Hidden curriculum in Medicine: what is learned without class

In the first week of the internship, the student notices things that no teaching plan mentions. On rounds, the resident calls a patient by bed number, and nobody corrects it. When she asks why a test was ordered, someone laughs and says that "you learn that on call". On the way out, the preceptor she admires most takes five minutes to explain a diagnosis to a frightened family, unhurried, looking them in the eye. In a few days, she learned lessons about hierarchy, about the value of questions and about what kind of doctor she wants to be. None of them was in the program.

This set of lessons that the school teaches without saying so has a name: the hidden curriculum. The term describes what is learned through culture, through examples and through the way institutions are organized, and not through classes. This guide explains what the hidden curriculum is, where it shows up in the day to day of training, what studies show about its effects on ethics, empathy and well being, the positive side it also has and how the student can recognize and deal with what is learned outside the classroom.

Key points

• The hidden curriculum is what is learned through culture and example, and not through the formal content of the subjects.
• It shows up in hierarchy, in the way people talk about patients, in assessments and in how time and resources are distributed.
• Studies link the hidden curriculum to ethical erosion, a drop in empathy and experiences of mistreatment during the course.
• The examples set by professors and residents, positive or negative, are among the most powerful forces in training.
• The hidden curriculum can also teach good things, such as commitment, care and humility.
• Naming what you see, talking about it and choosing good role models helps the student avoid absorbing the worst of it.

Summary

• What the hidden curriculum is
• Where the hidden curriculum shows up
• What studies show
• The power of examples
• The good side of the hidden curriculum
• How the student can deal with it
• Hidden curriculum and clinical reasoning
• How NEXO helps treat error as information
• Frequently asked questions
• Hidden curriculum checklist

What the hidden curriculum is

The expression comes from the sociology of education and was popularized in medicine by the sociologist Frederic Hafferty. In a 1994 article, he and Ronald Franks questioned the idea that adding more ethics classes would be enough to train more ethical doctors. They argued that most of the factors that shape a doctor's identity do not operate in the formal curriculum, but in a hidden curriculum, more subtle and less acknowledged, and they described medical training as a process of moral training.

Three curricula at once

In 1998, Hafferty proposed separating three components that coexist in every medical school. The formal curriculum is what is on paper: subjects, objectives, classes. The informal curriculum is what is taught in unplanned conversations and interactions, in the hallway and on rounds. The hidden curriculum is what the structure itself teaches, through policies, assessments, distribution of resources and language. For Hafferty, the school should be seen as a learning environment, and reforms should look at what students learn, and not only at what they are taught.

Curriculum	Where it is	Example
Formal	Teaching plan, classes, exams	Class on communicating bad news
Informal	Conversations, rounds, hallways	A resident's comment about a "difficult" patient
Hidden	Rules, assessments, resources, language	An exam that only rewards memorization, never conversation with the patient

A concept with many meanings

The term spread so widely that it came to mean different things to different authors. A scoping review found thousands of articles on the topic and showed that use of the expression grew a lot after 2012. The authors identified four conceptual boundaries: institutional, interpersonal, cultural and motivational. They also noted that the concept is usually understood as negative, that there are few ways to measure it and that data from schools in South America and Africa are almost absent.

Where the hidden curriculum shows up

The hidden curriculum is not in one place only. It shows up in day to day details that, added up, teach what the institution really values.

• In language: calling the patient by the disease or the bed number, nicknames, jokes about groups of patients.
• In the hierarchy: who can ask questions, who can disagree, who speaks first on rounds.
• In assessments: what counts toward the grade shows what matters, and what does not count shows what can be ignored.
• In the use of time: how much time is spent listening to the patient and how much filling out forms.
• In resources: which activities get space, funding and prestige and which are left for later.
• In how errors are handled: whether an error is hidden, punished or discussed in order to learn.

The corridors and the on-call conversations

Much of the hidden curriculum circulates in quick conversations: the remark in the elevator, the chat in the break room during a shift, the message in the class group. It is in these moments that you hear which specialty is "worth it", which patients "are a handful" and which preceptors "come down hard". These remarks seem harmless, but repeated many times they become beliefs. It is worth listening carefully and asking yourself whether that is a fair observation or just a label repeated out of habit.

Rounds as a classroom

Ward rounds are one of the places where the hidden curriculum is most visible. That is where the student sees how doctors talk to patients, how they treat nursing staff, how they deal with doubt and with error. A student who sees the preceptor admit "I don't know, let's look it up together" learns that uncertainty is part of the work. A student who sees questions ridiculed learns to keep quiet.

Exams teach too

Hafferty suggested that schools examine their assessments to uncover the hidden curriculum. If exams only test isolated facts, students conclude that reasoning, communication and care are secondary. The way you assess says more about an institution's priorities than any mission statement written on the wall.

Teaching materials

Even the cases used in class carry messages. A study analyzed hundreds of clinical vignettes used in teaching and exams at a medical school in Switzerland and found a distribution strongly marked by gender in the professions and family roles of patients, with male doctors and female nurses as the norm. The authors concluded that these materials convey a hidden curriculum with gender bias. The guide on implicit bias in diagnosis shows how these stereotypes can reach clinical reasoning.

