Dr. Karen Schultz, Associate Dean, Postgraduate Medical Education and Dr. Stephen Archer, Head, Department of Medicine (thank you to our 6 reviewers who helped shape our blog).
It can be hard for a medical student to choose what type of doctor they want to be. Experiences and role models have a huge impact on picking your place in the profession. In 1980 I wanted to be a hematologist, influenced by Drs Ginsberg and Galbraith, hematologists I met and respected as a clinical clerk. I also thought it might be cool to be a surgeon or an obstetrician. When I graduated from Queen’s Medicine in 1981 I chose a rotating internship at the Royal Columbian Hospital in New Westminster, BC. This program allowed interns to do a month of everything so they would know what they wanted to be “when they grew up”. The rotating internship also qualified one for a license to practice family medicine. At the Royal Columbian I decided I still liked hematology but also enjoyed critical care. I went to the USA to get research experience and felt that Internal Medicine was a good route for me because I was still undecided about careers and Internal Medicine is a gateway to dozens of specialties. At the University of Minnesota I decided malignant hematology and critical care were not for me but became excited by respirology. It was the attendings I worked with (and perhaps the patient encounters), more than the specialty itself, that evolved my career preferences. Ultimately, I chose to become a cardiologist because I happened to meet an inspirational mentor, Dr. E. Kenneth Weir, who suggested I join him in cardiology, “it’s a good profession”. My own wandering path led me to cardiology; but I’m pretty sure any of those other destinations would have been rewarding.
One advantage I had as a medical student was that there were not a lot of people discouraging me from potential career choices. It doesn’t help a young person make an informed choice if respected colleagues and role models lampoon certain types of medical practice. While humor may be “the Best Medicine”, it should not come at someone else’s expense. In that spirit I invited Dr. Karen Schultz, our new PGME Dean, to join me in writing a blog about the Hidden Curriculum. I am hoping we can talk about the Hidden Curriculum, frankly and recognize that it’s a failure of professionalism that serves none of us well. We should strive to eliminate interprofessional prejudice in much the same way we have begun to counteract harassment, racism, and sexism. Let’s begin with a definition of the Hidden Curriculum and then go on to demystify it. The hidden curriculum (HC) is defined as, “the implicit messages, intended and unintended, both positive and negative, about values, norms, and attitudes that members infer from their interaction with individual role models, as well as from group dynamics, processes, culture, policies, structures, and systems.” (adapted from Mulder et al, Med Teacher 2019: vol 41 (1): 36-43).
Findings of the HCWG:
#1) The survey showed variable levels of respect for different physician groups (see below). As one reads across the list of specialties one can only wonder why we would have less respect for a public health doctor than an internist. Medicine needs to take a page from broader society and celebrate our diversity, recognizing we are indeed stronger together.
The survey also captured statements that medical students and residents reported hearing. We debated whether to include these statements (knowing they are insulting and reflect extreme departures from professional behavior); but this is what the hidden curriculum can sound like!
Hidden Curriculum Examples (cited by medical students (MS), residents (R) or faculty (F)):
- “Many, many instances where Emerg docs were the punchlines to jokes.” (MS)
- “Told by a surgeon at KGH that if I pursued OB/Gyn I wouldn’t be a ‘true surgeon’ because the new generation of OBGyn’s are “pansies” and “don’t know how to cut.” (MS)
- “[Overheard} from medical learners: “Family doctors are stupid, Psych is a waste of time, Ob/Gyn are bitches.” (MS)
- “Pathologists are antisocial” (MS)
- “It’s very common to rip on surgeons (especially orthopedics) and psychiatrists for not being ‘real’ doctors.” (R)
- “Psychiatrist are portrayed openly as lazy.” (R)
- “Gen [Surgery] hates on everyone, internists hate on ED, family medicine hates on surgeons.” (R)
- “Pediatrics, ‘little people with little problems.” (F)
- “As an emergency physician, I can think of countless negative interactions with others regarding their opinion of my specialty.” (F)
- “I have heard a senior faculty member and executive level physician at the hospital describe the Family Medicine clinic as the ‘Slack Shack’.” (F)
These comments are clearly not acceptable. Our learners deserve to have a level playing field when they consider their career options. Our patients deserve a health care environment in which everyone who is involved in their care is afforded respect. Our colleagues deserve a work environment that supports them. So let’s blow up a few myths about the Hidden Curriculum and then commit to hold ourselves accountable for doing better. Like Aretha Franklin, all we want is little R E S P E C T! (click here).
