The formal curriculum well known to both the educator and the student. It is the curriculum subscribed to and endorsed by the medical profession containing the course syllabus, assignments, reading and scheduled testing.  In contrast, the hidden curriculum, or the informal curriculum, refers to the implicit education where values, behaviors, and principles are transmitted by means of the social environment. It is the curriculum that occurs through informal interactions between faculty and students – what students and residents observe while on the clinical wards, as well as the cafeteria conversations.  The hidden curriculum is, in essence, the lived experience of students.  Professionalism, an art amongst medical education, is mostly to be learned within the hidden curriculum.

The description of the Accreditation Council for Graduate Medical Education (ACGME) competency of professionalism includes that “residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.”

We expect that residents will demonstrate

1. Compassion, integrity and respect for others.
2. Responsiveness to patient needs that supersedes self-interest.
3. Respect for patient privacy and autonomy.
4. Accountability to patients, society and the profession.
5. Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities and sexual orientation.

The hidden curriculum and its influence on modern medical professionalism is nicely articulated in Thomas Inui’s report “A Flag in the Wind: Educated for Professionalism in Medicine.”

As Inui defined it, “Within the experience of students, but outside the courses lies the hidden curriculum, the students’ exposure to what we actually do in our day-to-day work with patients and one another – not what we say should be done when we stand behind podiums in lecture halls.  It is this modeling, not only by the faculty but by the residents, that constitutes the most powerful influence on students’ understanding of professionalism in medicine.”  A significant threat to professional development is the widening gap between what is formally taught in the classroom and students’  exposure to the clinical setting, especially the emergency department.

For many of us derogatory patient and staff stereotypes were perpetuated during our early clinical experiences, a practice that greatly contradicted our core values and reasons for committing to a career in the medical profession. Yet, we were likely to engender these values as a right of passage, or perhaps as a coping strategy for the stress we were enduring as trainees. While most medical curriculum focuses on teaching the rules of professionalism within the formal curriculum, it does not confront this hidden curriculum.

The hidden curriculum can be an effective method to role model positive behaviors; however it has also been recognized to perpetuate the negative attitudes and behaviors found in today’s medical residents and students. Consider the influences on your own professional development. What attributes and behaviors do you associate with positive role models?

I can vividly remember the physicians I most respected during my training were those who were not only knowledgeable and skillful, but who also demonstrated compassion for patients others were likely to disregard. I most admired their ability to be professional even when challenged and stressed.

Elements of a professional physician are well described for us in the literature and by accredited bodies, however, as noted by Inui, we fail to talk about the gap that exists between these expectations and what we actually do in the clinical setting. While most medical training programs include formal curricula on communication and professionalism, the culture, behavior, and language learners observe in the clinical wards is much more powerful. Inui comments that students, “noting the difference between what we say and what we do, [they] learn that medicine is a profession in which you say one thing and do another, a profession of cynics.”

Inui and others who have reported on professionalism in clinical medicine, recognize the need to improve the way we ensure that these attributes are acquired in our training physicians. Yet, they also bring attention to the complex and challenging environment that we work in which often conflicts with our ability to do what we say.

How can we better teach professionalism? As educators of medical students and residents, we strive to support the professional formation of our learners, and help them navigate through the conflicts and challenges they face in this domain. It is proposed that an effective strategy is to first acknowledge the influence of the hidden curriculum, be explicit about the challenges of professionalism in medicine and the discordance between the formal and informal curriculum, and work to incorporate these elements into our every day actions and systems.

A version of this article first appeared in Empire State EPIC Vol 31-04:14.