getting feedback from the attending. I think maybe it was a couple weeks into the rotation and I remember the attending asking me - specifically he said, “You know this all seems really new to you.” And he asked me if there was anyone in my family who had a career in medicine. I said, “No”. He said, “Yeah I can tell”. And I'm like what do you mean, “You can tell.”?  He said, “Everything seems very new to you.”  And I remember thinking to myself, “I thought it was new for everyone. What do you mean its new?”

JS: Then it causes you to reflect, right? I'm like, I have the same pocket medicine book. I read about the patients. I tried to build my knowledge base, just like everyone else. But what is it about me that stood out? What was I not doing? How we're my interactions different? And it really caused me to take a step back and do more observation. Just to try to glean a better understanding of what was it that I was missing that made me stand out as someone who you know was missing a part of what it meant to be successful as a medical student and successful as a physician. So I really, at that point, - I don't know if it was being paranoid or just feeling like I was behind - I was like, let me be observant and try to understand what I'm missing. Because there clearly are people who aren't standing out in this way that seem to have some experience and who don't have this air of newness that I do even though I thought we were on the same playing field.  I don't think any of us have done this before, but okay, maybe there's something that I missed along the way. 

[14:21]

BP:Yeah, thank you for sharing your experience, and I appreciate that you brought up the position paper from the ACP. You know, I read that too it was published in February of 2018 and they discussed... I think it was  put together by the ACP ethics, professionalism and human rights committee, and they talked about exactly what you said, that the hidden curriculum must become a positive curriculum that aligns with the  formal curriculum. In that position paper, they talked about how the learning environment needs to foster, respect, honesty and empower every individual. And what you're describing as what you experienced when someone is maybe making you think that you don't understand, what's going on you know or don't belong in that environment. It's very challenging.

Having Confidence As A Novice

JS: Yeah, I mean, I think you know one aspect about that hidden curriculum is this overarching air of you being expected to present yourself somewhat of an expert over material that you truly are novice with. Right? I think sometimes you can feel like am I being dishonest and my pretending? I don't really know what's going on yet? I just read about this two nights ago and I'm a medical student and I have a patient with it. Maybe I’m a sub-I or I’m an intern and I never saw this in medical school. But I’m supposed to speak with assertiveness as if have some kind of expertise over this material and I don't really know if I really do. I don't know if I feel comfortable in that realm.

JS: I remember with observation…I can think of a couple of other instances during that school. I remember being a medical student on a cardiology rotation. The third year medical students were all responsible for reading the EKG at the beginning  of rounds every single day.  It was something that people were very nervous about, had a lot of anxiety over. You can see people sweating right before rounds started and “I'm gonna get called on first?”

[16:39]

JS: Its the things we all go through. “I don't know! I don't know! Is that T wave peaked or is it a biphasic T wave? I don't know! What does that even mean?” I remember watching some of my classmates - I remember them reading the EKG’s and I'm like looking at them like, “I don’t think  that's what that says.” But the way that they read the EKG  was with a lot of just assertiveness. It was like I see “This, this,  this, and this.”

JS: And I was like, “Huh?” That's so interesting because I didn't see that. Initially, when I would read my EKG's I didn't have that same degree of assertiveness, but I watched the feedback that they receive. I caught on very quickly that even if you're not certain, you speak with the assertiveness and you speak in a manner where you're you say  this is what I’m trying communicate. I'm not going to communicate this with a question mark at the end of my sentence, but with the period. I started doing that and I clearly remember one day when I was reading an EKG and I wasn't sure about a few things. But I was like, “Let me go with what I see and what I know and I'm just going to speak with assertiveness. I clearly remember the attending, saying great job and then proceeded to tell me how I was wrong. As I reflected on it later, I thought, “I was wrong,but he told me, ‘Great job.’”

JS: From there on there's a lot of positive feedback. Over time,  you build your knowledge base and you truly have more confidence in what you're reading. But I didn't realize that you're supposed to display a degree of confidence from the beginning and it can be a fine line at times, but that you know that's a lesson learned, right? 