What the studies show

Research on the hidden curriculum mixes qualitative studies, surveys and some longitudinal measures. Together they paint a worrying picture, but they also point to ways forward.

Ethical erosion

In a classic survey of third- and fourth-year students at six schools in Pennsylvania, 58% said they had done something they considered unethical, and 98% reported having heard doctors refer to patients in a pejorative way, according to the study on ethical erosion among students in clinical clerkships. The authors asked whether students felt their principles were being eroded, and many answered yes.

What is taught and what is expected

In Hong Kong, final-year students responded to a vignette about telling a patient the truth. First, they chose what they thought was most correct. Then, what they thought would happen in real practice. The difference between the two votes in favor of avoiding full disclosure was 50% (95% CI: 36% to 64%), showing a large gap between what the formal curriculum teaches and what students believe practice does.

Hierarchy and humiliation

Interviews with students at a school in the United Kingdom found many examples of good teachers, but also a hierarchical and competitive environment, with disorganized teaching and teaching by humiliation, especially in the clinical years. A meta-analysis of dozens of studies found that 59.4% of students and residents reported at least one form of harassment or discrimination during training, with verbal harassment as the most common form.

Mistreatment and burnout

In a national survey of third-year students in the United States, most reported at least one episode of mistreatment, 64% by teachers and 76% by residents, since the start of their clerkships. The study also investigated the association between mistreatment and burnout, one of the most studied effects of the learning environment. The text about burnout in medical school brings warning signs and paths to prevention.

The decline of empathy

Longitudinal studies show that students' empathy, measured by questionnaire, tends to stay stable in the early years and fall significantly at the end of the third year, when intense clinical practice begins. Many authors link this decline to the hidden curriculum: the student learns, by example, that conversation with the patient matters less than the procedure.

The design of the clerkship makes a difference

There are signs that changing the structure of the clerkship can protect against this erosion. In a cohort study, students in traditional rotating clerkships had a significant drop in empathy over the year, while students in integrated longitudinal clerkships had no significant drop. In these clerkships, the student follows the same patients and the same preceptors over a long period, which favors bonding and continuity.

It is worth remembering that the hidden curriculum is not the work of ill-intentioned people. Most of the time, it results from time pressure, from traditions that are never questioned and from structures that reward productivity above teaching. Understanding this helps you look at the episodes with a critical eye, but without turning every preceptor into a villain.

The power of examples

If there is a central mechanism in the hidden curriculum, it is example. Students watch all the time how more experienced physicians act, and they learn from this consciously and unconsciously.

Narratives of professionalism

In a study with hundreds of accounts written by third-year students during the internal medicine clerkship, most of the experiences described involved witnessing positive examples of professional values, not failures. Attending physicians and residents were the central figures. The accounts showed that the informal and hidden curriculum teaches through both good and bad example, in interactions with patients, families and colleagues and in the teaching environment itself.

Being a role model on purpose

Canadian educators argue that teachers need to know the conscious and unconscious components of learning by example, so that the final effect is positive. This includes making explicit the reasoning behind their own attitudes, explaining why they did what they did and setting aside time to reflect with students after striking situations.

The good side of the hidden curriculum

Despite its bad reputation, the hidden curriculum is not only a problem. It also passes on positive values that classes alone cannot teach.

Good things learned without a class

• Commitment: seeing someone stay past the end of the shift to talk with a family.
• Humility: seeing a professor admit a mistake and correct the management.
• Curiosity: seeing the team look for the answer to a question nobody knew.
• Respect for the team: seeing physicians listen to nursing as a source of information.
• Care with language: seeing someone gently correct a disrespectful nickname.

How to make the hidden curriculum work for training

A recent systematic review analyzed the hidden curriculum as a possible promoter or inhibitor of the formal curriculum. It found effects of both kinds and gathered strategies so that it works in favor of training, such as structured reflection, faculty development and attention to the learning environment. The idea is not to eliminate the hidden curriculum, which would be impossible, but to make it visible and aligned with what the school says it values.

How the student can deal with it

The student has little power over the institution's structure, but has a lot of power over what they choose to absorb. Some attitudes help keep the worst of the hidden curriculum from becoming part of you.

Name what you see

The first step is to notice. When something bothers you, such as a joke about a patient or a question that gets mocked, write down the episode and what you felt. Naming what happens reduces the chance that it becomes normal to you.

Talk to people you trust

Discussing these episodes with colleagues, tutors or a trusted preceptor helps separate what is acceptable from what is not. Many medical schools have reflection spaces, case discussion groups or mentoring. If the situation involves harassment or mistreatment, seek the help you need through your institution's channels.

Choose your role models

You will spend time with many doctors during the course. Pay attention to who treats patients and colleagues well, who explains the reasoning, who admits doubts. Get close to these people, ask questions, ask to shadow them. Good examples are also part of the hidden curriculum, and you can seek them out on purpose.

Watch how you speak

Language is contagious. Calling the patient by name, avoiding nicknames and speaking about them with respect even when they are not in the room are choices you can make from the first day, regardless of what you hear around you.

