The Hidden Curriculum in Health Professional Education

The Hidden Curriculum in Health Professional Education is a guided tour of what is currently known about the hidden curriculum from research and from the viewpoints of 34 contributors and thought leaders in this arena. Dr. Joseph O'Donnell provides a superb introduction that lays out the organizational structure of the book very clearly for the reader. Thus, the reader can select the most pertinent sections or chapters, along with a brief history of the hidden curriculum as portrayed in the literature. This provision of context is crucial to appreciating the later sections. The introduction also provides definitions of the 4 types or levels of the curriculum.

• ▪ 

  The 1st type is the formal curriculum or the stated curriculum, the one that is approved by curriculum committees and sanctioned by the institution.

• ▪ 

  The 2nd type is the informal curriculum. “The informal curricular space refers to the idiosyncratic, sporadic, and happenstance learning that occurs when a student asks questions after class, or has a conversation in the cafeteria, dorm room, elevator, or on-call room, or in the corridor outside the patient's room with a peer or teacher” (Kindle location 203).

• ▪ 

  The 3rd level is the hidden curriculum as defined by Cowell as “that which the school teaches without, in general being aware that it is being taught” (Kindle location 174). The hidden curriculum is at the level of the organizational culture and “comprises the organizational context and cultural subtests that shape the way students make sense of their learning environments” (Kindle location 232).

• ▪ 

  The final level is that of the null curriculum, “what is not said or attended to . . . lessons that are conspicuous by their absence” (Kindle location 237). For example, “if nothing is said within the formal curriculum about social justice and teamwork, then students may conclude that these are unimportant issues” (Kindle location 241).

The editors envision this book as a “launching point” and encourage readers to “take the next step and try to harness the hidden curriculum, shape its use for good (better) outcome, and create what we all long for, innovation with change” (Kindle location 372).

The book is divided into 5 sections or thematic areas in examining the hidden curriculum for the education of health professionals as follows: (1) “Working with the Framework: Some Personal and System-Level Journeys into the Field,” (2) “Theoretical Considerations, (3) Methodological and Assessment Approaches,” (4) “The Hidden Curriculum and Health Professions Education,” and (5) “Special Topics and Applications.”

Section I, “Working With the Framework: Some Personal and System-Level Journeys Into the Field,” which includes Chapters 1 to 3, provides an overview of the field covering early work done in the United States, as well as contemporary work completed in Canada. The narrative of these chapters is very rich, but there is only space to share 1 important concept from each. From Chapter 1 the concept is the need to address the culture itself as opposed to continually working to add content to the formal curriculum or to change individuals within the culture: “Only changes in the hidden curriculum can shift the behaviors of the vast majority of students and physicians who are likely to be influenced by context” (Kindle location 615). From Chapter 2 comes a very important reminder that much that goes on in the hidden curriculum is positive, providing many excellent role models and many health professions graduates with appropriate values and behaviors (Kindle location 785). Finally, Chapter 3 provides evidence that policy change can happen, even on a national level, as happened in Canada in 2012. Recommendation V from the 2012 document, Future of Medical Education in Canada, Association of Faculties of Medicine in Canada, is to “address the hidden curriculum” (Kindle location 854).

Section II, “Theoretical Considerations,” includes Chapters 4 to 6. Chapter 4 discusses the concept of the hidden curriculum of the culture that teaches practitioners to see (notice, pay attention to, value) certain things and to “unsee” (not discuss, not pay attention to, not value) other things, and it provided a wonderful quote: “The hidden curriculum helps create the blind spots in which it then hides” (Kindle location 1121). Chapter 5 focuses on professionalism, the term itself as well as some of its underlying assumptions within medicine. Chapter 6 examines the values that underlie medicine and provides insights into both the breadth and depth of the hidden curriculum.

Section III, “Methodological and Assessment Approaches,” includes Chapters 7 to 10 and explores methods for examining the hidden curriculum. These methods include use of the logic model to evaluate the hidden curriculum in a manner parallel to the way in which the formal curriculum might be evaluated (Chapter 7) and use of discourse analysis (Chapter 8), narrative analysis (Chapter 9), and survey analysis (Chapter 10). Each of the methods discussed can provide a different perspective or lens through which we might examine and try to understand health professions education (the formal, informal, and hidden curriculum). The chapter on narrative analysis is particularly well done, and the chapter on surveys itself is, in fact, an excellent narrative.

Section IV, “The Hidden Curriculum and Health Professions Education,” Chapters 11 to 14, provides insights into the hidden curriculum and its exploration in 4 arenas: medicine (Chapter 11), nursing (Chapter 12), allied health (Chapter 12), and interprofessional education (Chapter 13). These chapters provide an interesting contrast between the 4 arenas covered, from extensive study in medicine to almost no study within allied health. It also eloquently highlights how medicine and nursing differ in how they view the gap between formal and hidden curricula.

Section V, “Special Topics and Applications,” Chapters 15 to 20, provides conversations on a variety of topics related to the hidden curriculum. These thoughtful discussions will be of interest to all those with concerns related to these issues. The issues included are professionalism and professional identity (Chapter 15), health of indigenous and underserved communities (Chapter 16), longitudinal integrated clerkships (Chapter 17), and the role of social media (Chapter 18). The chapters that touched me most were Chapter 16, as it reminded me that curricula need to openly address health disparities and the role of health professions education in closing the gap, and Chapter 18, since it reminded this baby boomer that it is our job to understand and learn to utilize the social media that our millennial, and soon postmillennial, learners are steeped in. Some readers may also be interested in the chapters that focus on the hidden curriculum for faculty (Chapter 19) and for research and preparation of future scientists (Chapter 20).

The editors close the book with an extended discussion entitled “The Next Generation of Work on the Hidden Curriculum: Concluding Thoughts.” Although this section seems primarily directed at those desiring to conduct research in this arena, the opening section would assist any reader in integrating the book's themes. In essence, the editors take the 20 chapters and integrate and cross-reference them for the reader by important themes and issues. This section guides the reader toward taking a deeper look at key issues of importance to him or her.

It is essential to understand the culture that has developed in any patient care setting, especially those that include future health professionals. The editors and contributors have presented evidence that makes that very clear. The hidden curriculum, the underlying culture, needs to be understood and changed, if necessary. This is as true for chiropractic as for every other health profession. We need to ensure that our learners are being trained in classroom, laboratory, and clinical settings that are consistent with the core principles of the profession. We cannot assume; we need to examine with an open mind, and then grow and change if needed. It is our charge to meet the learning needs of the next generation to help them meet the health needs of the future. The materials presented in The Hidden Curriculum in Health Professional Education can help guide that effort.