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What if the biggest threat to your success in medical training has nothing to do with how much you study? Vance Lehman, professor of neuroradiology and chief of neuroradiology education at the Mayo Clinic, spent over two years researching why capable trainees stumble despite strong clinical knowledge. In this episode, based on his KevinMD article “The hidden curriculum: What medical school does not teach you,” he explains how unspoken expectations, invisible social dynamics, and stealth influences shape evaluations and career trajectories far more than most trainees realize. You will learn why making a strong first impression on a new rotation triggers a powerful psychological feedback loop, how generational biases from attendings quietly distort trainee evaluations, and why years of excelling at test scores can actually leave you blind to the skills that matter most in clinical settings. Lehman also shares practical steps any medical student or resident can take tomorrow to stop leaving their reputation to chance. If you are in medical training or teach those who are, this episode reveals the forces you feel every day but have never had a name for.

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Transcript

Kevin Pho: Hi, welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Vance Lehman, professor of neuroradiology at the Mayo Clinic. Today’s KevinMD article is “The Hidden Curriculum: What Medical School Does Not Teach You.” Vance, welcome to the show.

Vance Lehman: Pleasure to be here. Thanks for having me.

Kevin Pho: All right, so let’s start by briefly just telling us about yourself and then why you decided to write and share this article on KevinMD.

Vance Lehman: Yeah, absolutely. So I’m a first-generation physician. Took a pretty linear path to get here. Managing challenges along the way, often through, like many people, trial and error. Guesswork, sometimes luck, sometimes figuring it out, sometimes not. Anyway, 2012 came on staff here at Mayo Clinic. And I should mention these viewpoints today are mine, not that of Mayo Clinic. And decided to take on a few roles with education, which I’ve always been interested in, other relevant roles as well. So I’ve been doing that for well over a decade now.

So a few years ago, I just happened to stumble on this concept in an article about the hidden curriculum. And immediately a light bulb went off. I thought, why hadn’t I heard about this before? So as I started to research it in more depth and to reflect, I started to realize that this concept was actually more impactful, perhaps far more impactful than was even recognized in the current literature. So I looked for some more resources, some more books, and I couldn’t find a single guide that was a practical guide. So I made it my mission to put all my other research aside and to focus on this for over two years.

Once I told some of my friends and colleagues I was doing this, I was kind of amazed because from all over the country, stories started coming in of their experiences with trainees every single day. And it was often where they stumbled, where they made a one little silly mistake that sabotaged their career. Oftentimes it was on the negative. And at that point I really realized that this concept, I knew it was important, but it’s actually central. It’s actually central to how well we do. And that’s also another reason why I like to say the book actually in the end wrote itself. I was just the medium that was writing the book from all these stories that started coming in and all the research I had done.

Kevin Pho: So tell us, what do you mean by the hidden curriculum?

Vance Lehman: Absolutely. I’m glad you asked. So it’s important to probably take a few moments to go into a little bit of detail because a lot of people, it turns out, have heard about this term, but there’s some confusion that surrounds it. So the short answer is that there’s a formal curriculum that is structured. It’s official and it’s acknowledged. And there’s many other types of curricula. But the other main type here we’ll talk about is the hidden curriculum, which is none of those things. It’s not official, it’s not structured, and it’s basically not even acknowledged.

I think it’s really useful to take a moment to understand where this term even comes from, because most people don’t know this. So doing the research, I discovered that the term was first used by this researcher in the 1960s. Researching grade school, primary school. So he decided, this guy, Philip Jackson, that he wasn’t going to do just surveys anymore. He was going to go in actually sit and watch and get an idea of what’s actually going on. And that really gave him the opportunity to go in a lot more depth of what are we actually learning when we’re in a learning environment. And yes, he found that the formal syllabus did matter, of course, but what kids were really learning had mostly to do with peer interactions and respecting a hierarchy and responding to rewards and just the effects of being in this environment for such a big percentage of their life. So he introduced the term hidden curriculum and he described it as this complex thing, but what he didn’t do is give us a formal definition that we can all agree on. So then that kind of opened the doors, for better or worse, for other people to take some creative liberty to use the term in different ways and define it in their own different ways in different circumstances. And I think that’s where some of the confusion comes from.

