Pushing Back on Medicine's Hidden Curriculum

There is a hidden curriculum in medicine. Some of it is good and some of it is terrible. Change is slow and fitful.

For those readers outside of medicine, the hidden curriculum is, "the many ways students learn the unspoken rules and culture of medicine, not through textbooks and formal lectures but through everyday exchanges in informal settings such as hallways and hospital cafeterias." Hippocrates probably absorbed the subtle rules of his time from watching his mentors care for patients. I know I did. The lessons might have evolved, but the arrangement continues.

Here’s an example: Years ago, I assisted a surgeon as he opened a foul-smelling abscess in the Emergency Room. The odor, which I was not expecting, nearly knocked me over, yet the surgeon showed little if any empathy for either the suffering patient or for me. If anything, he viewed the patient’s suffering as barely worth his notice and my reaction as humorous. It was just another procedure in the surgeon’s long day, but his lack of empathy likely showed me how I was “supposed” to react in similar settings. I learned a lesson: Being aloof and lacking compassion is just fine.

“Don’t get too involved!”

One of the principal tenets of the hidden curriculum is, “Don't get too involved!” On the surface, there are some reasonable applications of this rule.

• Emotional entanglement clouds judgement and objectivity. Some examples:

  • When the neurosurgeon has your head disassembled, you want her clear-eyed and intensely focused as she puts your parts back together.

  • If you undergo cardiac surgery, you might instinctively favor a surgeon known for technical prowess over one known for compassionate care.

  • In an emergency, you want an expert who can make difficult, evidence-based decisions unimpeded by emotional baggage.

• Everyone deserves the same level of attention. A bit less intuitive is the admonition that it is wrong to become more attached to one patient than another. Each patient deserves an identical level of attention no matter how much more we might be drawn to one person. Getting more involved with one person is not fair to the others. It is a matter of justice.

• Allowing emotions to escape from the workplace is dangerous. The hidden curriculum tells us that caregivers need to separate their day jobs from their personal lives. "Bringing your work home" is unhealthy and leads to disruption in the caregiver's life outside of the hospital. We must "leave it at the door."

• Getting too involved can lead to trouble. Unfortunately, there are too many reports where physicians crossed lines and ignored the unequal power dynamic inherent in physician-patient relationships. Clear boundaries provide safety. We all need our "bright lines."

When does the hidden curriculum begin having its effects?

Like people entering any profession, medical students imagine what being a physician will feel like even before they ever arrive on campus. Maybe they try to put themselves inside the heads of TV characters or while observing medical encounters. They wonder, What will being a doctor actually feel like? How will I learn all I need to know? Will I ever be confident? What will I do when a person dies right in front of me? Will people compare me to Gregory House, JD Dorian, or Meredith Grey?

A few years ago, I confirmed that the hidden curriculum begins to exert an effect even in the first days of medical school.

As a young faculty member, I sat with a group of brand-new students who had recently observed an office-based physician for the very first time. I asked them to tell the group about a patient they had met.

One student reviewed the visit of a high-performing high school athlete with joint swelling and discomfort. This teenager’s symptoms were not that worrisome but their parents had made the appointment because there were several close relatives with a debilitating form of inherited arthritis. They worried that the teen's symptoms, although mild, might foreshadow a lifetime of loss and incapacity.

The other students listened attentively to the presentation, the physical exam findings, the lab studies, and the clinician’s plans. They asked questions that focused on the findings of the case, the genetics, the known limits of the science, the most cost-efficient types of testing, and the most effective next steps.

After a few minutes, I stopped them. “Friends, we are witnessing a potential watershed moment in this teenager's life. Am I right?” Some of the students looked at me, their eyes widening. “I am a bit surprised that no one cried out on behalf of this fellow human being whose life might soon shift from being focused on high school athletics to one dominated by a terrifying, progressive, incurable long-term illness.” I paused. “Does anyone want to know what was going through the teenager's mind during the visit?"

The room was silent for several moments. It's not that the students didn't care—the athlete’s reaction had likely occurred to many of them—but they had pushed those ambiguous thoughts aside in favor of the objective medical aspects of “the case.” Confession: even I has wanted to know more about the immunology before I asked about the chaos building on the teen’s horizon.

Just weeks into medical school, these empathetic young adults had already donned their budding "doctor personas" and had suppressed the instinct to reach out with compassion to a fellow traveler struggling through a difficult time. It was hard to blame them; the presenting student told us that no one had asked the teen how he was doing during the office visit. As the students looked around the table, they likely noticed that all of their peers had effectively adopted the same approach. The hidden curriculum was, thus, reinforced.

Professionalism vs. humanism

There is a tension between professionalism and humanism in medicine. Our young doctors learn to be "professionals" through both formal education and by informally observing those around them. Their "humanism," on the other hand, is nurtured from infancy. Finding ways to “be professional” while preserving their humanity is a challenge in a vocation where professionalism is so highly valued.

