The Hidden Curriculum in Medical Education

04/01/2025

As a third-year medical student, Sara was eager to begin her clinical rotations. During her first week, she witnessed an unsettling scene: her attending dismissed a patient’s complaints of persistent pain, brushing it off with a wave. "She is probably just anxious," the attending said, moving on to the next patient. Sara recognized that the attending’s behavior contradicted everything she had been taught about patient-centered, trauma-informed care. As she watched her colleagues nod and follow suit without question, she understood that this moment was not an isolated incident.

Some weeks later, Sara observed a very different moment that would also leave a lasting impact. Amid a hectic morning, a senior resident paused during rounds to sit down with a patient who had been waiting for hours to speak with the care team. Instead of rushing through the encounter, the resident listened attentively to the patient's concerns, asking thoughtful questions and offering reassurances. This small yet powerful act, which contrasted sharply with the hurried pace of the day, taught Sara a valuable lesson that wasn’t explicitly covered in the curriculum: even in the most chaotic moments, empathy and patience are essential components of high-quality care. These contrasting experiences, both witnessed in the clinical environment, would come to shape Sara's understanding of what we refer to as the hidden curriculum.

Defining the Hidden Curriculum

The hidden curriculum refers to the implicit lessons learned in medical education, beyond formal textbooks and learning sessions. These lessons come to fruition through observation of behaviors, institutional practices, and unspoken norms within clinical settings. As we saw in our case, formal curricula might emphasize trusting that all reported pain is real, while the hidden curriculum may reinforce the idea that some patients have psychosomatic pain or even ulterior motives. Lessons such as these are not taught directly but are absorbed through everyday actions and interactions within clinical environments.

Why Does the Hidden Curriculum Matter?

The hidden curriculum plays a critical role in shaping how trainees develop their professional identity. When trainees observe experienced clinicians embody compassion or demonstrate unprofessional behavior, it can shape their perceptions of what is acceptable and expected in their own practices. Over time, these lessons can influence their future clinical interactions and even medical decision-making.

Impact of the Hidden Curriculum on Professional Identity

Difficulties in Addressing Hidden Learning Elements

One of the key challenges in addressing the hidden curriculum is that it can be difficult to measure or quantify. Unlike the formal curriculum, the hidden curriculum can be subtle and can go unnoticed until after its effects are felt by trainees and educators alike. Many educators may not even realize the impact of their actions, and some institutional cultures may inadvertently support unhealthy norms. Without awareness and intentional action, these hidden lessons can, and do, persist.

The Importance of Reflective Practice

A promising solution to addressing the hidden curriculum is fostering reflective practice among trainees and faculty. By encouraging regular reflection on their experiences, educators can help trainees critically examine the behaviors and attitudes they observe and internalize. Incorporating storytelling and journaling can allow trainees to process their experiences and explore how their observations align with their values. Creating an air of psychological safety among trainees to share their experiences of the hidden curriculum can foster a sense of community and support.

Building a Culture of Awareness

Addressing the hidden curriculum requires collective effort from educators, administrators, and trainees alike. It has been noted that organizational rules and structures are one of the highest drivers of the hidden curriculum and thus strongly influence teaching methods, assessment approaches, and even the physical clinical setting. Institutions should prioritize the intentional cultivation of a hidden curriculum that nets positive benefits while addressing harmful behaviors and unspoken norms that contribute to negative ones. Faculty should model ethical and clinically appropriate behaviors, and trainees should be empowered to critically analyze the culture around them.

By creating an environment where both positive and negative experiences are openly acknowledged and addressed, we can ensure that future generations of physicians are not only competent in their clinical skills but also embody the ethical principles that are essential to patient care.

Annie Suydam, M.D., is a pediatric hospital medicine fellow at the Saint Louis University School of Medicine and SSM Health. She is a fellow of the American Academy of Pediatrics. Suydam’s areas of professional interest include professional development, curriculum design, and artificial intelligence. She can be found on LinkedIn or contacted via email.