What I did is I tried to create a unifying definition of unspoken expectations, invisible challenges, and stealth influences. And of course that takes a little bit of context, but I think that really gets at the heart of what was going on. And I would also add an interesting thing in medical school. Although this was first described in grade school, I would say the hidden curriculum is more important in medical training than it is in grade school, is how I’d argue. And I would say ironically, we have been trained through years and years of school to not really care that much about the hidden curriculum. So it kind of hides itself.

So why would I say these things? Grade school, of course there are all those things I mentioned, but as long as you’re not super disruptive, at the end of the day, what matters? Your grades, test scores, we all taken MCATs and stuff to get here, so we’re kind of conditioned to think knowledge and technical things are really, really what matter. But it turns out that there’s a certain point at which in medicine that books on cards and these other things are only going to get us so far, because learning a profession like medicine is inherently experiential and social, right? And so even if you think the technical things, which I find most people care most about, you know, I need to know how to do a lumbar puncture, suture, diagnose. Even if you think those things are the most important, and I’d say they’re really, really important, you’re not going to learn the technical things nearly as well or as easily if you don’t understand these hidden curriculum social factors, because we learn from other people and from the environment. But I find that’s the biggest challenge here. People’s brains, and I was in writing that camp. I care about the technical, I don’t care about all this other stuff. But they kind of tune out when they start hearing some of this stuff. But I would say that’s a big mistake.

Kevin Pho: So I think that how you described it actually is how I feel about it and how you wrote about it in your article, that a lot of medical students and trainees, they struggle to name these forces even when they feel them every day, right? So it’s nice to have this type of construct and structure to define it. So now that we’ve given a definition, just give us some examples of how the hidden curriculum will play out every day in a medical student classroom setting or in an intern resident academic setting. What are some just common examples of how the hidden curriculum will play?

Vance Lehman: Yeah, absolutely. So I’d start off with a basic example and preface it. I think that there are kind of surface level examples and really deep examples, and I probably only have time to go into surface level ones, because that’s a little bit more what we’ll see every day. And the basic one would be starting a new rotation with a new staff and underestimating how important it is to make a good first impression. Basically when you start a new rotation, it’s critical that you know as much as you can ahead of time about the environment, even about your patients and about your attending. You know, put a name to the face and what some of their background is, because if you haven’t done that, you’re already not making a good first impression.

Now, beyond that, what I would say is it’s also really critical, really early on in your experience with an attending to say, “Hey, is there a time we can sit down and talk about this rotation?” And it’s important to ask that because they may be busy, you don’t want to interrupt. And that’s another thing people make a mistake, is they ask at the wrong time. You want to ask at the right time, and then what you want to do and say is, “It’s really important to me to do a good job. Do you have any advice for me?” It sounds so easy, but it’s so critical. Why is that so important to say it that way? By saying, “It’s really important to me to do a good job,” you’re signaling that you care, and that’s important because people make all sorts of assumptions about your interest level. And they also have biases, like generational biases, and you’re helping to preempt some of those right there. I see a lot of people saying, “Oh, I didn’t give them as much attention and let them do procedures because they just didn’t seem interested.” And then after the fact, the trainee is like, “I really wanted to do them. They didn’t let me do that.” So it’s really important to do that. It also establishes a relationship with them and shows them that you’re open to talking and that you care about their preferences as well. And it gets at some specific expectations because the formal curriculum will say you’re evaluating them on X, Y, and Z. Everybody knows there’s lots of wiggle room with that, and people are really going to evaluate you based on what they think is important. And you can’t assume what an attending thinks is important, right?

So anyways, you made a good first impression. The reason why that’s more important than most people think is there’s this psychological phenomenon that I’ve learned. It was from Daniel Kahneman. I’m sure other people described it too, called excessive coherence. So we want to make sense of the world and sense of other people. So when we first meet people, we do that with limited information. So we tell ourselves a story about who somebody else is based on how they act in that moment. And that causes either a positive or negative feedback loop. And if you can create a positive feedback loop, that will amplify, and also it amplifies because the attending will probably have discussions with other attendings. So things as simple as saying, “It’s important to me to make a good first impression. What can I do for that?”

