Educating For The Oath: A Medical Student’s Lived Experience With The Hidden Curriculum

The white coat ceremony marks the beginning of a new chapter in the lives of medical students. An academic ritual steeped in symbolism, the ceremony calls on new medical students to reflect upon and adhere to the values that guide the profession. The honor of graduating medical school returns these soon-to-be-doctors to the ideals of medicine. They must take an oath to avoid harm, build trust, and practice with integrity.

While these commitments bookend the medical education experience, the reality for many medical students is that their respective curricula are primarily focused on imparting scientific knowledge and skills required to succeed in the clinical environment. The values of the medical profession such as ethics, empathy, communication, and professional attitudes are concepts largely conveyed informally outside of medical school syllabi.

As a medical student, I have experienced different delivery methods of the values of the medical profession. We have the occasional seminar-style discussions of ethics, empathy, communication styles, and professionalism. If you’ve been involved with one of these, you likely are familiar with those students who groan, complaining that “this stuff is a waste of our time,” or “I’d rather be doing Anki,” as well as those who enjoy the theoretical discussions as a break from the objectivity of scientific knowledge.

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But we also experience an informal method of learning about these concepts, or the hidden curriculum. The hidden curriculum is delivered, “via educational structures, practices, and [through the] culture of an educational institution.” Medical students split their time between two institutions – the university granting their degree and the hospital at which they complete their clinical rotations. Therefore, the hidden curriculum is delivered through the culture at both educational venues.

The negative encounters we witness while on clinical rotations have as much impact as the positive encounters. I’ve seen physicians who have handled a challenging patient skillfully, but I’ve also seen health care providers make disparaging comments about other health care providers or even a patient. What I take away from witnessing both those encounters is highly dependent on not just my personality, but also how often I am exposed to each. Recently, there have been a lot of conversations about the culture of medicine, but how often do we talk about how the culture of medicine at different institutions influences medical education? Are the values of the medical profession being translated in our clinical learning environments?

A hospital’s stated values are a tangible representation of the institution’s shared commitments and overall culture. These values can be perceived by students directly or indirectly in the clinical environment. For example, I was directly taught the values of my institution during an orientation that welcomed my class to clinical rotations at the hospital.

Now in my third year of medical school, I have completed 5 of 6 of my core clinical rotations. While I’ve noticed how the values of my hospital have translated to my medical education, my classmates and I have not been given the space to formally reflect on how these values have informed our educational experience, whether positively or negatively. Moreover, there is no formal method to evaluate if I am learning the values of the medical profession that I will uphold at my graduation ceremony a year from now.

The field of medical education only recently started to formally incorporate didactic classes on empathy, communication, and professionalism; is it too soon to do away with those classes that students often spend flipping through flashcards? An alternate solution would be to take advantage of the existing hidden curriculum and instead allow students to reflect on how their clinical learning environment has informed their educational experience. This could help medical schools gauge if the values of the medical profession are being translated in practice.

Ultimately, formal evaluation of the hidden curriculum would allow medical students to learn about how they envision their future practice environment and guide students to consider the type of organizational culture they would like to be a part of and contribute to as a new physician.

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