Being like squid is easy. Don't be one.

Squid and other cephalopods have the amazing ability to change the color of their skin. In an instant, they can blend into their environment, matching the landscape perfectly to avoid detection. In contrast, they can turn a bright iridescent hue to warn predators or, in some circumstances, to attract a mate.

They do this in a rather complex way. Squid, cuttlefish, and octopus have special cells called chromatophores that contain elastic sacs filled with a variety of pigments. When activated by a special network of nerve and muscle cells, these sacs stretch, allowing for a change in coloration. A beautiful example of this can be seen here.

Many cephalopods also contain iridophores and leucophores; stacks of reflecting plates that, in essence, can mirror the local environment and produce iridescence. In addition to the ability to change color, many cephalopods can change their shape as well, using special muscle cells called papillae that can actually manipulate the surface texture of the animal. This allows them to completely blend into their environment both in color and texture, making them completely camouflaged with their surroundings.

Much like the squid, we, as people, like to blend into our external environment. This is particularly true in health care, a traditionally hierarchical system with both written and unwritten rules. This is the hidden curriculum of medicine.

The unwritten rules of medical and nursing practice. There can be some positives to the hidden curriculum, but traditionally it has been the conduit for disseminating and accepting negative and even harmful practices. Acceptance of speaking badly about colleagues, using derogatory terms towards patients, and a lack of civility and empathy can be infused into clinical practice through the hidden curriculum. If allowed to persist, these activities become ingrained as part of the culture of medicine.

Most people enter the health care field with a want to care for others derived from empathy, sympathy, and a moral compass. This can be eroded when these principles are slowly degraded by a hidden curriculum that allows harmful behaviors to exist and perpetuate. The hidden curriculum can erode these values and change the individual’s entire system of belief. The effects can be detrimental to both the system and the individual. It can debase empathy, idealism, sympathy, and civility.

Acceptance of practices that devalue patients, use derogatory language about other practitioners, or support unethical practice can lead to moral injury when one struggles with their own values while attempting to fit in.

Being a squid is easy.

If one decides to blend in, to assume these characteristics and traits, they will be protected.

The predators, the practitioners who perpetuate the hidden curriculum, will see them as obedient if they see them at all. They will blend into their environment, much like the camouflaged squid. This can create a better work environment in the short run, but over time can erode one’s ideals. Allowed to persist this can lead to moral injury and burnout, harm to the individual, the organization, and to patients.

Standing out is a bit harder to do. Being resilient to the hidden curriculum requires holding strong to one’s beliefs and morals. It means sometimes going against the grain of the culture of the department or even the institution. It can lead to ridicule and alienation among one’s peers; a significant cause of moral injury and burnout. It is not brave to stand out; it is imperative. It is necessary to end the disparity of sex and race in health care. It is necessary to allow people from different cultures, from different socioeconomic classes, and from different sexual identities to feel safe in clinical practice. It is necessary to make patients feel welcomed, feel safe, and to receive the best care possible from empathetic and caring providers.

The hidden curriculum that embraces toxic hierarchical structures allows for destructive personal interactions and embraces detachment is harmful at every level. It is a priority for institutions to recognize this as a root cause of moral injury and burnout and to take corrective actions to fix these issues. These are not problems that are solved with a snack cart or a five-minute chair massage. These are ingrained institutional problems that require high-level change.

I’m a little harsh on squid. They do have some wonderful attributes that provide a useful analogy. The Caribbean reef squid, for example, displays a bright red flashing coloration when attracting a mate. This is a bold move and helps the squid stand out among the crowd.

Display your colors proudly. Your empathy, your compassion, your passion for caring. Create a new culture and push for the institutional change that will allow us to heal, rebuild, and to prosper as a profession.