The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching
http://www.100md.com
《英国医生杂志》
1 Academic Rheumatology, Guy's, King's and St Thomas' School of Medicine, King's College London, London SE5 9RJ, 2 Department of Human Sciences, Brunel University, Uxbridge UB8 3PH
Correspondence to: H Lempp heidi.k.lempp@kcl.ac.uk
Abstract
The development of medical education has been described as a history of reform without change.1 During the past decade, all UK medical schools have implemented reforms to the manifest (overt) undergraduate curriculum, with changes to course content, teaching methods, and examinations.2 However, there has been less attention to the hidden curriculum, which has emerged as an influential concept in medical education.3-6 This refers to the "processes, pressures and constraints which fall outside... the formal curriculum, and which are often unarticulated or unexplored."6 It has been argued that hidden aspects of the curriculum are especially important in professional education, which characteristically includes prolonged periods of exposure to the predominant culture.6-9
Hidden curriculum: the set of influences that function at the level of organisational structure and culture including, for example, implicit rules to survive the institution such as customs, rituals, and taken for granted aspects
The hidden curriculum has been described in relation to training of house officers or residents,10 general medical education,4 7 11 dental education,12 and nursing education.13 Six learning processes of the hidden curriculum of medical education have been identified: loss of idealism,5 adoption of a "ritualised" professional identity,5 emotional neutralisation,14 change of ethical integrity,15 acceptance of hierarchy,7 and the learning of less formal aspects of "good doctoring."16 Together they achieve the enculturation of students as they develop into both practitioners and members of the medical profession.
Methods
This study relies on interview accounts rather than observation of actual teaching. Secret observations, which are perhaps ethically unacceptable, would be necessary for further verification of students' accounts. An added limitation of this study is the fact that data were collected from only one medical school. This means that there is some potential for contamination between students' accounts, although this was unlikely because fewer than 2% of all students at that medical school were interviewed. Even so, their reports suggest a worrying lack of accountability of medical teachers in overstretched clinical settings. The absence of any consistent formal system of monitoring in UK medical schools is currently under review in relation to the General Medical Council1 and the Quality Assurance Agency, although a system of peer review is gradually being introduced.
Medical education has largely escaped from the quality control rigours imposed on clinical practice. In part this may be because clinical practice and research have long dominated the attention of doctors, and teaching has been considered a lesser activity, without clear incentives or career structures. Indeed, relatively few doctors have received formal training in teaching methods, educational theories, or modes of assessment.20 The Dearing report of inquiry into higher education21 highlighted this as a deficiency for all teachers employed in universities, not only in medicine, and made clear recommendations, which have been endorsed by the General Medical Council.22 For this reason Leinster has proposed creating a proper system of rewards for teaching, a formal structure of accountability and monitoring within medical schools, a recognised teaching qualification, financial allocations for identified teaching sessions, and the provision of dedicated administrative staff to minimise the time doctors lose from patient care and research.23 Teaching could then be incorporated in the job plans of consultants and reviewed as part of their annual appraisals.
What is already known on this topic
The manifest undergraduate medical curriculum has undergone major changes in recent years in Britain
Less attention has been paid to the impact, process, and structure of the hidden curriculum, and how these are experienced by medical students
What this study adds
Many students report positive and effective role models, but with valued characteristics perceived according to traditional gendered stereotypes among teachers
Students often report a hierarchical and competitive atmosphere in which haphazard tuition and teaching by humiliation continue to occur
Recognition and reform of the hidden curriculum is required to achieve the necessary fundamental changes to the culture of undergraduate medical education
Although some NHS trusts have introduced measures intended to stamp out bullying among staff members,24 these measures have not yet been widely adopted within teaching hospitals. Indeed, this would involve a change in the core organisational culture and identity of medicine. Such policies could be framed in terms of "zero tolerance" towards the humiliation of students, made explicit in the contracts of teaching staff, with workable ways to allow confidential reporting of such behaviour without damage to the career prospects of whistleblowers.
Further studies of the hidden curriculum from other medical schools are needed, including the perspectives of clinical teachers, to assess the generalisability of our findings. For example, rapid changes in the ethnic composition and sex ratio of medical students may have important implications for medical education, and understanding these can result in evidence based changes to the hidden as well as the manifest curriculum in future.
The semistructured interview is on bmj.com
We are grateful to all the students who participated in the study, for their time and openness. We also acknowledge the valuable contributions of the senior staff at the medical school who supported this research. This study was carried out while HL was a PhD student in the Department of Sociology, Goldmiths College, University of London.
Contributors: HL designed the study and carried out interviews and the data analysis. CS advised on study design and dataanalysis. Both wrote the paper. Caroline Ramazanoglu assisted at an early stage of the study, Kate Nash provided invaluable advice and support, and Floss Chittenden provided unfailing support with the transcriptions of the interviews. HL is guarantor.
Funding: None.
Competing interests: None declared.
Ethical approval: The full relevant requirements for the ethical conduct of research, as set out by the British Sociology Association (www.britsoc.co.uk/Library/Ethicsguidelines2002.doc), were strictly adhered to.