JS: I think in medicine, the environment is unpredictable right. We tend round around the same time, but you know things happen with patients that sometimes we didn't anticipate or patients show up that require attention right away. So often times in this environment where you need to say what you need to say and leave out the fluff and be precise with your words. That's something that I saw as I was watching some of my classmates who already seem to have that information and  knew that that's how we were supposed to approach each rotation. I was like, “When did they learn that? No one told me!”

JS: Same thing when I was on a O. B. G. Y. N. rotation. At this point, I had had a couple rotations under my belt, and I would always take the first couple of days just to observe and just to kind of see what things seem not to go over so well with the residents and what same things seem to go over well with the resident or the attending in the context of being a med student. I remember when we have lecture and a couple days later one of my classmates asked, I believe, it was one of the residents about something that was covered in the lecture and the response to the medical student was, “Didn't you just have a lecture about this? Why didn't you ask a question during that lecture? Because when we teach you something and you don't have a question, we expect you to know it.”

[19:52]

JS: And I was like, “Oh, noted.” So you ask your questions during lecture and there's a way that you ask follow up questions, right? And, so my thing was, I'm not just going to ask a question: I'm, gonna, research, first and say, “Hey, I noticed that this guideline said to manage patients in this way, but this guideline says to handle a patient this way, can you help me reconcile that? Or what made you choose this path instead of this path? That's perceived as a very different question. That's not a medical student who doesn't want to look something up. That's a medical student who looks something up and is asking for clarification. I saw how the way that you phrase the question went over well. Even though me and my classmates were asking the same thing.

[20:38] Feedback vs Value Judgements

QY: This makes me think a lot about the importance of, as you mentioned, confidence throughout medical school. I think it can be hard to start, particularly the third and fourth years when you are actually seeing patients and expected to present, to start that process with confidence. I think that what your attending shared with you - I think a lot of times when we get constructive feedback, it's helpful because we can act on it and it's very specific. But what your attending shared with you about - “This seems new for you. Did you have any physicians in your family?” - that wasn't even really feedback or an evaluation that was kind of just a judgment... like a value judgment on you. I wonder what impact did that have on your confidence? And then how were you able to make that complete switch? Where if it did affect your confidence in a bad way, but the hidden curriculum is teaching you that you must be very confident. How would you recommend for students to make that switch when they hear something like that?

[21:42]

JS: No, I I think that's fair and I was taken aback when I got that feedback. And it  made me reflect on myself and say, “What was I doing wrong.” I had to realize that clearly there are others in my medical school class who may have had experience or may have been given some additional tidbits that maybe I wasn't privy to or maybe you know present themselves in a manner that I wasn't privy to. So, for me, the switch was that I had already made up my mind before being on this rotation, before entering med school, that I wasn't gonna let what someone else said about me negate what I already knew about myself. So I think the first step is always to be clear about who you are. So you would come in and you know you're a hard worker, right? You know there's a reason that you're there. You know how to retain information. You know how to take feedback. You know you know how to make an adjustment when needed. So, I think the first step was to reconcile myself and to reconfirm with myself that there's nothing wrong with me, right? But I think sometimes when you get feedback, it’s like something is inherently wrong with you. That suggests that maybe you don't belong here. And I said no, “There's nothing wrong with me. There's just information that I haven't been given access to. For whatever reason. And maybe that's because I didn't come from a legacy or maybe you know people knew who to talk to before coming on the this rotation, maybe I wasn't talking to those same individuals. 