And also I should also mention is showing up, being prepared. The other thing I didn’t mention that I should is oftentimes people are prepared, but it’s not obvious that they’ve done it. So it’s useful to have some physical proof, even like an old fashioned paper writing down. Don’t be obnoxious about it, but you can just kind of reference like, “I’ve got this paper and I’ve looked at these patients.” You’ve got just simple little tactics like that, I think make all the difference. So that would be like my basic example.

Kevin Pho: Now you’re at the Mayo Clinic, one of the top medical schools in the country. I’m going to assume that the students that are there have been playing some form of the hidden curriculum game just to get into the Mayo Clinic. Do you see a spectrum in terms of your students’ skills in managing the hidden curriculum? What are you seeing in the students today?

Vance Lehman: Yeah, absolutely. So again, my own personal perspective, so I deal more with residents and the fellows and the medical students here, I’ll give you that background. And there’s certainly a wide range. I think for some people these things just come really naturally and maybe it’s just that. It’s a natural skill for them. Maybe they have, they’re not a first-generation physician. They have built-in mentors and sponsors with their parents. Who knows? There’s a variety of things. I can’t know for sure. But there’s definitely a huge range.

And also, yeah, so people tend to have managed these hidden curriculum things to get to this point. But I’m still, and this is across medical centers, you can still be surprised that there’s quite a few people, because maybe it was mostly classwork up to this point, or I’m not sure why, where they just get the basic things wrong. So that’s why, again, I think the basic things, so the other things are these basic professionalism things, and some of the stories that I’ve heard from various departments here and various institutions are just the silliest things. Like, it seems like there’s a very common, I don’t know how common it is, but people remember it. Asking to leave early for optional personal reasons, like what’s going on with that? So I’ve heard stories about, “I need to leave early to beat rush hour traffic.” Well, we all would like to do that. That’s not good. To get to yoga class. You know, because I’ve got this optional appointment I could have done somewhere else. It’s not for like an emergency. And things like, you know, they wore a baseball cap to radiology or pathology sign out, because they’re not seeing patients. Well, that’s not appropriate.

So although I do think there’s a spectrum, and I do think that’s true, it’s almost surprising to hear, you can get really, really far in our system of test taking without having some of these basic skills. So that’s another reason I think it’s important to have this conversation.

Kevin Pho: So what do you propose going forward? As you said, medicine is pretty much experiential, right? Learn one, teach one, right? As the saying goes. So should some of these things be explicitly taught in a formal setting? Should they remain just being passed down from resident to intern to medical student? What’s a path going forward?

Vance Lehman: Yeah, that’s a great question. I haven’t really been asked that before. I do think you want to make a lot of this as explicit as possible because if somebody comes in and they’re eager and they’re capable, they should have the opportunity to succeed. They shouldn’t just be some gut luck that they just weren’t clued into something or another. So I think as much as we can make things as explicit as possible, that’s useful. And you can do that by trying to spread the word, doing it during the day, during formal rotations. I’m trying to do some grand rounds. I’m trying to do my part with that as much as I can.

Now, you’ll never get rid of a hidden curriculum. It’s never going to go away. But some of the egregious things I think that we can improve. And the other thing is, we have to understand, I think that there’s three main components to what determine an outcome for a trainee. There’s the trainee themselves, there’s the teachers, and then there’s a system. In the end, I think we tend to put a lot of the responsibility on the trainee, but we as teachers have responsibility too to not make too many assumptions. So like, I always ask if somebody’s coming in, what are their goals? What do they want to do? I don’t just try to assume. So I’ve tried to take that on. I encourage others to do it as well. And the system thing is a whole nother discussion, but I’m focusing more on what we can do as individuals.