Years ago, Anatole Broyard encouraged physicians to allow their humanism to shine through.

Broyard, a literary critic and editor, died of aggressive metastatic prostate cancer two months after publishing an essay, “Doctor Talk to Me,” in the New York Times Magazine in August 1990. In the piece, Broyard provocatively challenges physicians—although the challenge is apt for all healthcare providers—to move beyond professionalism.

After jettisoning his first urologist for being “a man fixed in a pose, playing doctor,” Broyard sought a physician who would understand that “inside every patient, there's a poet trying to get out. My ideal doctor would ‘read’ my poetry, my literature” because the illness is “the crisis of my life.” Although he does not expect the doctor to offer love or special treatment, he does expect brief periods of complete and undivided attention: “Just as he orders blood tests and bone scans of my body, I'd like my doctor to scan me, to grope for my spirit as well as my prostate.”

In the essay, Broyard describes—and dismisses—medicine’s “hidden curriculum” without using those exact words. He writes:

Physicians have been taught in medical school that they must keep the patient at a distance because there isn't time to accommodate his personality, or because if the doctor becomes ‘involved’ in the patient's predicament, the emotional burden will be too great,...[but the] emotional burden of avoiding the patient may be much harder on the doctor than he imagines.

A doctor's job would be so much more interesting and satisfying if he would occasionally let himself plunge into the patient, if he could lose his own fear of falling.

Foreshadowing his own death, Broyard concludes:

Not every patient can be saved, but his illness may be eased by the way the doctor responds to him—and in responding to him, the doctor may save himself. But first he must become a student again; he has to dissect the cadaver of his professional persona; he must see that his silence and neutrality are unnatural. It may be necessary to give up some of his authority in exchange for his humanity, but as the old family doctors knew, this is not a bad bargain. In learning to talk to his patients, the doctor may talk himself back into loving his work. He has little to lose and much to gain by letting the sick man into his heart. If he does, they can share, as few others can, the wonder, terror and exaltation of being on the edge of being, between the natural and the supernatural.

So, how should we respond to suffering?

Throughout much of my career, I intentionally reached out to patients and families when they were in times of crisis. I wasn't perfect by any means, but I tried to accompany people who were dying; I attended visitations whenever I could. I wrote sympathy cards. When things went badly, I said I was sorry and meant it.

When I told colleagues about my approach, some (not all, by any means) thought I was nuts. Early on, there was a fear that any sign of contrition would lead to calls from the Risk Management Office and threats of malpractice lawsuits. Later, the reactions centered on concerns that emotions shared in the workplace would have a chilling effect on my life outside the hospital.

My experience was just the opposite. The more I allowed myself to be open, the more resilient I became. Families were warm and grateful when I appeared at funerals (with one memorable exception). I always found closure and healing at bedsides where I had nothing to offer other than my presence.

Not every day, of course, but over the long haul, being open proved to be a good thing.

I did not read Broyard’s piece until much later in my career, but its message resonated with me after decades of wrestling with my experiences through journaling and essay writing. I sensed why paying attention to and responding to patients’ stories felt like the right thing to do. His words allowed me to be more vulnerable.

Pushing back on the hidden curriculum in my retirement

Now that I have shifted from being a “healthcare provider” to being more of a “healthcare consumer,” I watch my own providers’ willingness to, as Broyard wrote, “plunge into the patient.” Some do this routinely while others do not. For example, some of my doctors have clearly reviewed my chart and listen intentionally. They ask about my family. Others—who are great doctors, mind you—seem baffled when I visit. Some have never stopped by to check on me after procedures. It’s not a big deal; I know physicians are extremely busy, I might have still been asleep, or they might prefer to delegate such "mundane" duties to others. I tell myself they are caring for people who need them more than I do. Still, I noticed.

So, I do what I can to influence the next generation.

I have had some delightful opportunities to speak to groups of physicians and others about the rewards of teasing out patients’ illness stories. I try to explain to these younger providers that being open to the Narrative Medicine principles of Attention, Representation, and Affiliation takes effort and commitment but, by practicing intentionally, taking care of themselves, and being open to the patient’s story, there is healing for both the patient and the provider.

I don't think anyone disagrees with pushing back on medicine's hidden curriculum; the devil, of course, is in the details. For me, engaging with the humanities, remaining open to narrative, being intentionally vulnerable, and developing my love of stories brought increasing levels of healing and satisfaction to my 35-year career. I believe it can make a difference for both patients and caregivers.

During moments when I felt most connected with patients and families, I was reminded of why I went into medicine in the first place. I hope the next generation of physicians learns this lesson earlier and more effectively than I did.

Bruce H. Campbell, MD FACS is a retired head and neck cancer surgeon. He still volunteers at the Medical College of Wisconsin.

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