[23:24] Recommendations for Learners

JS: And so, again, the first shift was recognizing within myself that there was nothing wrong with me, but then I had to take the next step and say, “Okay, where else can I get this information?” And so, one thing that I made it a point to do from that point forward is to find everyone that I could who have been through those rotations and just pick their brain instead. Okay, so I know the things that I need to read for the knowledge, but tell me the things that you wish you knew before you were on this rotation that would have made you more successful or tell me the things that you wish you never would’ve done. Or what was the mistake that you make that you keep thinking about. And I'll be honest, some people were forthcoming and some people weren't right. But for me that didn’t stop me because I was like, there’s something that I don't know and this is my first time being in this environment where there is a hierarchy in medicine. I think there's been a lot of work to say, let's remove that hierarchy. But it still exists because there's an attending who has more experience than you, a resident that has more experience than you, an level medical student has more experience than you. So they're going to know more than you, right? And so I was like, “Let me identify  people who can serve as on-the-go mentors, for lack of a better term, to help me understand what I might be missing, because there's something HIDDEN that I'm not seeing. I want to do whatever I can to make sure I have access to that.

JS: So again, the initial shift is acknowledging that there's nothing wrong with you and then moving to say, “Where can I identify resources to give me access to this curriculum that I seem to be missing.”

[25:08] Conflicts between formal education and culture

BP: I really like that and you talked about how you reached out to get advice from other people. I am just reminded of some different issues in medicine. For instance, women who are surgeons, right? So, oftentimes they come into residency and maybe don’t know to ask others “What’s the experience been?” Because some things that I have heard is that [women] assert themselves and for their male colleagues it may be seen as assertion but for them it’s seen as aggression.

JS: Right

BP: Or you know we teach wellness to our students and our residents. But then that senior resident brags about how they just did a 36-hour shift.

JS: Right

BP: So it’s kind of conflicting messages. So what would you say to educators or people who are interested in being mentors on how they can address this upfront and teach trainees on how to navigate these difficult issues?

Addressing the Hidden Curriculum

 JS: So I’d say the first thing is to admit that it exists, right? There are a lot of medical school curriculums  there are these couple of weeks where it’s kind of like Boot camp for going into the pre-clinical years. Let’s remind you that you know how to present a patient, let's remind you that you know how to write a note, let’s kind of run through the process of making a differential diagnosis but I think we also need to admit that there's some elements outside of those specific lectures that are focusing on clinical knowledge and maybe some degree of presentations that you’re missing in that boot camp. So, admit that some of that information is missing, first of all. But I think also, acknowledge that those who have privy to that information will have an advantage. The other thing that I want to pause and say is that some mentors themselves I don't think feel like that you have access to the hidden curriculum themselves, right? So, I think there are some interns that might reflect and say, “Oh, you know what? I didn’t know these things” and maybe they learned and navigated their way through and then on the other side of their training now they're hearing their colleagues talk about a medical student that they’re working with and how they're going to evaluate them and say, “Oh my goodness that's probably how people were talking about me because I didn't know to do that or I didn't know not to do that etc, etc.” So, acknowledge that there is an advantage and acknowledge whether or not you feel like it you know what that hidden curriculum is. I think educators and mentors maybe should take some time to collaborate and reflect on those items that they felt like were missing from the former curriculum and put them in an accessible form, because I think access is something that's missing and so whether a lot of people like to formalize things into a lecture. But it doesn’t have to be a lecture, it could be a discussion. It could be a document that's posted somewhere.  Giving people access through directing them to someone else who might be able articulate those things or just even one on one reflecting on the items they wish they were aware of before they entered into those clinical years. I think also as a mentor and educator advocacy, right?  So knowing that not everyone has access to this curriculum when you hear someone, a student or a resident being evaluated on a parameter that that person didn't even know existed, advocate for that person. Let’s say you are the intern and say, “Hey, maybe you should be upfront with that expectation that you have that medical student or resident before you evaluate them on that perimeter, right?

