Hidden curriculum: what medical school teaches silently
Table of contents
In the ethics class, the group learned that the patient should know who is examining them and that a student needs to introduce themselves as a student. On the rotation, the resident introduces the intern to the patient as "the doctor", and nobody corrects it. No exam tests this scene. Even so, it teaches something, perhaps more than the class does.
NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.
This teaching without a program, which comes from the environment, from examples and from unwritten rules, has a name: the hidden curriculum. This guide shows what it is, what studies have found about ethics, empathy and examples on the rotation, and how the student can recognize it and choose what to take with them.
Key points
- The hidden curriculum is what is learned through the culture of the institution, not through classes: values, attitudes and rules that nobody teaches explicitly.
- One of the first authors on the topic argued that much of a doctor's identity is formed in this curriculum, not in the formal one.
- In a survey of students on rotation, most reported having witnessed unethical behavior and many said they had lost part of their principles.
- Final-year students chose the ideal conduct in theory, but predicted another conduct as the most likely in practice.
- The hidden curriculum also teaches good things, and positive examples from preceptors appear often in students' accounts.
What the hidden curriculum is
Three curricula at once
In 1998, Frederic Hafferty proposed separating three components of medical training: the formal curriculum, which is in the syllabi and the classes; the informal curriculum, which happens in day-to-day interactions between teachers and students; and the hidden curriculum, which comes from the structure and culture of the institution (Hafferty, 1998). His proposal was to think of the school as a learning environment and to look at what students learn, not only at what they are taught (Hafferty, 1998).
Training as moral training
Four years earlier, Hafferty and Franks had already argued that the main determinants of a doctor's identity act outside the formal curriculum, in a hidden curriculum, more subtle and less acknowledged (Hafferty and Franks, 1994). For them, medical training works as a moral training, of which formal ethics classes are only a small part (Hafferty and Franks, 1994).
The practical consequence is uncomfortable: a school can have excellent ethics classes and, at the same time, teach something else in the hallways.
Hidden curriculum and clinical exposure
The hidden curriculum is not about how many patients each student sees, the topic of the guide on the gap between theory and practice. It is about what the student learns to value, to hide and to repeat while seeing those patients.
Where the hidden curriculum appears
Four places to look
Hafferty suggested that institutions look for their own hidden curriculum in four places: institutional policies, assessment activities, decisions about where to spend resources and the institution's slang (Hafferty, 1998). Each one teaches something without saying it.
| Where to look | Question to ask | What may be being taught |
|---|---|---|
| Institutional policies | What is required and what is only recommended? | What is recommended can be ignored |
| Assessment | What is on the exam and what is not? | What is not assessed does not matter |
| Resources | Where does the school invest time and money? | What receives fewer resources is worth less |
| Slang | How are patients and areas referred to in the hallways? | Who can be treated with less respect |
Assessment teaches what matters
If the exam only tests disease names and conduct, the student learns that communication and reasoning are secondary, even if the classes say otherwise. The way of assessing tells the student what is worth studying. The guide on feedback in clinical cases shows how feedback also teaches priorities.
Error as shame or as data
One of the strongest hidden lessons is the way error is treated. If the person who errs is exposed, the student learns to hide doubt and not to ask. If the error is discussed as part of reasoning, they learn to talk about it. The guide on the error notebook shows how to use error as study material.
What the studies show
Ethical erosion in the clerkship
In an anonymous survey of third- and fourth-year students at six Pennsylvania schools, 665 of the 1,853 invited responded, or 36% (Feudtner et al., 1994). Among those who responded, 58% reported having done something they considered unethical, 52% reported having deceived a patient, and 98% had already heard doctors refer to patients in a derogatory way (Feudtner et al., 1994).
The same students showed the personal weight of this: 67% had felt bad or guilty about something they did during the clerkship, and 62% believed that at least part of their ethical principles had been eroded or lost (Feudtner et al., 1994). Those who acted improperly out of fear of a bad evaluation or to fit in with the team were about twice as likely to report this erosion, with odds ratios of 2.25 and 1.78 (Feudtner et al., 1994).
The study is old, but the mechanism it describes is the core of the hidden curriculum: the pressure of evaluation and of belonging teaches conduct that the ethics class would not teach.
The theory and the expected practice
In a voting exercise repeated over six years with final-year classes, students read the same vignette and chose between two answers, first the most desirable one and then the one they thought most likely in real day-to-day clinical practice (Joynt et al., 2018). The choice to avoid full disclosure to the patient rose 50% from the first to the second vote, with a confidence interval of 36% to 64% (Joynt et al., 2018). The authors interpret the difference as a sign of an inconsistency between what the formal curriculum teaches and the perception created by the hidden curriculum (Joynt et al., 2018).
The third year
In a longitudinal study with 456 students at an American school, empathy measured by a validated scale stayed stable in the first two years and fell significantly at the end of the third, when activities with patients begin, remaining lower until graduation (Hojat et al., 2009). The authors call it ironic that the drop happens precisely when the curriculum starts to revolve around care (Hojat et al., 2009). The drop has many possible explanations, and the clerkship environment is one of them.
Effects on both sides
A systematic review of 23 articles concluded that the hidden curriculum can work for or against the formal curriculum (Ullah et al., 2025). Among the negative effects, the authors list a harmful learning environment, learning of unethical practices, gender inequalities, stress and burnout (Ullah et al., 2025). Among the positive ones, communication skills, practical knowledge, cultural competence, moral growth and professionalism (Ullah et al., 2025).