Myth 1: The Hidden Curriculum is primarily about protecting family medicine from criticism This is simply not true. Every specialty has tropes associated with it. At best these tropes are used humorously, at worst they are used to marginalize or vilify colleagues. The trash talking is directed more at some specialties, like Family Medicine and Psychiatry, but all groups are impacted. The figure below shows that 18% of surveyed medical students and 15% of residents reported hearing negative comments about the field of medicine they have chosen.
The survey also discovered that no physician group was immune from being disparaged. The graph below shows that medical students (blue bars) reported receiving negative comments about their proposed field of practice in >12% of cases in each of five specialties.
In reality Medicine is a team sport and needs good doctors of all types (regardless of age, sex, gender, race, specialty). There are currently 24 Canadian RCPSC physician categories and Family Medicine has its own subspecializations (click here) (click here). Despite this, we seem to have a cultural predisposition that makes it OK to bad mouth colleagues by their medical group, perhaps as a way of elevating our own groups stature. It would be great to change people’s minds but as a starting point let’s change their behavior and at least follow the dictum, “If you can’t say anything nice, don’t say anything at all!” There is no “best” type of Medical discipline. The medical profession is like the body-all parts are needed; why would the hand resent the foot?
Diminishing other types of physicians makes little sense when one considers the realities of medical practice. Let’s take the example of a patient who uses drugs intravenously and presents with fever, chills and a visual disturbance. The patient is first seen by a family doctor who suspects the diagnosis of bacterial endocarditis, orders initial testing, and refers them to hospital. Then an emergency physician reviews the case, concurs and orders more diagnostic blood tests, performed by physicians in laboratory and molecular medicine. The lab tests together with the murmur of tricuspid regurgitation lead to an urgent consult to general internal medicine, who admits the patient and initiates antibiotics. They consult cardiology, who performs a transesophageal echocardiogram and an angiogram. A diagnosis of tricuspid valve endocarditis related to the use of intravenous drugs is made and a medical microbiologist identifies the organism as Staph epidermidis. A cardiac surgeon is consulted and decides the valve can be repaired. The patient has a CT scan of the head because of transient visual disturbances. The study is interpreted by a radiologist, who identifies mycotic aneurysms in the brain. A consult liaison psychiatry and an addiction medicine specialist see the patient to deal with their addiction. The patient is seen preoperatively by an anesthesiologist and, after 2 weeks of antibiotic therapy directed by an infectious disease specialist, the patient undergoes valve repair. Valve tissues are sent to a pathologist. Postoperatively, the patient has a stroke and is seen by a neurologist and then transferred for rehabilitation therapy to of a physical medicine and rehabilitation specialist. After a month the patient is discharged back to the care of their family doctor and cardiologist. This breadth in a collaborative care team is not rare! If we can recognize our unique skills, our limitations and our obligatory interconnectedness we will be much less likely to demean or joke about a particular type of X-ologist!
Myth 2: The Hidden Curriculum wouldn’t be a problem if people didn’t have “thin skins”
A lot of the messages in the Hidden Curriculum occur in the form of attempted humor. The world is changing and, with greater awareness of the value of a respectful and diverse culture, a “thick skin” shouldn’t be our profession’s primary response to insulting stereotypes. An interesting German study examined the hidden curriculum through a study of jokes about doctors. This study is entitled, Just fun or a prejudice? – physician stereotypes in common jokes and their attribution to medical specialties by undergraduate medical students by Harendza and Pyra BMC Medical Education (2017) 17:128. This study asked 999 students to examine 152 jokes about five physician specialties. This study addressed asked which characteristics in doctor jokes are assigned to which medical specialists and do the perceptions of medical students change over time?