[29:17] Reflection on encounter as chief resident

JS: Sometimes I can recall being a chief resident and it was like the first week of the academic year and I remember I got an email from an attending physician who said, Oh, it was this intern’s first night on call like ever in life, right? What possibly it's like their first day I'll call every like this is our first time being up all those hours. I was like goodness gracious. A faculty member sent an email saying “I have concerns about this intern’s performance. It took them too long to finish all of their documentation and I had to wait for them.” And I was like it's their first night on call ever. I think it probably took everyone a little bit longer than what you do now. You know how to write a note but like it's your first night being…you know being a doctor. And so I remember saying, “Well, why don't you share with that person you know that it's you know your expectation for when the documentation needs to be completed? And also recognize that it was the first time that they've ever had to do this task and ever be this role and ever having to push some of their physical limits in this manner before in your life.” And provide that feedback to them directly and because I think some time there’s a lot of talking around the issue and sometimes people don't receive that feedback. And again, I think holding colleagues accountable to say make sure, again like I was saying before, if you're going to evaluate someone on a parameter that's not overtly evident then you need to make sure that they're aware of that. So that’s something I would say in terms of mentors, things that they can do to help make this information accessible and help advocate for their mentees who may not be aware of all these things.

[30:13] How to effectively evaluate trainees

QY: I think it's so important and when thinking about operationalizing that, in academic medicine, we think about attendings and residents, a lot of us have these evaluation forms that we use and we have a lot of times meetings and things like that where we discuss this is where we’re going to be evaluating students and this is how we expect. And honestly to your point I think the hidden curriculum should be a discussion when we're orienting our attendees and our residents to what they're going to be doing for evaluations because it all plays into each other, too. Even thinking back to the confidence as you're going through your 3rd year rotations, if you put a couple of rotations together and your evaluations are not taking into account this hidden curriculum and you're getting a couple “passes” that can play a huge role in how you perform the rest of the year. I think it's such an important point teaching about the hidden curriculum and also training those evaluators and those attending physicians who were going to be doing those evaluations to actually address the hidden curriculum.

[32:20] 

JS: Yeah, I agree with what you're saying and I think it is important to operationalize that. I think you know everyone wants to say we do evaluations so that we can make sure that as much as we can remove subjectivity and make the evaluation system as equitable as possible and we put it in an online form or a paper form. It's a standardized question. But if we're honest there's always going to be a level of subjectivity to that, right? So if you are an evaluator and I think also someone being evaluated,  set some time to say… When I was in medical school another thing that I started doing was asking the resident I was working with or a resident working with an attending asking “Hey, I want to be successful and learn all I can during this experience. Tell me things or any advice that you have for helping me to be successful during this rotation and are there things that other people in my position have done that haven't gone well?  Or that you wish they wouldn't have done? Or have not led to good interactions with the patient or with the team?” Just kind of what are the dos and don’ts.

[33:43] 

JS:And one thing that I tell students and residents or mentees to do is one thing that you can do because you're like well “how do I know what I don't know, right?” Asking upfront for expectations from each of those individuals that’s going to be evaluating you because you make it to standardized form that says, “Oh there's six domains of clinical knowledge, professionalism, like did you show up on time? Did you make the child cry?’ Whatever, I’m just making these up but just asking what their specific expectations are upfront and write that down. And just say OK, here are the domains I was given on the evaluation form but this person who's evaluating me, these are the things that they said they expected of me. And you also reap having had that information, then you have to do your part, right?  So when it comes to the end of the evaluation period. You're like well I didn't know supposed to do that? The evaluator will say ‘Well, you asked me what the expectations were and you know I'm going to hold you to that.’ So as a trainee asking for those expectations, asking for feedback. So that something else today I think I put even into better practice when I was in residency. In my residency, we have these “Feedback Fridays” that sometimes people did, sometimes they didn't.  But like I had my own feedback schedule, right?

Once or twice a week I would just check in with people who are evaluating me and say “Hey, how do you think I'm doing? What is something I can do to improve? I really wanted you to take good care of his patients. I really want to contribute to the team.” I think asking every single day may get a little bit cumbersome but asking 1 to 2 times a week, I think most people would be receptive of that. And I would even know sometimes  I would even send an email back and say “Oh, thank you so much for that feedback. I really appreciate you sharing these points with me and I'm going to put us in the practice immediately.” So #1, that's a reminder for me but #2 when it comes to the end of the evaluation period and if someone tries to say you didn't meet my expectations you have a written record that says actually you just said that I did.

