In medical school, we only learn a fraction of what we need to know to succeed as doctors. The rest, we learn serendipitously through role modeling, trial and error, and other venues. Without luck, however, we may not learn these factors at all. It turns out that unspoken forces, the so-called “hidden curriculum,” may have a greater impact on our personal and professional outcomes than most people realize. As educators and career-long learners, we can do more to understand, teach, and leverage these forces.

A few years ago, I stumbled on an article about the hidden curriculum in medical training, and it resonated with my own experience navigating a career in medicine. Over the ensuing three years, I reflected on everything I wish I had learned earlier, reading everything I could find on the subject, including over 1,000 articles and 50 relevant books. Realizing there was no single source that explained it all, I committed to writing a book about it to try to help the uninitiated. When I told colleagues and learners about the book, I received nearly daily examples of how and where trainees stumble. Though these stories were from a spectrum of specialties and institutions, certain themes emerged. By far, the two most common topics related to professionalism and generational perceptions, and often a combination of both.

While researching the hidden curriculum, I was also surprised to learn that many of the common beliefs held by many (including myself) are partially or flat-out wrong. Here are just two examples: First, subjective performance evaluations are around 75 percent bias and noise, far greater than I had supposed. Second, failure is an ineffective teacher unless we and our evaluators adopt the right mindset. Learning the basics about these little-known facts can help us succeed in training and beyond.

I also learned that there is a wealth of information relevant to the hidden curriculum of medical education from sister fields, such as psychology, sociology, business, and complexity science, as well as concepts such as habit formation, well-being, and more. These disciplines shed light on many of the most important, but undertaught, skills for success. We can do more to incorporate concise learning resources into medical training and add these concepts to our everyday vernacular.

Four types of curricula

Where does the hidden curriculum fit into training? To understand this, first consider that there are four major types of curricula: formal, informal, null, and hidden.

• The formal curriculum is what we usually think about: learning objectives and activities that are structured and acknowledged.
• The informal curriculum, also expected and acknowledged, is unstructured; a key example of this is teaching during daily rounds.
• The null curriculum describes topics that may be acknowledged but, generally due to time limitations, are deprioritized and omitted from the formal and informal curriculum.
• The hidden curriculum, then, describes important factors contributing to holistic medical education but that are unacknowledged.

The term brings confusion for a couple of reasons.

The first source of confusion is that authors have studied portions of it from different angles, making it difficult to fully comprehend its scope. The second reason is that the number of articles describing the hidden curriculum in medicine has increased exponentially in recent years and describe dozens, if not hundreds, of topics. For example, these topics span spirituality, professionalism, specialty selection, teamwork, malingerers, and much more. The term has also been applied to myriad concepts outside of medicine too. While these may all be accurate uses of the term, there are not too many sources that tie all these factors together. These are just special cases of the broader idea that the hidden curriculum is the single, distilled concept that unspoken forces profoundly shape learners’ personal and professional outcomes. These unspoken forces include unspoken expectations, challenges, and influences.

Case studies

Two otherwise identical trainees start medical school the same day. One is clued into the hidden curriculum, seeks out expectations, feedback, mentorship, intentionally manages the effect of influences and, with work, shines during training. The other is unaware of the hidden curriculum and struggles, wondering why they keep hitting dead ends.

A third-year medical student is asked why she is considering radiology as a career because “why would she want to waste her people skills?” Subtle interactions like this may impact specialty choice and limit opportunities.

A medical school formally espouses problem-solving and deeper understanding of materials. However, it administers tests that rely on (and promote) rote memorization. What is said does not match what is rewarded in testing evaluations, leading to confusion and inadvertent promotion of learning “shortcuts,” which are not necessarily best for enduring mastery of medical material.

Though a general internal medicine resident listens to a lecture on professionalism, he tends to act more how his senior residents and attendings do than what the lecture recommends. Data show that real-life role modeling has greater impact than impersonal lectures.

On the first day of his rotation, a clued-in resident arrives early, shows proof of preparation, and has gained some insights into her specific attending’s typical expectations. Positive first impressions carry an outsized impact due to a cognitive bias called excessive coherence. That is, attendings, and us all, try to make sense of a situation by compiling a complete story based on limited information. Positive first impressions have disproportionate effects, leading to labeling, positive feedback loops, and reputation-sharing with others.

On the first day of his rotation, a resident arrives late and underprepared. In addition to making a negative first impression, the resident inadvertently invokes generational biases from his attending. That is, attendings, and us all, tend to judge younger individuals by the standards of our current, rather than younger, selves. This includes both a confirmation bias and an illusion of moral decline. Nevertheless, trainees must understand that generational perceptions exist and take action to counteract them.

A resident starting a procedural rotation arrives with plans to execute each procedure start to finish, tactfully showing this to her attending. She makes it clear she is interested in participating as fully as possible and discerns her attending’s expectations and feedback. She gains valuable experience which she then leverages to become even more involved as the rotation progresses.

Takeaways

Mastering the hidden curriculum is a key to success. This helps us fill in gaps in the formal curriculum, adapt to various situations, manage influences, make sense of mixed messaging, and demystify training subtext.

This essay is cited in the KevinMD record on medical school.

Vance Lehman is a professor of neuroradiology at Mayo Clinic and chief of neuroradiology education. His work spans clinical practice, medical education, research, and academic leadership. Dr. Lehman’s clinical practice focuses on advanced imaging techniques and nonvascular interventional neuroradiology, including MRI-guided focused ultrasound and laser interstitial thermal therapy of the brain.

He is the author of Mastering the Hidden Curriculum: Unlocking Success in Medical Education and founder of the educational resource Medical Hidden Curriculum, which explores the informal systems and professional dynamics that shape medical training and career development.

Dr. Lehman has authored more than 120 peer-reviewed publications indexed on PubMed. His research and teaching focus on neuroradiology, medical education, and helping trainees navigate the hidden curriculum of academic medicine. Professional updates are available on LinkedIn.