Abstract
This study explores how preclinical medical students experience particular elements of their training, specifically their pursuit for medical knowledge and how this may impact their attributes as well as their relations with those outside of the realm of medicine. Ten first-year and 10 second-year students of a US medical school were interviewed regarding their experiences with and perceptions of their medical training. The students reported a cognitive and emotional distance from non-medical students that appears to be accentuated not only by their strenuous academic responsibilities but also elements of the hidden curriculum nested within medical training. Furthermore, students discuss experiencing disapproval, mistrust, and negative judgment toward laypersons thereby suggesting that this distancing may lend to deleterious effects on students’ ability and willingness to connect with others. A Parsonian lens is utilized to examine the notion of a ‘Knowledge Gap’ as well as aspects of the hidden curriculum in medical education and their role in professionalizing medical students.
Keywords
Introduction and background
Medical knowledge is an integral element of the role of the physician and therefore acquiring the clinical and technical competency necessary to practice medicine is the paramount goal of each student who enters medical training. Researchers have highlighted how medical knowledge is imparted in the explicit, implicit, and hidden curricula (Bennett et al., 2004; Epstein and Hundert, 2002; Weissmann et al., 2006) but there is a lack of understanding of how the quest for medical knowledge may impact students as they progress, especially in the preclinical years. Recognizing these aspects of becoming a doctor can spotlight manners in which preclinical students experience their medical training as well as uncover various potentially influential mechanisms lurking within the formal and informal curricula.
Through interviews with preclinical students this article explores the effects of students’ quest for medical knowledge. It examines whether the ‘knowledge gap’ between medical students and laypersons may be exacerbated by the arduous nature of medical training and how the norms and values of the profession embedded within the hidden curriculum extends and deepens this social and emotional distance between students and those outside the realm of medicine. A Parsonian lens is utilized to examine the notion of a knowledge gap as well as aspects of the hidden curriculum in medical education and their role in professionalizing students.
Parsons and the ‘knowledge gap’
In The Social System, Talcott Parsons (1951) argues that there is a ‘communication gap’ between doctors and laypersons (i.e. patients). At one end of the gap is the doctor who possesses knowledge of various aspects of health and wellness gained from their extensive medical training. At the other end of the gap however, is the layperson who has received inadequate, if any, professional or technical medical training and therefore is reliant on the physician’s expertise: ‘He [the layperson] is not only generally not in a position to do what needs to be done, but he does not “know” what needs to be done or how to do it … There is, that is to say, a “communication gap”’ (Parsons, 1951: 441).
According to Parsons, the layperson is unable to understand or discuss what is causing their ill health and how to go about correcting it. Furthermore, given the physician’s professional knowledge it is difficult for the physician to communicate to the patient the actual diagnosis and treatment recommendations in a manner that they can comprehend. This disparity in medical knowledge creates a figurative distance between the doctor and the patient disturbing fluid interactions, lending to the authoritative role of the doctor over the patient in their encounters due primarily to the patient’s necessity of the doctor’s knowledge in order to get well. Although Parsons suggests that there is a ‘communication’ gap, it could be argued that the gap is actually rooted in the differences in levels of technical medical knowledge – there is a ‘knowledge gap’ between doctors and laypersons.
Parsons and the hidden curriculum
The hidden curriculum represents an undercurrent of norms, values, and regulations within the training process that students are to assume and embrace in order to function effectively in a social role (Wren, 1999). Apple (1979) suggests that students’ internalization of these rules, codes, and values creates and reinforces boundaries of legitimacy of the institution that the students will come to represent in their professional role. Research on the hidden curriculum has addressed how education processes perpetuate inequalities, dominance of particular social groups, and individual disempowerment (Giroux, 1985), and these tenets of the hidden curriculum are argued to exist in medical training (D’Eon et al., 2007). Professional education attempts to reproduce hierarchies, degrees of marginalization, ways of thinking, and other values of that particular institution (Margolis et al., 2001). Aspects of the hidden curriculum within medical training are found in customs, rituals, and everyday experiences that replicate ideologies regarding inequality and stratified relationships, most notably being that between doctors and patients (Hafferty and Franks, 1994): ‘a great deal of what is taught – and most of what is learned – in medical school takes place not within formal course offerings but within medicine’s “hidden curriculum”’ (Hafferty, 1998: 403).