So that would be my basic. There’s a bunch of little minor things you can do to try to incorporate a lot of these topics into our teaching. A whole bunch of other little things we can do. And in the book go into all sorts of other little topics I think are under-recognized but useful. I think it’s, we have a false economy that we can’t teach these things because we’re bloated with stuff, information overload. Why are we going to add more? Well, I’d say it’s a false economy because we can teach some of these things because it makes it easier to learn the other things. Actually, it’s a false economy not to teach it. We can’t take whole classes on every topic. We can’t read a book on every topic, but we can introduce the basics.

Kevin Pho: Now from the perspective of a medical educator, when you say that, you ask your interns and residents what their goals are. So what are some other things that medical educators can do to more explicitly address the hidden curriculum and make less things assumed?

Vance Lehman: OK, yeah, that’s also another good question. Well, they can also explore some of their inner potential biases. So here’s another controversial, but another big topic that I’ve run into all the time, is the concept of the generational assumptions. And I hear this and there’s podcasts on it and writing. It’s like these days, it’s blasphemy to call it a calling. You know, you’ve heard that controversy, right? Yeah. And I know that’s kind of a loaded thing, but people, they’re just not finding joy. They want to come in, clock in, clock out, all of these things about the generational assumptions.

And I think we can question some of our assumptions there. So, and I know you’ve had other guests talk about the generations, but yeah, so we can question our generational assumptions by this, right? It’s a different environment and people are doing a natural response, typically, to their current environment. And we also have a spectrum of people here too. But a lot of the negative perceptions, right? Like there’s no doubt there’s differences, but a lot of the negative perceptions boil down to a constellation of cognitive biases. And the big one I found is called the illusion of moral decline. People like organizational psychologists like Adam Grant talk about this. Going to entire conferences where they talk a lot about generational trends, I sometimes don’t even see this come up and talk in the panels. And basically that’s a cognitive bias where, when we’re judging, because we always do judge people, when we’re judging other people who are younger, we tend to compare them to our current self because that’s very accessible, rather than our former self, younger self. And that leaves a very distorted view of what’s going on, right? So yeah, so it’s called the illusion of moral decline.

So I think we have a lot of internal potentially biases. And we can also forget just what it was like to be at a certain stage. Like somebody’s rotating through general internal medicine, they’ve got all these things to know. They’re not just doing oncology in radiology, they’re rotating to all these things. They’re not just doing neuroradiology. So I think we can question some of our internal judgments and give a little bit more leeway as well. That would be one example.

Kevin Pho: If a medical student or trainee is listening to us now and they want to navigate the hidden curriculum better starting tomorrow, what’s the one thing that they need to do?

Vance Lehman: Well, the honest answer is, get my book, because that’s my honest answer. They need basically is understand that you have to be proactive and get these easy professionalism things right. OK, you can’t, if you do one negative professional thing, that will spiral out of control. So you got to get the easy things right, and you got to be proactive. You can’t just count on these things happening, because a lot of times people are doing the right things in the background, showing up, but they don’t want to disturb people. They want to be polite, but then they have a perception of them that’s just not accurate. So yeah, get the easy things right. Be proactive.

Kevin Pho: We’re talking about Vance Lehman, professor of neuroradiology at the Mayo Clinic, author of the book “Mastering the Hidden Curriculum: Unlocking Success in Medical Training.” We’re talking about his KevinMD article, “The Hidden Curriculum: What Medical School Does Not Teach You.” Vance, let’s end with some take-home messages you want to leave with the KevinMD audience.

Vance Lehman: Absolutely. So in medical training, satisfactorily completing your coursework or rotations will usually lead to a medical degree. But if your goal is to not just pass, but to excel, I think the difference lies in what most people aren’t seeing, and that’s the hidden curriculum. The good news is that you can navigate the hidden curriculum with lots of easy to do small steps that have big downstream positive effects. And the even better news is that we’ve created this book for you, which is a comprehensive guide that shows you the way for many high-yield, often forgotten topics that can help you save time, learn medicine, open doors, and ultimately will level the playing field.

Kevin Pho: Vance, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Vance Lehman: Thank you very much.