No medical resident looks forward to working night float. The initial glamour of doing chest compressions in the rising light comes up against a litany of administrative tasks. As the glamour wanes, the gulf between the objective curriculum and actual practice widens. On paper, residents learn how to manage acute emergencies and learn deeper clinical reasoning. Actual practice, or the “hidden curriculum” of training, can be a different experience, involving mountains of paperwork and distractions to clinical care. My confessions come from two overnight cases, and lead me to two conclusions. First, the hidden curriculum is not all bad. Second, recognizing its limits can help us understand how to train better residents and doctors.
The first case of the night is a 45-year-old obese female presenting with chest pain and concern for a heart attack. It is a slow night and I grab a chair to sit next to the patient and her son to take a detailed history. It becomes clear the pain is likely non-cardiac, though there are significant barriers to health literacy. The tasks of admitting this patient are increasingly electronic and performed behind the scenes: ordering EKG’s, assigning an appropriate diet and reconciling medications. Despite this, I linger awhile and discuss her compliance with medications. Meanwhile, her son picks up the phone to order her fast food (a hamburger with fries) over the phone, which leads to a rich discussion about diet and exercise. In one sense, my lingering was the antithesis of quality care: time-consuming, inefficient, and not amenable to electronic quality metrics. On the other hand, it was the paragon of care, both for me and the patient.
The second case of the night is a 50-year-old man also presenting with chest pain. He has heart failure and is set up to get a cardiac catheterization in the morning. I examine him, lump him into the “stable” category, and fill out his paperwork. I also tell that if I were a betting man, I would say his coronary arteries would be “clean.” The next evening the intern informs me of my two errors. Mistake one: He had multi-vessel disease and will need surgery the next day. Mistake two: He had disease of his carotids and may needs further imaging. The first error was due to lack of experience, the second lack of competence.
In the first case, the hidden curriculum pushed me to be efficient over humanistic. This was hidden in that all forces, including electronic ordering, multiple competing time-demands, and interruptions to patient care incentivized efficiency. The lesson here is not to malign the hidden curriculum as soulless or inhumane, but rather for hospitals and residency programs to create equally compelling incentives for quality humanistic care.
In the second case, while the objective curriculum asked for competence (correctly identify a carotid murmur), the hidden curriculum asked me to stake a claim on a diagnosis. Again, this was hidden in that over time, declaring one’s diagnosis boldly is praised more than admitting uncertainty. The lesson here is that competency-based training is not enough: Training doctors involves teaching to competency and providing sufficient experiential learning to be able to predict the right diagnoses. As my second evening of night float looms close, I have given up on glamour and hope only for more cases and fewer hamburgers.
Tom Peteet is a board-certified internal medicine physician, educator, and writer. For nearly a decade, he has practiced at Commonwealth Care Alliance, focusing on home-based care for patients with complex disabilities. He also cares for patients in long-term care facilities and works with InstED, a mobile health program that brings acute care into patients’ homes.
As an adjunct professor at Massachusetts College of Pharmacy and Health Sciences, he directs a year-long pharmacology course for physician assistant students. At Boston University, he has taught more than ten courses through its prison education program and is developing courses in neuroscience and medical anthropology.
His scholarship spans medical ethics, medical education, and health equity, including work on the treatment rights of incarcerated patients, the role of theory and the humanities in medical training, and the intersection of quality improvement and equity in residency. His writing has appeared in the AMA Journal of Ethics, Medical Teacher, and the Journal of Family Medicine, and he authored a 2025 textbook chapter on renal disorders in Pathophysiology in Focus.
His writing explores health care ethics, medical education, and the overlooked paradoxes of human physiology. He writes Against Medical Advice, a Substack on the hidden science of medicine, and is working on a nonfiction book about the strange science of blood pressure. More of his work is available on his personal website.