The hidden curriculum serves as a socializing mechanism within the larger structure of the medical education institution and teaches medical students the authority driven power dynamic that exists between themselves and laypersons – based primarily on the differences in medical knowledge. Interestingly, however, explorations of the hidden curriculum have frequently neglected to explicitly employ a functionalist perspective, namely a Parsonian lens, to examine this specific arena of medical education. Although recognized for his discussion of the socialization processes within primary and secondary education (Parsons, 1959), Talcott Parsons would have undoubtedly argued the utility of the hidden curriculum within medical training to promote and sustain the authority and power of doctors and the maintenance of their professional role.
Doctors claim the knowledge and mastery of the intricacies of the human body, of particular medical technologies and procedures, as well as the diagnosis and treatment of disease (Fainzang, 2002) and this knowledge is gathered through their years in medical school. Wear and Castellani (2000: 606) argue that the current culture of medicine that is reflected in the medical school curricula touts science, scientific methods, and the knowledge gleaned from medical education as the true ‘knowledge’, much more valuable than the patient’s knowledge: ‘Moreover, the existing medical curriculum, aligned as it is almost exclusively with science and its methods, results in doctors, not patients, who are the real “knowers”.’
According to Parsons (1951), physicians serve as agents of social control, empowered to regulate what behavior is deemed normal (healthy) or deviant (sick), and as Latham (2002: 365) states, ‘At the base of the Parsonian view is the idea that the authority of professionals is grounded in their knowledge and expertise.’ Therefore, from a functionalist perspective, the primary instructional onus of the hidden curriculum is that the attainment of medical knowledge brings with it particular authority over those that do not have medical knowledge (laypersons).
Methodology and methods
The methodology was qualitative, based on interviews, and applying a constructivist grounded theory approach to interpretation.
Interviews
In-depth interviews were conducted with 10 first-year (M1) and 10 second-year (M2) students toward the end of the school year (April 2008) and were held away from the School of Medicine grounds, at a location of the subjects’ choosing in attempts to minimize issues affecting the confidentiality of the subjects’ identity. All interviews were recorded using a digital voice recorder and permission to use the recorder was requested from each subject prior to recording. During these interviews students were also asked to discuss their encounters with stress, interactions with family, friends, fellow students, patients, instructors, and physicians, as well as their perceptions, ideas and beliefs regarding their medical curriculum and the practice of medicine in general.
During each grade cohort’s orientation, when students were introduced to the project, it was stated that interviews were an integral part of the study and students interested in being interviewed should contact the principal investigator. Although a number of students from both grade cohorts personally contacted the researcher, it was important to recruit subjects that varied in gender and race.
Analyses and interpretation of data
Interview data were transcribed into Word files, converted into Rich Text Files and uploaded into MAXQDA, a professional qualitative data analysis software package. Regarding data analysis, a constructivist grounded theory approach was employed (Charmaz, 2006). The constructivist grounded theory approach was applied within this project because the primary goals of the analyses were to identify a pattern of perceptions and understandings of the pursuit of medical knowledge (from the students’ perspectives) as well as categories of the role(s) of medical knowledge within the preliminary stages of medical training, and to use these patterns and categories to promote a clearer conceptual and theoretical understanding of the social phenomenon studied. As a contemporary derivative on Glaser and Strauss’ (1967) classic grounded theory, the constructivist perspective promotes an appreciation ‘that that meaning is created through interaction and that researchers influence both the research process and outcomes’ (Hulko et al., 2010: 322). This approach not only provides a lens into the subjects’ social world, but also how they sense and understand various elements of that world.
In keeping with the constructivist grounded theory tradition analyses began with open coding to allow more codes and relevant themes to emerge from the data. As Charmaz and Mitchell (2001: 165, emphases in original) state, ‘Grounded theory codes arise from analyzing data, rather than from applying concepts from earlier works to data.’ Data analysis occurred simultaneously with data collection and codes were kept active throughout the analysis process (Atkinson and Delamont, 2008). As codes and themes surfaced through the analyses they were pursued through further excavation of the data.