 QY agrees

 JS: So asking for feedback, listening intently. Observing intently. Being tactful and again, tapping into resources of people who have been through that experience before you. Another thing that I try to put in practice is to always try to model myself after the person who was one step ahead of me in training. So, if I was a third-year medical student look at what the fourth-year medical student was doing. If I was a fourth year, look at the intern was doing and so on and so forth. And that often was helpful because I was like how are they operating? How are they acting? If I could model myself after that person than I should be doing more than what was expected for me at my level.

[37:10] Practical Points

BP: I think you've given us so much great advice. Us and our listeners who are either looking forward to going to medicine or who are training now. Some of the highlights of what I hear you saying about the hidden curriculum is #1 to really acknowledge that it really exists. #2 to be observant as a learner or a medical student, or resident and to be proactive. So, I really liked your suggestion about creating your own feedback schedule. Asking for expectations upfront so that you know what's required of you . And then thirdly, advocacy. You talked a lot about the importance of being objective when giving feedback and that may be something that we all need to think about to make sure that we are evaluating our trainees based on where they should be but also keep in mind if there's something that they seem deficient in, do they have the resources and the tools to know... First all, do they know it’s an expectation and do they have the resources and tools to meet that expectation.

JS: Exactly.

BP:  Is there anything else about the hidden curriculum that we haven't covered that you'd like to leave our audience with?

[38:40] Responding to discrimination

JS: I do. As I was reflecting on this topic, I think there's a hidden curriculum that again that has been described in the literature that talks about whether it's speaking with confidence or kind of the nuts and bolts of interacting with attendings and residents and understanding the hierarchy of medicine. Or just how to interact with your ancillary staff members etc. etc. That is something that I think everyone in the medical field learns or is clued in on. But I think there's even an additional hidden curriculum that trainees who don't look the way that some people feel like a physician should look and have to be aware of as well. So in that realm, I think about - OK there's an additional curricula about how to respond to others and that could be patients or that could be people evaluating you or that could be your peers. How to respond to people who believe that you don't fit the profile of a physician, you don't look the part of the physician. Or someone who feels like you don’t belong in a certain space, right? So how do you navigate that? So you have this other curriculum that you're supposed to be confident. You're confident and respectful . You’re supposed to be an expert but you're also a novice. Additionally, how do you deal with those challenges when it’s laced with someone who feels like you don’t belong in that space or doesn’t expect you to be in that space. And some of their commentary or the way they interact with you may produce some added challenges. So, I think that's also something that needs to be acknowledged and admitted. And I think that takes  an even larger degree of advocacy to say ‘are you evaluating that person, can we really think about the concrete examples that you have of why you're giving that person that evaluation? I feel like I was observing with you and I feel like they were on par, if not better than some of our colleagues, right?’

[41:05] 

JS: And I think about another experience that I had when I was on surgery rotation and it was myself and two of my male colleagues in medical school and the surgery attending was asking us about antibiotics and was asking us about the D-test related to some of the inducible resistance that develops in clindamycin.

So he was asking us some specific questions and I read like as often as I could in medical school because I felt like I don’t know anything, I’m going to read, read, read. And so when he asked that question I was like “oh my gosh! I read this two days ago. I know what this is. I got this.” I was so excited. I was like I got this. [Everyone laughing] I know exactly what this is and don’t even need to reference my notes. I got this down. I was spouting out all the answers. This, this, and this. This is why it happens, etc. etc.

I was so proud of myself and the attending’s response wasn't, “great job you knew the answer”. The attending's response was to turn to my colleagues and say, “Hhy does she know that and you don't?” I was like “wait what?” And he said, “How come she knows that and you don't.” And I feel like it was a very specific comment, “why does she know that and you don't know it?” I wanted to be like, ‘because I read it two days ago’. It wasn’t “oh yes, you know you’re stuff” but more of “she shouldn’t know that answer without you guys.”

BP: Wow.