The good side of the hidden curriculum
The examples that stay
In a study with 272 accounts written by 135 third-year students in a professionalism diary kept during the internal medicine clerkship, most of the recorded experiences showed professional values lived in a positive way, not violations (Karnieli-Miller et al., 2010). Preceptors and residents were the central figures in the accounts, and interactions that showed respect and good communication with patients, families and colleagues taught in a striking way (Karnieli-Miller et al., 2010).
The hidden curriculum, therefore, is also the place where one learns to be the doctor one admires. The preceptor who sits down to deliver the news, who apologizes for being late, who says "I don't know, I'll check" teaches as much as the one who humiliates, only in the opposite direction.
Strategies the literature recommends
The review by Ullah and colleagues gathers strategies so that the hidden curriculum works in favor: making the topic known to everyone, aligning what is practiced with what is taught, creating institutional policies, taking care of the examples and offering mentoring (Ullah et al., 2025). Joynt and colleagues also recommend preparing teachers to be good examples and preparing students to choose theirs carefully (Joynt et al., 2018).
How the student can deal with it
Name what you observe
The first step is to notice. When a scene on the rotation contradicts what was taught, write it down: what happened, what the class said, what you felt. The study by Karnieli-Miller and colleagues used exactly this kind of record to reveal the hidden curriculum (Karnieli-Miller et al., 2010).
Choose your examples
You will work with many preceptors. Notice who treats patients and staff well, who admits doubts and who explains their own reasoning. These are the people worth taking as role models. The guide to clinical reasoning in the internship shows how to make the most of conversations with your preceptor.
Talk about what you saw
Take the difficult scenes to a conversation with colleagues, a tutor or the academic league. Talking about what you saw helps separate what was an exception from what is culture. Group discussions, like those described in the guide to active learning, also serve this purpose.
Watch your own thinking
The hidden curriculum comes in through ready-made phrases: "this patient is a complainer", "this one is psychological". They carry shortcuts that can get in the way of diagnosis. The guide to heuristics in clinical reasoning shows how these shortcuts work, and the guide to metacognition teaches you to think about your own thinking.
Protect your time and your health
Pressure over assessment and belonging weighs heavily, and the study by Feudtner and colleagues shows how it can push behavior (Feudtner et al., 1994). Organizing your study so you arrive at the rotation less overloaded helps you resist that pressure. The guide how to study during the internship with little time offers practical suggestions.
Error as information in NEXO
The hidden curriculum often teaches that making a mistake is failing. NEXO starts from another idea: error is information. With each guess in the case of the day, the ICD-10 proximity in five levels shows how far the hypothesis was, whether in the same chapter, the same group or the same category. The case arrives in up to six clues, and guessing close becomes the starting point for the next hypothesis.
The cases are fictional with a real clinical presentation, and the guide what NEXO is explains the whole game. How the modes are unlocked is on the NEXO economy page.
If you coordinate a medical school, a league or a residency and want to discuss with the class how error is treated, get to know NEXO Closer. Researchers in medical education can propose studies through NEXO Researcher. Doctors who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.
Frequently asked questions
What is the hidden curriculum in Medicine?
It is what the student learns from the culture, the unwritten rules and the examples of the institution, outside classes and syllabi (Hafferty, 1998).
What is the difference between the formal, informal and hidden curriculum?
The formal one is in the classes; the informal one happens in day-to-day interactions; the hidden one comes from the structure and culture of the institution (Hafferty, 1998).
Is the hidden curriculum always bad?
It can harm or help. A review found negative effects, such as stress and unethical practices, and positive ones, such as communication and professionalism (Ullah et al., 2025).
Why does the rotation weigh so much?
It is when the student starts working with teams and patients. In one study, empathy dropped precisely at the end of the third year (Hojat et al., 2009).
How can you recognize the hidden curriculum?
Notice what is assessed, what receives resources, the rules nobody writes down and the way patients are referred to in the corridors.
How does NEXO treat error?
As information: the ICD-10 proximity in five levels shows how far each guess was from the diagnosis.
Hidden curriculum checklist
- Write down the scenes that contradict what was taught.
- Notice what is assessed and what is left out.
- Choose your examples carefully.
- Talk about what you saw with colleagues or tutors.
- Be wary of ready-made phrases about patients.
- Treat error as data, not as shame.
- Protect your time so you do not give in to pressure.
Want to practice treating error as information? Play the case of the day on NEXO.
References
- Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998. https://pubmed.ncbi.nlm.nih.gov/9580717/
- Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994. https://pubmed.ncbi.nlm.nih.gov/7945681/
- Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development. Acad Med. 1994. https://pubmed.ncbi.nlm.nih.gov/8054117/
- Joynt GM, Wong WT, Ling L, Lee A. Medical students and professionalism - Do the hidden curriculum and current role models fail our future doctors? Med Teach. 2018. https://pubmed.ncbi.nlm.nih.gov/29268632/
- Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009. https://pubmed.ncbi.nlm.nih.gov/19707055/
- Ullah H, Huma S, Tahir N, Yasin G, Ashraf M, Shabana H, et al. Effects of Hidden Curriculum on Medical Education and Strategies to Reshape Hidden Curriculum as a Curriculum Promotor - A Systematic Review. Adv Med Educ Pract. 2025. https://pubmed.ncbi.nlm.nih.gov/41257082/
- Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, Inui TS. Medical students' professionalism narratives: a window on the informal and hidden curriculum. Acad Med. 2010. https://pubmed.ncbi.nlm.nih.gov/20042838/