A specific example of this process is the emergence of the ‘knowledge gap’ concept and its relation to the hidden curriculum in medical education. In reading the transcripts of preliminary interviews it was noted that subjects’ consistently referenced a figurative and physical distance between themselves and those outside of medical school. This initial code of ‘distance’ was logged and utilized during the examination of other interview transcripts. Once data specific to the notion of ‘distance’ was extracted from the transcripts this subset of the data was again analyzed using open coding to allow themes and categories to emerge. This process yielded such themes as distance because of amount of work, distance because of type of work, distance because of lack of time, and distance because type of knowledge, among others.
These themes were then employed as codes and all interview data were analyzed multiple times to continually extract processes and categories behind these themes (Charmaz and Mitchell, 2001). These processes spotlighted the significant nature of ‘medical knowledge’ and the existence of distance between students and others based, in part, on medical knowledge – which, in turn, was theretofore referred as the ‘knowledge gap’. These and related concepts were then engaged in the coding and analyses process, and themes such as the authority of medical knowledge, the superiority of medical knowledge, and others emerged. This led to the exploration of the hidden curriculum within medical curriculum and issues relevant to professionalism.
Case study: County School of medicine 1
The subjects featured in this study were first-year (M1) and second-year (M2) students at County School of Medicine (SOM) in the United States. County SOM has over 450 students, roughly 1000 residents and fellows, about 50 MD/PhD students, and over 300 students in five allied health programs. Faculty clinicians in the eight affiliated hospitals are responsible for 2700 patient beds and more than 2 million patient visits annually. 2 The use of human subjects was obtained through Institutional Review Board (IRB) approval of this study.
The preclinical curricula of County SOM
Data gathered for this study began in the summer of 2007. During this time, County SOM was ushering in a ‘new’ curriculum that would begin with the entering class of 2011 to symbolize an innovative era in medical training that was to begin at County, one that would create more professional ‘physicians dedicated to the understanding of the social, psychological, and economic issues of the patient, the family, and the community’. Given that the curriculum of the class of 2010 was the ‘traditional’ curriculum that existed at County SOM for many years, 2007 represented a potentially dramatic change in the structure and culture of the medical training.
Class of 2010: the ‘traditional’ second-year curriculum
During the 2007–2008 academic year, the second year of medical training extended over a period of roughly 10 months and contained about 34 weeks of instruction. This formal curriculum can be considered traditional because its basic configuration has existed and been employed for decades by a majority of American medical schools (Becker et al., 1961; Coombs, 1978). The curriculum represents what Becker et al. (1961) refer to as ‘The Big Three’ (Pathology, Microbiology, and Pharmacology), in which students are focused on attaining further basic medical knowledge that they will use when on the wards during their third and fourth years. The class of 2010 was also required to take Human Behavior, a semester long course that explored normal and abnormal mental mechanisms, personality deviations, and the more common mental disorders. Medical Problem Solving consisted of problem-based learning (PBL) exercises. Introduction to Clinical Methods, also common in the second-year curriculum, instructs students in the fundamentals of history taking, conducting a physical exam, basic comprehension and interpretation of lab tests, and patient communication. As required by the Clinical Methods course, the class of 2010 visited local clinics and hospitals for approximately four hours each week, and students had opportunities to shadow practicing physicians, interview patients, and possibly conduct other remedial medical tasks with live patients.
Class of 2011: the ‘new’ curriculum
The M1 curriculum for the 2007–2008 academic year was to serve as a new approach to medical training and medical education. One of the new curriculum’s core objectives is to create physicians who are committed to understanding, valuing, and addressing the sociological, psychological, and economic issues of their patients, the patients’ family, and the overall community. Not only are students to attain the core competencies in basic and clinical science as they had in the tradition system but this new curriculum touts the integration of more ‘hands-on’ patient experience by continuing the Week on the Wards as well as introducing OPEX (Out-Patient EXperience), where students spend four to five hours every other week shadowing a practicing physician(s) in Family Medicine, Internal Medicine, or Pediatrics. Whereas Week on the Wards serves as an introduction to the role of the physician for the M1’s first week of medical school, OPEX is a 12-month experience where the shadowed specialties were chosen specifically because doctors within these specialties are known to have a high level of patient contact, communication with their patients, and be more involved in their patients’ lives. Furthermore, one of the primary goals of OPEX was for students to experience a deeper level of doctor–patient interaction, and exhibited professionalism.