JS: It was an experience that really struck me and it bothered me. I'm on top of my stuff. I'll never know everything there is to know in medicine but I really try to continue to build my knowledge base because we’re lifelong learners. And it was a moment where I was just like, you know what, there will still be times even if you are on your game that that’s not something that’s celebrated. But somehow that's twisted into there's something wrong with our system if you are excelling in these other people that I think should be excelling are not. And that's how I received that comment, and so how do you respond to that? And again, acknowledgment that those experiences will continue happen especially if people still hold the opinion that there's a certain look to what a physician looks like. Or what the profile of someone in this specific specialty should look like. That doesn’t mean like you as the trainee... you don’t shrink back. You know your stuff, you know what you're doing. You know you're continuing to build your knowledge base. And again, like back to what I was referencing before, don't like the comments of others cause you to question who you are and what you know.

 QY agrees

[44:23] 

BP: Yeah. I mean your stories, I know that a lot of our listeners will be able to relate to that and you know I think it's just so important for all of us to really be vulnerable and to be honest about the kind of situations we've been in, even if it's painful. I know you said this really bothered you and it probably still bothers you today. But I think just sharing is so important so that other people can know ‘OK I just experienced this but I'm not alone’ and I know that I have the strength and the knowledge to keep moving forward. Especially in medicine which is very challenging not only in training. As a practitioner there are things that happen that are just tough. And we really do have to have resiliency and that faith in ourselves.  

[45:22] 

JS: Definitely and something my father taught me was to find ways to flip the situation and so in that experience, yeah in the moment it was hurtful but I use it to say OK when it's time for my evaluation, I'm going to remind this attending and say “Hey, remember when you noted that my knowledge base was seemed to better than my colleagues? Let’s use that in my evaluation.” You know you can’t tell someone what to put in the evaluation but just remind them “Oh, I really appreciated it when you pointed out that I was able to answer your questions and have that knowledge base and had that depth of knowledge to understand the questions that you were asking me. It really showed me the importance of continuing to read and build my knowledge base.” Find a way to flip it for the positive. Is everything going to work out perfectly all the time? Probably not, but flip it right? Because even if someone tries to turn that situation to a negative, you have the power in the words to flip it back to a positive.

[46:36] 

BP: OK, thank you so much for this discussion. I think that you've given us a lot of practical points about what the hidden curriculum is and how to navigate it a little bit better. So we appreciate your time.

QY: We’d like to ask our audience to continue this discussion online. We’d love to hear your stories to deal with this topic, your questions and the specific barriers/challenges you’ve faced.

BP: We will have additional resources including a transcript and summary on our website at thedeishift.com. We will also add a link to the ACP article on the Hidden Curriculum. Feel free to contact us at thedeishift.com or follow us on social media including Twitter and Instagram @thedeishift. You can also email us at thedeishift@gmail.com

[47:29] 

BP: Thank you so much, Jasmine, for joining us and talking with us today.

JS: Thank you so much for having me.

QY: It was great to have you all with us today. Tune in for future episodes.

[47:43] Music starts playing

[47:55] Disclaimer: The DEI Shift podcast and its guest provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with.

Season 1 of The DEI Shift podcast is proudly sponsored by theAmerican Medical Association's Joan F. Giambalvo Fund for the Advancement of Women and theAmerican College of Physicians Southern California Region III Chapter.

The DEI Shift theme music is by Chris Dingman. Learn more at www.chrisdingman.com. 

Credits:

Co-hosts/Producers: Dr. Brittäne Parker  and Dr. Quentin Youmans

Executive Producer: Dr. Tammy Lin

Co-Executive Producers: Dr. Pooja Jaeel, Dr. Tiffany Leung

Senior Producer: Dr. DJ Gaines

Editor: Johanna Jain

Production Assistants: Sarahy Martinez, Darian Harris

Assistant Producers: Deepti Yechuri

Website/Art design: Ann Truong

Music: Chris Dingman

Special thanks to: Dr. Jasmine Smith, Twitter: @DrJasmineSmith

Contact us: thedeishift@gmail.com, @thedeishift, thedeishift.