So widespread is mental death that we scarcely comment upon it to our friends. The real tragedy is the moral death which, in different forms, overtakes so many good fellows.William Osler, Aequanimitas
During my final year of medical school, I scrubbed in on the C-section of an African-American patient with a BMI of 78. She coded on the table shortly after her incision was closed, the weight of her body literally preventing her from breathing appropriately (a phenomenon called Pickwickian syndrome or obesity hypoventilation syndrome). My supervising resident leapt on the table, straddling the patient while performing CPR. Eventually she regained spontaneous circulation and we sent her to the SICU, intubated and sedated. When the chief resident from the critical care team came in, he took one look and said, “What the **** am I looking at? I didn’t know we were treating whales. Holy ****.”
The attending loved it. Everybody loved it. One-breath chuckles popped off around the room. I laughed too, and then remembered the patient’s newborn. For some reason the image of that little one made me pause, and I began to sense that something was terribly wrong about all of this. I imagined if the resident and the patient were friends, or if the patient’s mother was secretly standing outside the room, listening. But mostly I couldn’t stop thinking about Mao Ze Dong—one of the only recorded instances of him laughing is at the death of a tight-rope walker at a circus.
What is the “Hidden Curriculum”?
This is just one example of the so-called “hidden curriculum.” Well-known among medical educators, the hidden curriculum refers to the lessons that medical trainees receive behind the scenes and in “the real world.” Some of these lessons stand in stark contrast to the high ideals of humanism and professionalism espoused in medicine’s codes of ethics and echoed during medical school orientation. In his 2013 New York Times op-ed “Medicine’s Search for Meaning,” David Bornstein described it this way:
“While the training formally espouses the ethics of empathy, compassion and altruism, doctors and researchers say that the socialization process—the ‘hidden curriculum’—teaches something very different: stay detached, objective, even a little cynical.”
The lessons of this curriculum are many: The well-respected attending who wonders aloud “Why we let these people breed.” The resident with nuanced advice for maximizing income but disdain for the poor, the non-complaint, and the “frequent flier.” The medical student who works up the patient with empathy but presents them to the team with parenthetical mockery. If the explicit curriculum is the well-lit statue—the noble bust of the physician—the hidden curriculum is the social shadow, and it has been present for at least sixty years.
Sparked from insights in The Student-Physician: Introductory Studies in the Sociology of Medical Education (1957), Boys in White: Student Culture in Medical School (1961), and that celebrated satire of resident life, The House of God (1978), the hidden curriculum made its first formal appearance in a 1994 paper in Academic Medicine. It has suffered much commentary since, suggesting that habits of un-professionalism are being taught in today’s medical schools despite any formal attention to professionalism. These informal “lessons” not only cast the cold light of “this-is-normal” onto what medical students observe, but also illuminate how they should then act. They make a type of moral universe known and call students to enter it and participate accordingly. Most tragically, they tell medical students who they should expect to become. In that sense, the hidden curriculum does not merely highlight hypocrisy or bemoan cynicism—it suggests the normative way students become doctors.
The prevalence of burnout and moral injury supports this. Every week it seems there is a new study, op-ed, or blog from sources as untouchable as the New England Journal of Medicine to those as familiar as Facebook lamenting the ethical degradation and empathy decay of today’s medical students. And yet the hidden curriculum is understood by many as an inevitable rite of passage—just part of the crucible essential to thickening the trainee’s skin. As pediatric oncologist Raymond Barfield puts it, the primary lesson of the hidden curriculum is “weakness is despised.” Medical students may slowly learn to despise weakness not only in themselves, but eventually in the very patients they seek to heal.
Oncologist Rachel Naomi Remen, creator of the celebrated “Healer’s Art” curriculum (in many ways conceived as a direct response to the hidden curriculum), offers a sobering example. At the beginning of her training, after the death of a three-year old, she wept with the parents, quick to apologize and say, “I’m sorry.” She was told afterward by a superior that this was professionally inappropriate—weak. So she hardened, toughened up, outlined some good professional boundaries, and at the end of her training, when another toddler died, she stood in the room tearless, having achieved the goal of professional posture and poise, becoming “the person a grieving father apologizes to” at the death of his child. It would seem that we enter medical school apologizing to the weak and come out with the weak apologizing to us.
Another example: an older orthopedic attending once told me about a particularly overwhelming 40-hour shift when he was a resident. He was paged that yet another patient was headed his way, to which he sighed with exhaustion and outrage. About twenty minutes later he was paged again, this time from the emergency room—the patient had died on admission. He let out a relieved and joyful “Yes!”
As he tells it, his realization was swift and devastating. It was like a slap in the face—the rooster’s crow waking Peter up to the reality that he had denied Christ three times. He stood stunned, asking himself, What has happened to me that I have celebrated the death of a person I have yet to even see? Peter went out and wept bitterly; I don’t know what that surgeon did.