The authors offer insight into the nature of the demeaning comments that comprise the hidden curriculum, referring to it as the “group dominance model of humor” and noting, “In the group-dominance model of humor, social dominance motives predict favorable reactions towards jokes targeting other groups. The “superiority of humor” theory describes that jokes are experienced to be funnier, if they portray the group one identifies with as “victorious”. In simple terms we mock others to feel better about ourselves (not exactly CANMEDS worthy behavior)! If you have been in the medical profession for even a short period of time you will have heard the stereotypes that learners culled for jokes and assigned to various specialties (see Table below).
Hidden curriculum attributes identified from medical jokes by trainees as applying to specific specialties
Why not celebrate the diversity of our profession; rather than mocking colleagues, who like ourselves are dedicated to improving human health. We should also be mindful that not everyone has the same world view or experiential frame of reference. As a result, some medical trainees/faculty are more negatively impacted than others by adverse comments, due to intersectionality or their stage of training. This is particularly true for medical students, women, and those training and working in Family Medicine. No one wants to play on a “B” team and, left unchecked, the Hidden Curriculum can have a significant negative impact on learner wellness and physician burnout, which in turn can adversely impact the learning environment and patient care.
However, our practices can be stressful and many comments that are hurtful arise from good colleagues who in stressful situations or, during a misguided attempt at humor, make statements that are deemed prejudicial by others. We all have our moments! For most of us, accidental slights or inappropriate use of stereotypes can readily be corrected. We don’t need a sledge hammer in these cases, we just need to say to the offending colleague, “That’s probably not what you intended to say!” An apology is often all that is required to move forward. The bottom line: humor is a very complex thing and highly contextual. It should be used to bring people and groups together, not separate them.
Myth 3: Negative perceptions and biases about various physician types are solely the result of doctor-doctor jealousies and misunderstanding
In the previously mentioned German study the authors found that some biases were learned but others were preexisting (before medical school). For example, they noted no increase in assignment of the stereotypic characteristics to surgeons and psychiatrist during the course of medical school, which suggests that “these stereotypes might be common knowledge, e.g. from movies or books”. In contrast, for internists and orthopedics, the extent to which assigned characteristics were ascribed increased as medical school progressed, “suggesting that some of the stereotypes might develop during undergraduate training”.
For those old enough to be fans of MASH, think of Dr. Hawkeye Pierce, the playboy, impulsive, courageous, surgeon versus Dr. Sidney Friedman, the quiet but inciteful psychiatrist. These stereotypes no doubt influenced a generation of medical trainees; however, like all tropes they are simplistic and ultimately flawed. Indeed, even in MASH, Hawkeye had a sensitive side and Sidney could be courageous (and ultimately it was Sidney that “saved” Hawkeye, not the other way around)! None of us, and none of our specialties, are “Flat Stanleys’; we all have depth and nuance and this merits thoughtful individual consideration-not the use of stereotypic shorthand.
Interestingly when it comes to MASH we can also think of generational change. In the Korean war era having a psychiatrist was rare and carried stigma. Arguably in 2021 many, if not most, people have counsellors or psychologists, if not a psychiatrist, and this generational change may gradually change the narrative around what it means to be a psychiatrist. There is always an unwitting soaking up of role model behaviors and ongoing perpetuation of these beliefs. Think of your favorite medical TV shows; most are about surgeons or ER doctors. There have been few TV shows about family doctors or psychiatrists (click here). Maybe Northern Exposure or Dr. Quinn Medicine Woman. Nephrology and Infectious Diseases only gets one show for the two specialties, albeit a good one (House). The popular media influences perception and these perceptions inform the Hidden Curriculum (which exists in society at large, not just within the hospital walls). Maybe Netflix needs more content featuring dynamic and heroic GPs and psychiatrists! Regardless, a lack of knowledge or media hype about someone’s type of work needn’t devolve into disrespect.
Myth 4: If we address the hidden curriculum it will stifle collegiality and create censorship
The vast majority of physicians are well-intentioned and professional, and only occasionally misstep. We don’t want a police state, where Department Heads and Deans must intervene in response to daily anonymous complaints about Hidden Curriculum microaggressions. We can help keep each other accountable to our institutional values of equity, diversity, inclusion and respect by being mindful of the problem and, as with racism, when we hear something, say something. In a healthy collegium we could follow be REAL policies (below), resorting to formal disciplinary procedures only in rare cases. This is already the reality as it pertains to disruptive physician behavior or departures from professionalism. Heightened awareness and self-education addresses most hidden curriculum slip ups. It is in rare cases with ongoing patterns of misbehavior and no attempt by the person or organization to achieve improvement where the real concern lies.