Yet another arena in which the new curriculum focuses on demonstrating the importance of the psycho-social aspects of patient care to the students is through the significance placed on the societal system for organizing students. At County SOM there are a total of four societies. These societies have been in existence at County SOM for some time, even the students of 2010 were divided into these particular societies, yet these small groups’ responsibilities and level of significance in terms of the overall curriculum had been greatly expanded within the new system. There are four clinician-advisors within each society (16 total), and each advises eight to 10 students within the small group: ‘The faculty members are teachers of clinical skills, small group mentors, and the students’ primary link with the School of Medicine and [County] Resources.’
First-year students begin their training, after Week on the Wards, in the ‘Healthy Human’ section (lasting for four months) which emphasizes ‘behavior … community, environment, family, and the “whole” of the person’. The ‘Healthy Human’ section is followed by the ‘Human Disease’ section which includes instruction on the principles of Microbiology, Pathology, Immunology, and Pharmacology. ‘Human Disease’ consists of organ block sections, focusing specifically on particular organs and systems of the body at a time. First-year students take Human Anatomy and participate in cadaveric dissection during the first five months of this section.
Further evidence that the new curriculum truly focuses more on the psycho-social aspects of patient care (as compared to the traditional curriculum) was presented within the very first week of medical school for the M1s, after Week on the Wards. During this week the first-year students were bombarded by issues of multi-cultural competency, medical anthropology, medical sociology, public health, professionalism, patient communication skills, issues involving patients’ families, and empathy. In a lecture to M1s on Healers in the Cultural Context (16 August 2007), a professor in the anthropology department at County University stated: ‘With this new curriculum, we’re trying to change the culture so that it has more of an emphasis on cooperation, teamwork, and patient-centered care.’
This description of the M2 and M1 curricula is meant to not only provide a context for the points and concepts raised in this article, but also to highlight that subjects featured in this work were subjected to socialization and professionalization processes within either a more traditional curriculum (M2s) or a more patient-centered/early patient contact ‘new’ curriculum (M1). As is evident from the data presented in the sections that follow however, students’ perspectives seem devoid of any particular relation to the specific curriculum they were engrossed in.
Findings
Studies have shown that medical school-related stressors and the rapt focus on attaining medical knowledge can have detrimental effects on students’ personal relationships (Dyrbye et al., 2006; Mitchell et al., 1983; Parkerson et al., 1990; Thomas et al., 2007). Therefore, during the interviews students were asked to discuss if and how their medical training had affected their interactions and relationships with individuals outside of medical school.
Do you find it hard to talk to people who aren’t in medical school?
Um, I don’t know what to say to people. You know, people ask me like ‘Hey, what’s going on?’ and I’m like ‘Hey, I can tell you about the kidney.’
You know, you’re around this stuff all the time. It’s what you talk about when you’re in class, out of class, on the weekends, you make jokes about it. So that sort of thing puts up a wall between you and the people in your life who aren’t in medicine.
Medical school just keeps you away. I mean, you just stop doing stuff with other people and engage with other people far less often and then it feels kind of funny when you do, especially with people outside of medical school.
As they became more engaged and involved in their training preclinical students reported difficulties relating and connecting with individuals outside of medical school. These accounts spotlight a physical, emotional, and cognitive distance that exists between medical students and laypersons. These preclinical medical students were not only faced with increased academic responsibilities and decreased personal time which hindered their ability and willingness to connect with others outside of medical school, but given the nature of preclinical training students were constantly surrounded by other students thereby minimizing their social network to simply other medical students.
I’m just around [medical school] all the time. You can’t be immune to its effects. It’s hard. You gotta (pause), it’s not like we have different classes, or different labs. Everyone is together doing the same thing all the time. It’s not like there’s any separation.
I can’t meet people around here and it’s really weird because I’m used to having friends that do all different things and have different experiences, but now I really only hang out with med students and when I make other friends I can’t continue that friendship. It just fizzles out for whatever reason. I mean it’s because I’m busy and it’s really easy to hang out with people who are always around you. You know, they tell us that the medical school community is really insular and doctors tend to associate with other doctors and I totally see that.
In med school your personal life and your academic life are really the same thing. Same friends, same people. There’s not a ton of separation between the two. I mean, you’re with your friends studying at school until 10 and then you all go out together and then you see them all again the next day at school. You know when people, they’re always like ‘No school talk. No science talk’, and then sooner than later med school topics come up, and everyone starts talking about science and it’s inevitable because that’s what you do. There’s not much else to talk about.
