“It is, I think, not easy to exaggerate the importance of the informal social element in the promotion of science and learning.”
– Abraham Flexner, 1930
As stated by Mr. Flexner, the importance of the informal social element of science and learning is one of the key fundamentals of the hidden curriculum, a well-understood but unspoken rule in medical education and training. The hidden curriculum consists of the unspoken or implicit academic, social, and cultural messages that are communicated to trainees while they are in a learning environment. This enhances a trainee’s medical, clinical, and surgical acumen while developing and sometimes warping the identity of the trainee impacted by such.
As doctors, we are all faced with the formal curriculum (structured learning), the informal curriculum (spontaneous learning), and the infamous hidden curriculum (norms and customs associated with a particular branch of medicine). All medical trainees have undoubtedly gone through every type of curriculum. However, the hidden curriculum always proves to have everlasting effects on both the professional life and personal life of medical students and practicing doctors alike. By recognizing how the hidden curriculum affected me, I am able to speak on the changes in perspective and behavior experienced, how they manifested professionally and personally, and how I intend to prevent the negative aspects from affecting medical students and peers.
Upon completing foundation year one and becoming a senior house officer in the general surgical department, I was filled with excitement and zeal for becoming a surgeon. Foundation year one was difficult, and when I started my surgical rotations, I noticed something different from the other specialties. There were sarcastic and embarrassing remarks often made to senior house officers from consultants in the presence of patients, with the occasional tearful moment. At the time, I thought this might have been justified by a lack of knowledge or difficulty following up or completing tasks. In response, I avoided any eye contact with anyone and kept my head slightly hunched over. These beginning patterns signified the dismissive attitude that many consultants had undergone during their years as a trainee and deemed it normal to continue such actions. However, only now, looking back and understanding the hidden curriculum, can I say this.
I advanced in the surgical department to become a senior house officer, and the shift was almost immediate. No longer a spectator, I started receiving the full blast of the firing squad. The belittlement, patronizing, shouting, and scolding during theatre time and ward rounds in the presence of peers and patients ensued on an almost daily basis. Eventually, in retaliation, I started holding up a mirror to my consultants, now being the sarcastic or patronizing one. I found myself having a negative attitude toward my peers from different departments, periodically swearing and justifying this behavior with the sentiment that, “It is what we surgeons do.” However, the turning point was when this attitude began translating to my personal life and affecting my wife, then my fiancé. I did not recognize the person in the mirror anymore and set out on a path to change the idea that “doctors in the surgical department all have an attitude problem.”
All the patterns mentioned above were norms and customs associated with the surgical department in many parts of the world. Research by Kirsty Louise Mozolowski (2025) explores the reasoning behind these patterns and found that both students and consultants acknowledged that they would act in certain ways to meet their aims of gaining or imparting knowledge. Surgeons, who spend many years developing and maintaining the knowledge and skills to deliver surgical care, are given little time to practice the skills required to teach their students. Surgeons considered teaching in a classroom to be most effective, but students felt that the operating theatre was where most surgical education may occur. This discord meant that surgeons did not necessarily appreciate that teaching may occur in settings where students are having to learn more than what is in the curriculum, such as the language, culture, or unwritten rules of the operating theatre. This can lead the student to become overwhelmed and less able to learn what is intended.
To negotiate a successful surgical career, trainees perceive that they must first build networks because career information flows through relationships. Trainees often see relationships as fundamental to understanding how to engage in the surgical world. Building a network is critical to encountering, uncovering, and managing the surgical hidden curriculum. Students enact the hidden curriculum by accumulating the practical achievements required and displaying the personal characteristics expected of surgeons. Thus, they identify themselves, and are identified by others, as future surgeons and are able to fit in and access participation in surgery, which is important to the further expansion of their networks and helps them to gain more information about surgical careers. As a result, the norms and customs associated with the “surgical identity” (both positive and negative) are passed down from one generation of doctors to the next.
I reflected deeply on the philosophy surrounding medicine, and through deep thought, I identified three steps to mitigate the negative aspect of the hidden curriculum.
Be nice to everyone. This has been achieved by keeping a warm and welcoming smile, greeting everyone with respect, and, even when busy, being able to give a listening ear or helping hand to a colleague, family members, and patients. Being nice not only shows a degree of professionalism, but it is also picked up on by medical students and peers. Being able to show a great attitude and aptitude for your work begins to tear down the negative attributes that may have been acquired by peers. This therefore begins the reversal of the learned negative aspects of the hidden curriculum.
Publicly praise and privately criticize. This particular step can be by far the most difficult for someone stuck in the negative attributes of the hidden curriculum to overcome. A practical example is when I publicly praised my emergency room colleague on her swiftness in alerting the surgical team of an impending widespread subcutaneous emphysema, manifesting as respiratory distress with ensuing respiratory arrest. She was, however, privately criticized for her inability to put the chest tube in herself prior to alerting the staff. This approach allowed both parties to be viewed with high praise by the wider medical teams but also allowed for dialogue about how to prevent such an instance from happening again.
Ensure that protected times for study, research, and leave are respected and given. Many times, courses are given as part of continuous professional development in the form of lectures and hands-on, practical-skill procedural modules. Historically, senior consultants were allocated specific times for these activities but frequently missed the dates due to the demands of clinical responsibilities, which made it difficult to step away. This was a norm and formed part of the hidden curriculum. As a result, in the present day, the lack of allocated time for junior doctors is not perceived as a significant issue by consultants who believe they survived, adapted, and succeeded, so will the new generation of doctors. Many times in my department, the on-call junior doctors may not be able to get a replacement to go to seminars. However, I would allow him or her to go, and although I would have to bear the burden of added responsibility, I feel it is necessary to show by example how to change the narrative. It is indeed possible to get your stipulated time. Faculty involvement can be helpful in driving institutional culture change.
Despite the negatives, there are also positive aspects of the hidden curriculum, including but not limited to arriving at work thirty to forty-five minutes early, prioritizing patient safety above all, and treating every single patient, from young to old, with dignity and respect. The hidden curriculum in medical education, though often implicit, can positively impact students by fostering professional development, enhancing communication skills, and shaping a strong professional identity. By observing and interacting with role models, students learn unspoken norms, values, and behaviors that are crucial for becoming competent and ethical health care professionals. Through observing how doctors interact with patients, students can learn valuable lessons about empathy, compassion, and building strong patient-physician relationships. Positive feedback, encouragement, and opportunities to develop skills can all be powerful messages conveyed through the hidden curriculum.
The hidden curriculum carries both positive and negative attributes; however, the negatives can outweigh the positives, sometimes deterring medical students from pursuing particular specialties (particularly surgery). Having reflected on these negative aspects, understanding what has transpired, and considering how to effect positive change, I believe that these three steps, along with others, can help curb the long-lasting negative trends of the hidden curriculum. As a Bulgarian Proverb states, “Nature, time, and patience are the three great physicians.” I believe that by enforcing simple but effective measures, we can begin to “heal” the culture of the hidden curriculum, allowing it to be a bit more supportive, constructive, and ultimately less harmful.
Sheldon Jolie is a urologist in the United Kingdom.
