Jane Philpott is Dean of the Faculty of Health Sciences at Queen’s University.
Tony Sanfilippo is Associate Dean, Undergraduate Medical Education at Queen’s University.
Karen Schultz is Associate Dean, Medical Education at Queen’s University.
Canadian Resident Matching Service (CaRMS) season is upon us — an exciting if anxiety-laden time of year when medical students finalize their residency program choices. This process is mandatory for medical students who hope to complete their residency in Canada. It involves ranking the specialties and institutions where they wish to complete their training. The programs follow suit with their rankings of each applicant. A match ensues where preferences are optimized against the number of seats and medical students are ranked accordingly.
In an ideal world, medical students would go into the match feeling that all areas of medicine are equally valued, and their choice would be based solely on interest and aptitude. Unfortunately, it is increasingly clear that students are exposed during medical school to attitudes that suggest medicine is hierarchical, with some disciplines more valued than others. This causes many students to question and even change their intended career paths.
“Since entering this environment I have felt more of a need to compare myself and have felt that choosing a primary care specialty will be looked down upon…. why is that? I did not come here with that attitude.”
– medical student
These subtle and not-so-subtle messages that students infer from actions and inactions of people and institutions, constitute an unfortunate aspect of what has come to be referred to as the “hidden curriculum.” The hidden curriculum is a powerful thing. It can either reinforce or undermine formal curriculum and values.
To better understand the impact of the hidden curriculum, the Queen’s School of Medicine recently surveyed its medical students, residents, and faculty members. Although the survey results revealed many examples of positive hidden curriculum, where peoples’ actions reinforced affirmative values, there were too many disturbing examples of negative hidden curriculum undermining core values of our curriculum and our school. These negative actions, because of their disharmony with formal curriculum and institutional values, are particularly impactful and were found to affect people at all stages of their career and in most areas of medicine.
“Oh, you’re too smart to go into…. [insert specialty here — several were mentioned as examples in the survey]”
– multiple survey respondents
For learners, this negative hidden curriculum is poignant. It impacts educational opportunities, influences career choices, and undermines confidence. It fosters doubt and dissatisfaction with a chosen path and counters the learner-centered teaching we espouse at Queen’s.
So, what is the root of the problem? What creates the personal and structural climate where these negative biases and value judgements can be spread? Respondents had many ideas:
“I think that those negative attitudes are first taught and then as we have our own experiences as learners, we are biased by those comments and then it is a self-perpetuating problem as we then pass those biases on to the junior learners who then become seniors and pass it on again”
Siloed working environments foster a lack of understanding each other’s work. Often, we do not know each other, and it is easier to be unprofessional to an unknown person. Other factors include overwork, burnout, and loss of resilience; perceptions driven by payment schedules, length of training, competitiveness to get into some programs; immediacy of outcomes from procedures vs the more intangible impacts of generalism or preventative medicine; and the process for how and who we admit into medical school.
As an institution that values respect, collegiality, diversity, and inclusion, we need to address these root causes and be a part of the solution. We need to ensure that all areas of medicine are equally appealing to students so they can make their choices based on interest and aptitude. Addressing the hidden curriculum will require a multifaceted approach and an ideological shift within our profession. All of us will need to be committed and involved.
This work is underway. It will be tied to the Dean’s Action Table on Equity, Diversity, and Inclusion as, in its negative form, the hidden curriculum is another example of (in)equity and (lack of) inclusion. We must flatten hierarchies that corrosively impact clinical care and education. We expect people to be professional and respectful. We must go beyond eliminating the negative hidden curriculum to embrace a positive hidden curriculum that embodies our institutional values.
Although the hidden curriculum survey was conducted only in the School of Medicine, we are deeply cognizant that there are equally damaging hidden messages that are communicated about the value of other members of the health professional team. We also intend to address this in the Faculty of Health Sciences. We will not achieve equity outside our health teams unless we respect one another within our health teams.
We went into health care and teaching to be a positive influence — for our patients, for our learners. Reconnecting to that will optimize our educational and clinical impacts. And in this, the CaRMS season, it will support our medical students in making choices that truly resonate.
“We all need to respect each others’ disciplines and the fact that all of our jobs are difficult in many ways. If we all showed more respect, and just assume our colleagues are doing the best they can, burnout would be less, and patient care improved.”
– faculty member
Editor’s note: This piece was originally published earlier this month on the Queen’s University Faculty of Health Sciences Dean’s Blog
I believe there is also a need for return of the rotating internship.. Too many students spend half their medical training picking a specialty and then concentrating all their efforts toward getting into that specialty, whatever that may be. In doing so they miss out on learning to be a well rounded clinician. The rotating internship was one of the best years of my life! It also helped me spend more time in rural medicine afterward which I never would have done, and as a complete aside it helped me pay off my debts.
Gordon H. Dyck
I agree with Harry regarding trauma. A study on cortisol levels at the onset of Med I and at the end of the year showed enough impact to define medical students as having PTSD. Brain changes occur in children post trauma. Acknowledging trauma in others may require us to recognize it in ourselves, and for some doctors, that might have the potential of derailing their confidence and efficacy in a system that praises the fittest, fastest, winningest players.
It’s difficult to overcome hierarchal conscious and unconscious thinking and to foster inclusion when a fundamental principle of medical culture, practice, and admission to the profession is inconsistent with equality and inclusion. Hierarchy and exclusion is written policy: graduates of Canadian medical schools first, graduates of American medical schools second, graduates of international medical schools last. Is the devaluation of family medicine and the other generalist specialties a function of these disciplines being available to international medical graduates? In support of this hypothesis, a review of historical data indicates that these generalist disciplines are less popular today than they once were.
A very good point. Worth noting that international medical graduates who are excluded from residency positions at first and second rounds include Canadian citizens and permanent residents. Equity, Diversity and Inclusion means nothing if all those eligible by citizenship and residency are systematically and illegally excluded from applying to all positions. If those principles are only applied to those who have the magic password from attending a Canadian or American university then the principles are meaningless. When you are considering the “hidden curriculum” please widen your vision to what is truly going on.
Another part of the hidden curriculum is earning potential. Students come out with massive debt.
Also the work done in primary care can be skewed. For example you can see 100 patients as a family physician and the one that you struggle with and send to the ER or a specialist is the only one they see. They don’t see your triumphs.
I did 20 years as an FRCP emergency physician then 28 as a family physician so I have lived in both worlds.
Another part of the hidden curriculum is an ongoing disavowal of the reality of trauma and the growing need for trauma-informed approaches. This minimizes the very real effects of trauma, shame and ongoing unremitting stress on medical students, physicians, other healthcare practitioners and the populations we serve. It prevents clearly facing and addressing the deep embodied wounds (which often show up in unexplained or “medically unexplained” illnesses) of childhood adversity, racism and oppression. It shows of in myriad others ways that a short reply cannot adequately convey.
There are now sights of hope – such as Women’s College and Mount Sinai Hospital in Toronto, or McMaster University – where the courage to acknowledge trauma has brought a light of hope.
For the rest of our medicine culture, I believe that the sheer act of beginning to comprehend and address trauma, from a sincere and multidisciplinary viewpoint, will allow many of the other issues within the hidden curriculum to work themselves out on their own.