The struggles reported by students appear to be side-effects of the laborious and intense nature of medical training. Simply put, there appears to be a gap between medical students and lay persons generated not only by the students’ quest for medical knowledge, but from the medical knowledge (as compared to layperson knowledge) itself – there is a knowledge gap.
Preclinical students also reported being taught that medical knowledge carries particular qualities. These students spoke not merely of having trouble communicating with laypersons because of distinctiveness of what they were learning, but that what they were learning was also powerful and was accompanied by a level of authority, according to their instructors.
… there are little things that instructors would say here and there that encourage you to remember the greatness of what you’re doing or how serious it is that you can take someone’s life in your hands. And those things are true I guess but it breeds a sense of greatness that’s just kind of gross, you know. It’s just sort of sickening, and a huge turn off in medicine in general. But you’re around that all the time and the fact of the matter is that you do have people’s lives in your hands so to not feel that way at all is difficult.
And also, during Orientation, and I’m not sure you noticed this, but like not all the time but often, they like engrain in you this sense of superiority. As a physician you are somehow morally and intellectually superior to other people.
I do think that med school, they really make you feel that, that this and that are so important. I think they really build us up you know. We’re the smartest people, but we’re really not. You want us to stay humble, then don’t constantly build us up.
Preclinical students sensed teachings of medical authority nested within their education. The students implied that the faculty and administration were suggesting that they (students) were superior, smarter, and of more social worth than those outside of medicine. As discussed earlier this type of instruction is indicative of the hidden curriculum within medical education. The issues of status differentials and superiority were even evident when speaking with preclinical students about their relations with individuals outside of the realm of medicine.
Like I feel even with my best friends, we would go out to dinner and the things they would have to talk about I was absolutely not interested in and the things I would have to talk about I felt that they wouldn’t even understand on an academic level and on an experience level, you know. That has been a challenge over time and I’m sure it will continue to be that way, but I’m trying really hard to not let that happen.
It’s this weird attitude. Like, I never (pause), when I was in college, I never met anybody and thought about how much education they’d have. I liked and disliked people based on how they treated me and if they were fun to be with, I didn’t care about their background or what they wanted to do in life. And now when I meet people I find myself judging them and it’s very disturbing, this whole judgmental attitude. I mean you’re around these people all the time and we build each other up or build ourselves up because of all of our education and I don’t like the attitude. So it’s like this pompous attitude where subconsciously you think you’re better than other people because you’re going through all this, and I don’t like that, but I can’t deny that I feel it. It’s really been detrimental to my social skills.
I find myself disapproving of things or others’ choices that don’t involve helping people. And I’ve felt this way before, you know, my friends in their finance jobs like I devalue them. Or my friends from college, or my friends from high school that are not as intellectual, you know, at times I devalue them.
You know, especially when I am with my OPEX, it’s the nature that a lot of these patients are poorly educated and don’t have the medical authority that a doctor has and so that makes the whole relationships automatically a little (pause), because the doctor has a lot of knowledge and the patients don’t have a lot of knowledge. When the patient does have (pause), maybe he or she doesn’t understand in the broader scope of things. Anyways, being more skeptical of the patient is something I’ve started to develop.
Although the students acknowledged elements of the hidden curriculum (i.e. the ‘teaching’ of the authority of medical knowledge), these students still recognized that they judged, disapproved of, and even harbored mistrust for those individuals (including patients) that did not possess the medical knowledge. Hence, it can be argued that there are detrimental side-effects of the hidden curriculum. Although these teachings are primarily concerned with sustaining the authority of the professional role of the physician, the distance between students and those outside of medicine reflected by the knowledge gap and accentuated by the quest for medical knowledge has been further exacerbated by aspects of the hidden curriculum. Therefore, medical knowledge and the quest for that knowledge not only serve to distance preclinical students and laypersons but are also manipulated within the hidden curriculum to signify that distancing as a quality of professionalization. Furthermore, it would appear that particular elements of the hidden curriculum are discordant with the values touted by ‘professionalism’, and researchers have highlighted the contrasting nature of the hidden curriculum and the stated objectives of medical education institutions (Atkinson and Delamont, 1985; Murakami et al., 2009).