Keep a clerkship diary

A simple notebook, with one line per day, helps a lot. Write down a situation that taught you something good, one that bothered you and one question that went unanswered. At the end of each month, reread it. You will notice patterns: which environments encourage questions, which teachers explain the reasoning, which situations repeat. This record is also useful for conversations with mentors and for choosing where to do elective clerkships, because it shows with data what worked for your training. Many students discover, on rereading, that they absorbed habits they did not even notice, such as speaking faster with certain patients or no longer asking questions in certain services.

Treat mistakes as learning

One of the most harmful effects of the hidden curriculum is teaching that mistakes should be hidden. When you make a mistake, tell someone, understand what happened and learn. The text on morbidity and mortality sessions shows how to draw lessons from mistakes, and the guide on metacognition in medicine helps you review your own reasoning.

Hidden curriculum and clinical reasoning

The hidden curriculum is usually discussed as a matter of ethics and behavior. But it also shapes how the student learns to think in front of a patient. Reasoning habits are passed on by example just as conduct habits are, and many of them never appear in a teaching plan.

Whoever is older is right

In very hierarchical environments, the student learns that the more experienced doctor's hypothesis is not to be questioned. This can be comfortable in the short term, but it teaches anchoring on the diagnosis of whoever has more authority, not on the data. When a new finding does not fit, the tendency is to ignore it instead of raising the doubt. An environment that welcomes the question "and what if it is not that?" teaches the opposite: that the hypothesis is tested by the data, whoever it comes from.

The copied progress note

Another habit passed on without words is copying the previous day's progress note and changing only a few numbers. The student sees this happen, understands that this is how it is done and starts repeating it. The effect on reasoning is subtle but real: the diagnosis recorded on the first day becomes established truth, and daily reassessment disappears. The guide on how to organize reasoning in the medical record shows how to keep the progress note as a place of thought, not of copying.

Saying "I don't know"

Perhaps the most important hidden lesson is about uncertainty. If the student sees doctors who never admit doubt, they learn that uncertainty is a sign of weakness and start hiding it. If they see doctors who say "I don't know, let's find out", they learn that doubt is a starting point for investigating. This difference directly affects the quality of diagnoses, because those who hide doubt tend to close the case too early. The text on diagnostic uncertainty offers strategies for deciding well even without certainty.

What the student can do here

Even in a not very open environment, you can train good reasoning habits on your own. Before hearing the preceptor's opinion, form your hypothesis and write it down. Then compare. When a piece of data does not fit, record the doubt, even if only in your notebook. Over the course of the rotation, this creates a record that shows where your reasoning is right and where it leans too much on someone else's authority.

How NEXO helps treat error as information

One of the antidotes to the hidden curriculum that hides error is to practice in an environment where making mistakes is part of learning. In NEXO, the case of the day arrives in up to six clues, and each wrong guess is information: the proximity in ICD-10 across five levels shows how far your hypothesis was from the diagnosis, without humiliation and without an audience.

The cases are fictional with a real clinical presentation, which allows you to make mistakes, review and try again without risk to anyone. The guide what NEXO is explains the game, and the limits of use are on the NEXO Economy page.

Teachers and coordinators who want to discuss cases in a group, in an environment safe for questions, can learn about NEXO Closer. Researchers can propose studies through NEXO Researcher, reviewing physicians take part through NEXO Curator, and health content creators through NEXO Creators.

Frequently asked questions

Is the hidden curriculum always bad?

No. It also teaches commitment, humility and care through good examples. The problem is when it teaches the opposite of what the formal curriculum says it values.

What is the difference between the informal and the hidden curriculum?

The informal one is in unplanned conversations and interactions. The hidden one is in the structure: rules, assessments, resources and the institution's language. In practice, the two mix.

Can the hidden curriculum be measured?

There are few instruments. Most studies use interviews, written accounts and surveys about the learning environment.

What should I do if I witness mistreatment?

Record the episode, talk to someone you trust and use your school's or hospital's channels. Seek the help you need if the situation affects your well being.

Can the school change the hidden curriculum?

It can influence it. Reviewing assessments, training teachers as role models, creating spaces for reflection and reorganizing rotations, as in longitudinal rotations, are strategies that have been studied.

Is the hidden curriculum the same as the formation of professional identity?

No. Professional identity is the process of becoming a physician, of integrating personal and professional values. The hidden curriculum is one of the forces that influence this process, alongside the formal curriculum, personal experiences and relationships with patients and colleagues.

Do the cases used in class also have a hidden curriculum?

They do. Cases written without care can repeat stereotypes, for example in the professions and roles assigned to men and women. It is worth looking closely at who appears as the physician, who appears as the patient and how each one is described.

Hidden curriculum checklist

• Write down episodes that bothered you and what you felt.
• Talk about them with colleagues, tutors or mentors.
• Identify and seek out the good role models in your rotation.
• Call the patient by name and avoid nicknames.
• Ask questions even when the environment discourages it.
• Treat your mistake as information for learning.
• Know your institution's support and reporting channels.

Want to train reasoning in an environment where making mistakes teaches? Play the case of the day on NEXO.

References

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