References
Bloom SW. The medical school as a social organisation: the source of resistance to change. Med Educ 1989;23: 228-41.
General Medical Council. Tomorrow's doctors: recommendations on undergraduate medical education. London: GMC, 1993.
Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994;69: 861-71.
Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med 1998;73: 403-7.
Sinclair S. Making doctors. An institutional apprenticeship. Oxford: Berg, 1997.
Cribb A, Bignold S. Towards the reflexive medical school: the hidden curriculum and medical education research. Stud Higher Educ 1999;24: 195-209.
Hafferty FW. Reconfiguring the sociology of medical education: emerging topics and pressing issues. In: Bird F, Conrad P, Fremont AM, eds. Handbook of medical sociology, 5th ed. New York: Prentice Hall, 2000: 238-56.
Bloom SW. Innocence in education. School Rev 1972;80: 333-52.
Assor A, Gordon D. The implicit learning theory of hidden curriculum research. J Curric Stud 1987;19: 329-39.
Anderson DJ. The hidden curriculum. Am J Roent 1992;159: 21-2.
Marinker M. Myth, paradox and the hidden curriculum. Med Educ 2001;31: 293-8.
DeSchepper EJ. The hidden curriculum in dental education. J Dent Educ 1987;51: 575-7.
Mayson J, Hayward W. Learning to be a nurse: the contribution of the hidden curriculum in the clinical setting. Nurse Pract N Z 1997;12: 16-22.
Helman C. The dissection room. In: Body Myths. London: Chatto and Windus, 1991: 114-23.
Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations—teaching tomorrow's doctors. BMJ 2003;326: 97-101.
Wright S, Kern DE, Kolodner K, Howard DE, Brancati FL. Attributes of excellent attending-physician role models. N Engl J Med 1998:339: 1986-93.
Lempp HK. Undergraduate medical education: a transition from medical student to pre-registration doctor . London: Goldsmiths College, University of London, 2004.
Seale C. The quality of qualitative research. Introducing qualitative methods. London: Sage, 1999: 119-39.
Savage J. What is happening to nursing? BMJ 1995;311: 274-5.
Seabrook MA. Medical teachers' concerns about the clinical teaching context. Med Educ 2003;37: 213-22.
Dearing R. Summary report: the National Committee of Inquiry into Higher Education. Norwich: HMSO, 1997.
General Medical Council. Tomorrow's doctors: recommendations on undergraduate medical education. London: GMC, 2002.
Leinster SJ. Medical education in the real world. Med Educ 2003;37: 397-8.
Hicks B. How can a deanery win the battle against bullying? BMJ Careers 2003;326(suppl):S129.(Heidi Lempp, senior quali)
Correspondence to: H Lempp heidi.k.lempp@kcl.ac.uk
Abstract
The development of medical education has been described as a history of reform without change.1 During the past decade, all UK medical schools have implemented reforms to the manifest (overt) undergraduate curriculum, with changes to course content, teaching methods, and examinations.2 However, there has been less attention to the hidden curriculum, which has emerged as an influential concept in medical education.3-6 This refers to the "processes, pressures and constraints which fall outside... the formal curriculum, and which are often unarticulated or unexplored."6 It has been argued that hidden aspects of the curriculum are especially important in professional education, which characteristically includes prolonged periods of exposure to the predominant culture.6-9
Hidden curriculum: the set of influences that function at the level of organisational structure and culture including, for example, implicit rules to survive the institution such as customs, rituals, and taken for granted aspects
The hidden curriculum has been described in relation to training of house officers or residents,10 general medical education,4 7 11 dental education,12 and nursing education.13 Six learning processes of the hidden curriculum of medical education have been identified: loss of idealism,5 adoption of a "ritualised" professional identity,5 emotional neutralisation,14 change of ethical integrity,15 acceptance of hierarchy,7 and the learning of less formal aspects of "good doctoring."16 Together they achieve the enculturation of students as they develop into both practitioners and members of the medical profession.
Methods
This study relies on interview accounts rather than observation of actual teaching. Secret observations, which are perhaps ethically unacceptable, would be necessary for further verification of students' accounts. An added limitation of this study is the fact that data were collected from only one medical school. This means that there is some potential for contamination between students' accounts, although this was unlikely because fewer than 2% of all students at that medical school were interviewed. Even so, their reports suggest a worrying lack of accountability of medical teachers in overstretched clinical settings. The absence of any consistent formal system of monitoring in UK medical schools is currently under review in relation to the General Medical Council1 and the Quality Assurance Agency, although a system of peer review is gradually being introduced.
Medical education has largely escaped from the quality control rigours imposed on clinical practice. In part this may be because clinical practice and research have long dominated the attention of doctors, and teaching has been considered a lesser activity, without clear incentives or career structures. Indeed, relatively few doctors have received formal training in teaching methods, educational theories, or modes of assessment.20 The Dearing report of inquiry into higher education21 highlighted this as a deficiency for all teachers employed in universities, not only in medicine, and made clear recommendations, which have been endorsed by the General Medical Council.22 For this reason Leinster has proposed creating a proper system of rewards for teaching, a formal structure of accountability and monitoring within medical schools, a recognised teaching qualification, financial allocations for identified teaching sessions, and the provision of dedicated administrative staff to minimise the time doctors lose from patient care and research.23 Teaching could then be incorporated in the job plans of consultants and reviewed as part of their annual appraisals.