Discussion
The students’ accounts strongly suggest that a knowledge-based gap between themselves and laypersons exists within the early stages of medical training, regardless of whether they participated in a more traditional or ‘new’ curriculum. Preclinical students state that their pursuit of medical knowledge, and the grueling nature of that pursuit, keeps them at a social, emotional, and even intellectual distance from those outside of medicine. This in turn creates difficulties for preclinical students to relate and connect with laypersons. Furthermore, aspects of the hidden curriculum in medical education, specifically the ‘teaching’ that medical knowledge is power and that power is accompanied by authority, has the potential to ripen the negative effects of the knowledge gap and breed mistrust and negative issues involving superiority between future doctors and laypersons.
The notion of the knowledge gap spawning mistrust and hostility between groups that possess the knowledge and those that do not, is similar to Wilkinson’s (2005) discussion of how the income gap leads to poorer social relations. He argues that the widening of the income gap leads to a decrease in the sense of common identity between the groups. This, in turn, leads to more dominance over the subordinate group, more downward discrimination, and a reinforcement of authoritarian values. Furthermore, according to Wilkinson, this distancing between groups leads to a general lack of concern regarding the out-group, and an increase in hostility and mistrust between groups, which breeds poorer social relations. The argument presented in this article is similar in that the knowledge gap creates difficulties for preclinical students to interact with non-medical students, and there clearly is a loss of common identity as is evident in the students’ accounts. When widened by the emphasis placed on the value of medical knowledge, which emphasizes the notions of medical personnel’s authority and superiority, the knowledge gap fosters qualities of poor social relations between future doctors and laypersons and has the potential to breed judgmental attitudes, mistrust, and disapproval.
Furthermore, it could be argued that this distancing may lead, in part, to the detriment of students’ levels of empathy due to a corrosion of their ability to take others’ perspectives. Previous literature has depicted changes in medical students’ levels of empathy during their years of training (Hojat et al., 2004; Michalec, 2010), and key to the experience of empathy is the ability and willingness to take the perspective of the other person (Davis, 1996; Eisenberg and Miller, 1987; Halpern, 2001; Hojat, 2007). Given that preclinical students expressed difficulties with cognitively and emotionally connecting with and relating to laypersons their ability and willingness to take the perspective of the ‘other’ could be severely stunted due partially to the knowledge gap and its expansion. What is more, elements of the hidden curriculum that seem to hasten the expansion of the knowledge gap appear to contradict with what has been labeled as professional development by medical school administrators.
Medical education research has touted the value and necessity of instructing medical students in the arts of ‘professionalism’ (Baernstein et al., 2009; Elliott et al., 2009). According to Dyrbye et al. (2010: 1173), professionalism includes honesty, integrity, patient advocacy, and ethical conduct. Others have suggested that professionalism in medicine also includes such traits as altruism, patient-centeredness, compassion, empa-thy, as well as high-quality interpersonal skills (Camp et al., 2010; Epstein and Hundert, 2002). These attributes are held in high regard by medical school administrators, so much so that a number of medical schools have constructed courses, lecture series, and seminars specifically aimed toward medical students in hopes to engrain these traits into their future practice (Baernstein et al., 2009; Branch, 2010; Rabow et al., 2009). These notions of professionalism however, appear to conflict with the teachings of the hidden curriculum. More specifically, despite an advertised mantra of humanistic values, effec-tive communication and interaction skills, patient connectivity, and meaningful bedside manners, these qualities are not consistently reflected within the training process (Michalec, 2011).
Furthermore, it would seem necessary to dissolve the hidden curriculum in order to allow professionalism to flourish, at least those aspects of professionalism apparently relished by current medical education institutions. Perhaps, as Hilton (2004) argues, the hidden curriculum is actually central to the development of medical professionalism. These courses and seminars advertising patient connectivity and patient advocacy may be mere window-dressing or camouflage for the true professional role socializing mechanism – the hidden curriculum. In fact, the hidden curriculum can be seen as a wolf in sheep’s clothing, lurking for decades within medical training processes. Yet, instead of any significant effort to tame the beast, it would appear that medical institutions (schools, clinics, hospitals) continue to feed it and provide it shelter despite the vocalization to the contrary and the lack of harmony with the stated aims of professional medical institutions. From a functionalist perspective however, it is clear that the hidden curriculum sustains the values, belief systems, and level of authority that accompanies the professional role of the physician and therefore serves a crucial role in the socialization processes of medical students. In short, the beast is a guardian of the profession and therefore cannot and will not be tamed. The question is: are medical educators and medical school administrators comfortable with the potential consequences to students that experience the hidden curriculum?