Such stories seem universal—if students can only get their supervisors to open up about them. A 2015 series called “Our Family Secrets” in Annals of Internal Medicine highlighted how misogyny, misanthropy, racism, and even sexual assault are repackaged within medical culture and justified as gallows humor as a necessary means of getting through the day.
Perhaps it is worth pointing out that no one is seriously advocating for some sort of chaste, goody-two-shoes humor that has attendings, residents, and medical students walking around on eggshells. Some form of “releasing steam” is probably inevitable, worthwhile, and healthy across all professions. We see a lot of absurdity—even and perhaps especially as trainees. Humor is important to build camaraderie, take ourselves a little less seriously, and even to grieve. As the mantra goes, “Time plus tragedy equals comedy.”
But what we laugh at still matters. Even the AMA Journal of Ethics is dedicating its July 2020 theme issue to humor because it recognizes that what makes us laugh also makes a claim about what we think is good. On a formative level, laugher points to what is socially expected and even rewarded. As neuroscientist Sophie Scott has observed, junior doctors in the UK laughed more than usual at the jokes of senior doctors, even if the humor was “straight up offensive.”
Despite these stories and reflections, many argue that the hidden curriculum remains a good thing. It prepares medical students for the reality of modern health care. The curriculum is an ironic complement to the professionalism and humanism lessons so often cited to remediate it. In other words, the curriculum does its job, situated between the ideal world of medicine and the jaded world, and therefore teaches “the lessons that students and educators need for the everyday work of medicine.”
Changing the hidden curriculum
We will need more than mere curriculum reform to push back against the hidden curriculum. But I suspect we will also need more than addressing the culture. One can imagine very articulate ways of naming the overarching institutional culture (surely many already exist) that are divorced from imaginative ways of actually changing. With that in mind, I offer four suggestions:
Make the implicit explicit
Name the hidden curriculum directly and explicitly at the beginning of medical training. Refer to it throughout professionalism and ethics lectures. Simply naming the hidden curriculum aloud can be a powerful tool. It was when Harry Potter began to speak the name of Voldemort that he developed a certain degree of courage in the face of the villain’s hidden presence. One way of naming the curriculum could be to ask medical students to reflect on how they are being formed: “While our formal curriculum taught me to _____, the hidden curriculum has formed me to _____.” Asking students to reconcile the two curricula could be a powerful exercise.
Tell better jokes
Humor is bound to the moral life. As C. S. Lewis wrote, “jokes as well as justice” come with speech. There is a difference between humor that calcifies against the most vulnerable of patients and humor that names the absurdities of life while also offering a bid of solidarity with the suffering. The reason my friends can make fun of me is precisely because they are my friends. The wit of their ridicule is evidence of a kind of loyalty and deep knowledge of my life. The burden on all of us as medical workers is not to tell less jokes about patients, but perhaps to tell better ones.
Be a disruptive witness
Medical students and trainees are often content to endure rather than to thrive. I certainly sat submissively in the call room and stayed silent in the operating room when the hidden curriculum was “taught.”
Resisting the hidden curriculum in many of the stories I’ve shared would require interrupting the workflow—an unforgiveable offense in a world of modern medicine that prizes efficiency above all. It also risks appearing holier-than-thou, naïve, or petty. Particularly for medical students and interns “at the bottom of the totem pole,” this can be a difficult charge.
Challenging the hidden curriculum will take courage, a good slug of humility, and an invitation to a larger conversation. English professor Alan Noble calls this being a “disruptive witness” rather than a sanctimonious antagonist. Faithful resistance reveals an alternate way of life and medicine that is so beautiful and honorable that others can’t help but pause to observe the difference.
Participate in a moral community
Very little thought is given to how institutions and organizations outside of medical education contribute to the hidden curriculum, and what they can do to undo it. As I’ve written elsewhere, we often overlook the reality that it is the local moral community—embedded in specific moral practices and active relationships—that shapes our conception of what is good and what is professional. We need particular traditions that embed virtues in daily life, as well as relationships that both inspire us and hold us accountable to actually grow in the character qualities that the formal professionalism and ethics curriculum so loudly trumpets.
To conclude, I believe that I can’t white-knuckle behavior change and simply “be more good.” It never works that way. To truly become good, I have to be bound up in the life of my community—particularly a community that binds me to my neighbor and especially to the lives of the vulnerable. Only when I am caught up in what theologian Susan Eastman calls “that gracious social matrix” can I find myself actually living into something like authentic goodness—not because I’ve articulated a profound moral argument or conjured up moral effort, but because my heart has learned under the curriculum of the sick. And there I can laugh with the overweight and the weak, not because I find their misfortune amusing, but because I recognize my friend.