The Department of Medicine approaches harassment, and could approach the Hidden Curriculum, with a policy borrowed from Kingston Health Sciences Centre, called be REAL: Respect, Equality, Accountability and Leadership. This policy is enforced not by anonymous complaints but by talking to the person who made the offending comment and attempting to resolve the concern before escalating it. When there are major power imbalances there is a chain of command that protects learners (i.e. intervention by program directors or Department Heads). As always, it works best to be direct and to provide specific feedback to the person involved; not generic advice to all faculty (most of whom are not at fault).
The be REAL policy
Myth 5: Hidden curriculum is the responsibility of a committee-not me
The Hidden Curriculum plays out at many levels—the individual, institutional and organizational level. At the individual level it is the everyday interactions that impact people and it is those interactions where change must occur. Thus, improving our culture and our communication is a mutual responsibility, just like it is a shared responsibility of the collegium to address racism, sexism or gender bias. As faculty members we should role model respect for all disciplines . If you witness something in the Hidden Curriculum domain-say something; otherwise we are promoting what we permit. That said feedback can be given without humiliating or vilifying the person. You are a visible and impactful person. Taking the time to think about those generational messages you may have absorbed and reflecting on the intent behind what you say, is helpful. Instead of telling learners, “You’re too smart to be a family doctor”, meant as some back-handed compliment, why not say what you mean, “You are smart and capable and I enjoy working with you”?
Summary: A culture of positivity and respect makes for a safer, happier work-place. Speaking ill of a group of physicians, even if the attempt is humorous, is unprofessional. While learners in formative stages may be most susceptible to negative comments, even a senior physician can be negatively impacted by stereotypical tropes implicit in barbs and jokes. Most physicians and learners at Queen’s are well-intentioned and collegial. Efforts to address the hidden curriculum should strive to strike a balance between celebrating positive examples and remediating those who demonstrate a sustained inability to embrace the Faculty of Health Science’s values of diversity, respect, and collegiality.
The Hidden Curriculum is less “hidden” (more discussed) in 2021 than before because of new societal sensibilities which expect more civility and equality amongst people. There may also be more negative commentary afoot. There is more stress in medicine and this may trigger inappropriate comments. There is also often a silo effect where different types of doctors work apart from one another. In the past many of us worked for significant periods of time embedded within specialties other than our own. The loss of the rotating internship (click here) and CBME 'pull-backs' of trainees into their own specialties have contributed to an “Us vs Them” culture. The lack of awareness of other people’s work often seems to translate into a perception that others are not working as hard, which cultivates a feeling of disrespect. Creating hierarchy seems to be a default organizational strategy in many contexts, medicine being only one example. It is understandable for people to want to belong to a group; however, defaulting to a hierarchical ordering of importance is not helpful or acceptable.
Here are some suggestions to address the Hidden Curriculum:
- Acknowledge that it exists but at the same time realize we can do better.
- Put the patient and the learner in the center of the picture-neither benefit from a Hidden Curriculum culture
- Think before you speak. Take a page from my late mother, Barbara Archer RN (nee Arthurs), who would often reminded me, “If you can’t say anything nice; don’t say anything at all”.
- Participate in a culture shift and display positivity and openness to change and personally strive to improve your own rhetoric.
- Thoughtful and deliberate use of change management principles can be used to change behaviors (and eventually change hearts and minds).
Medicine is a team sport and we need all types of doctors. No team succeeds if it allows a culture which fails to value all players, coaches, managers and trainers. We close with an aphorism from Dr. Schultz’s mother, who always advocated “Leave things better than you found them”. Positive change! If we are mindful of the impact of our words, when talking to our colleagues and our students and residents, and express respect for the diversity that is medicine, we are taking the first step to unveiling the hidden curriculum. Hopefully you are happy with your choice of practice; treat the chosen profession of others with same respect. It is a simple step toward leaving things better than you found them.