Findings from this study suggest that the hidden curriculum, and the messages nested therein, appear to not only survive but also thrive within medical training despite the clear contradiction to the goals and attributes of professionalism touted by the ‘new’ curriculum. Similarly, this study found that there was no clear distinction between accounts and experiences from students in the ‘new’ curriculum as compared to students of the more tradition curriculum, which suggests in part that elements of the hidden curriculum are so engrained in medical training that ‘new’ curriculums may need to be implemented for a significant amount of time to be of influence, if they are to have any influence at all, in the development of professionalism among students. It is important to note that M1s within this particular study were the first to experience the ‘new’ curriculum at County. Therefore, longitudinally designed projects that explore students’ experiences within their sequential years of training, as well as their behaviors and perspectives during their professional practice would be essential to best understand how medical students are actually affected by the hidden curriculum and the formal curriculum (‘new’ and traditional).
Given that Parsons proposed the idea of a gap between doctors and laypersons 60 years ago and that gap was found to exist in contemporary medical education it would be beneficial to reexamine the typologies of doctor–patient relationships offered by the theorists of yesteryear as well as utilizing their perspectives to reevaluate various concepts and perceptions regarding socialization processes in medical training. Although social movements in medicine (i.e. the women’s health movement and the consumer movement, among others) have altered the doctor–patient relationship, it is evident that particular elements are engrained in the overarching culture of medicine and are translated through medical education. In taking a Parsonian perspective this particular study has merely scratched the surface of understanding the role(s) of the hidden curriculum and its relation to the development of professionalism among medical students. Future research, utilizing the work of Eliot Freidson, should therefore explore how the hidden curriculum within medical training contributes to the development and maintenance of the professional autonomy of physicians as compared to nurses, physical therapists, and other health-care related ‘professions’.
There are particular limitations to this study. It could be argued that because interview subject selection was based on subjects’ willingness to participate (and not selected randomly), there is a strong potential for selection bias and an overall lack of representation within the sample of students. Similarly, because this study was conducted at only one medical school the total sample may not be representative of all medical school students. Only 10 students were interviewed from each grade cohort and therefore findings presented, and conclusions drawn from those findings, stem from simply 20 students’ views. Finally, this study features only one interviewer and coder. Recent single-author (and single-coder) medically oriented studies that utilize a grounded theory approach however, have not listed this as a distinct limitation (Banner, 2010; Caldwell, 2010; Elliott, 2010; Kirk, 2010; McCreaddie, 2010; Murty, 2010). Rather, these articles promote the full disclosure of the data collection, analysis, and interpretation procedures, as well as the value in the review of findings by research supervisors. Regarding this specific study, not only have all methodological procedures been outlined in much detail, but these procedures, as well as findings, have been reviewed by colleagues specializing in qualitative methodologies, as well as County SOM administrators.
Future research should not only continue to explore the experiences of preclinical students from various institutions to better understand the presence and potential consequences of the knowledge gap within the preliminary stages of medical training, but also strive to examine the various facets of the hidden curriculum in more detail. More specifically, an interesting avenue of research would be to further excavate the relationship between the hidden curriculum and the formal curriculum, especially within institutions that have constructed and implemented a ‘new’, more patient-centered curriculum.
Conclusion
Although numerous researchers have attempted to dissect the hidden curriculum and examine its characteristics, even exposing its incongruity with the stated magnanimous objectives of medical education, the hidden curriculum is clearly nested within medical training and is an invaluable mechanism in the professionalization of medical students. What this particular study shows however, is that there are potential consequences to the teachings of the hidden curriculum. The pursuit of medical knowledge and the characteristics of the material itself led students to report experiencing distance from those outside of medicine. This knowledge gap, however, appears to be widened by aspects of the hidden curriculum and seems to lead to the mistrust and harsh judgment of laypersons, and an unwillingness to connect with them. Research has uncovered the basic characteristics of the hidden curriculum in medical education, but it has just begun to unearth its association with the formal curriculum or its potential side-effects (negative and positive) to our future doctors and their patients.