What is already known on this topic
The manifest undergraduate medical curriculum has undergone major changes in recent years in Britain
Less attention has been paid to the impact, process, and structure of the hidden curriculum, and how these are experienced by medical students
What this study adds
Many students report positive and effective role models, but with valued characteristics perceived according to traditional gendered stereotypes among teachers
Students often report a hierarchical and competitive atmosphere in which haphazard tuition and teaching by humiliation continue to occur
Recognition and reform of the hidden curriculum is required to achieve the necessary fundamental changes to the culture of undergraduate medical education
Although some NHS trusts have introduced measures intended to stamp out bullying among staff members,24 these measures have not yet been widely adopted within teaching hospitals. Indeed, this would involve a change in the core organisational culture and identity of medicine. Such policies could be framed in terms of "zero tolerance" towards the humiliation of students, made explicit in the contracts of teaching staff, with workable ways to allow confidential reporting of such behaviour without damage to the career prospects of whistleblowers.
Further studies of the hidden curriculum from other medical schools are needed, including the perspectives of clinical teachers, to assess the generalisability of our findings. For example, rapid changes in the ethnic composition and sex ratio of medical students may have important implications for medical education, and understanding these can result in evidence based changes to the hidden as well as the manifest curriculum in future.
The semistructured interview is on bmj.com
We are grateful to all the students who participated in the study, for their time and openness. We also acknowledge the valuable contributions of the senior staff at the medical school who supported this research. This study was carried out while HL was a PhD student in the Department of Sociology, Goldmiths College, University of London.
Contributors: HL designed the study and carried out interviews and the data analysis. CS advised on study design and dataanalysis. Both wrote the paper. Caroline Ramazanoglu assisted at an early stage of the study, Kate Nash provided invaluable advice and support, and Floss Chittenden provided unfailing support with the transcriptions of the interviews. HL is guarantor.
Funding: None.
Competing interests: None declared.
Ethical approval: The full relevant requirements for the ethical conduct of research, as set out by the British Sociology Association (www.britsoc.co.uk/Library/Ethicsguidelines2002.doc), were strictly adhered to.
References
Bloom SW. The medical school as a social organisation: the source of resistance to change. Med Educ 1989;23: 228-41.
General Medical Council. Tomorrow's doctors: recommendations on undergraduate medical education. London: GMC, 1993.
Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994;69: 861-71.
Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med 1998;73: 403-7.
Sinclair S. Making doctors. An institutional apprenticeship. Oxford: Berg, 1997.
Cribb A, Bignold S. Towards the reflexive medical school: the hidden curriculum and medical education research. Stud Higher Educ 1999;24: 195-209.
Hafferty FW. Reconfiguring the sociology of medical education: emerging topics and pressing issues. In: Bird F, Conrad P, Fremont AM, eds. Handbook of medical sociology, 5th ed. New York: Prentice Hall, 2000: 238-56.
Bloom SW. Innocence in education. School Rev 1972;80: 333-52.
Assor A, Gordon D. The implicit learning theory of hidden curriculum research. J Curric Stud 1987;19: 329-39.
Anderson DJ. The hidden curriculum. Am J Roent 1992;159: 21-2.
Marinker M. Myth, paradox and the hidden curriculum. Med Educ 2001;31: 293-8.
DeSchepper EJ. The hidden curriculum in dental education. J Dent Educ 1987;51: 575-7.
Mayson J, Hayward W. Learning to be a nurse: the contribution of the hidden curriculum in the clinical setting. Nurse Pract N Z 1997;12: 16-22.
Helman C. The dissection room. In: Body Myths. London: Chatto and Windus, 1991: 114-23.
Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations—teaching tomorrow's doctors. BMJ 2003;326: 97-101.
Wright S, Kern DE, Kolodner K, Howard DE, Brancati FL. Attributes of excellent attending-physician role models. N Engl J Med 1998:339: 1986-93.
Lempp HK. Undergraduate medical education: a transition from medical student to pre-registration doctor . London: Goldsmiths College, University of London, 2004.
Seale C. The quality of qualitative research. Introducing qualitative methods. London: Sage, 1999: 119-39.
Savage J. What is happening to nursing? BMJ 1995;311: 274-5.
Seabrook MA. Medical teachers' concerns about the clinical teaching context. Med Educ 2003;37: 213-22.
Dearing R. Summary report: the National Committee of Inquiry into Higher Education. Norwich: HMSO, 1997.
General Medical Council. Tomorrow's doctors: recommendations on undergraduate medical education. London: GMC, 2002.
Leinster SJ. Medical education in the real world. Med Educ 2003;37: 397-8.
Hicks B. How can a deanery win the battle against bullying? BMJ Careers 2003;326(suppl):S129.(Heidi Lempp, senior quali)