Fins, Joseph J. MD; Rodríguez del Pozo, Pablo MD, JD, PhD
Previously, we reported on the premedical curriculum in medical humanities at the Weill Cornell Medical College in Doha, Qatar1 and on a clerkship in clinical ethics and palliative care at Weill Cornell Medical Center's New York campus that uses participant observation and reflective practice to counteract the hidden curriculum when learning about clinical ethics and end-of-life care.2 In this article, we report our longitudinal experience teaching this clerkship to our students in New York and Doha. We consider how their experience with this formal element of the curriculum is influenced by the implicit and hidden curricula in Doha and by broader cultural differences that affect communication and information exchange.
At the outset of this cross-cultural educational experiment, we appreciated that “the autonomy-based ethics so prevalent in the West would be alien to, or even discordant with, our students' traditions and professional values.”1 Little did we know that we might be able to add to a deeper understanding of the nature and extent of the hidden and implicit curricula,3 constructs that have been misunderstood and simplified to the point of becoming clichés that obscure deeper import. We have now concluded that there are many hidden and implicit curricula and that each is dependent on the degree of specificity that characterizes communication in a given society.
Medical Education in Societal Contexts
We came to this conclusion after comparing the clerkship experiences in Doha and New York through the prism of cultural anthropology, which classifies communication modes that societies use as either low or high context. As we have written elsewhere, communication in Doha—in both medical and quotidian contexts—occurs in ways that are not obvious to Western observers because information exchange is governed by cultural clues and signals that are essentially invisible to those who visit from another culture.4 For example, advertisements for stores in Doha rarely provide their store hours or exact address. Instead, they make reference to a neighborhood or area such as “Al Saad zone” or “old airport area.” These areas leave much to the Westerner's imagination, as they can sometimes refer to a mile-wide area of the city.
Whether it is imprecise or absent street signage or vague, underspecified efforts at informed consent, the message remains clear to the local insider, who infers meaning from contextual clues such as traffic flow or the specialty name of a referral hospital that treats only cancer patients. This inferential mode of communication is ripe for misconstrual from the perspective of Western eyes, because it is just the opposite of what is done in an Anglo-Saxon and Western European context. In that frame, shared to a greater or lesser extent by nations in Western Europe, Scandinavia, North America, and the English-speaking Commonwealth, communication is far more explicit, relying less on contextual clues than on the actual words used in the exchange of information. Metaphor and double-entendre aside, Western-style communication is transmitted by, and nearly limited to, the explicit words of the message, sometimes to excess, as seen by the many traffic signs across Germany5 or by dense and voluminous informed consent documents in the United States or other low-context countries like Norway.6,7
Hofstede and Hofstede8 have described these modes of information exchange as low-context communication, in which “the mass of information is vested in the explicit code,” and high-context communication, in which “most of the information is either in the physical context or internalized in the person.”9 Low-context communication is more typical in individualistic cultures, whereas high-context exchange is more prevalent in societies that tend to be more communitarian.
In our previous work, we analyzed how these culture-related differences influence the practice of informed consent, suggesting that in low-context Anglo-Saxon and other Western European societies the norm is explicit written exchange and that in high-context societies, like that found in Qatar, effective information “has to be delivered by the doctor and extracted by the patient from the correct mix of words and contextual clues.”4 If communication relies on explicit words rather than on implicit environmental signs, “patients [in high-context societies] can become confused, even distrustful.”4 These cultural particularities are not only central to the doctor–patient relationship but to our understanding of medical education both at home and abroad. Let us explain.
A Single Explicit Curriculum Across Contexts
Since Hafferty's3 seminal article on the hidden curriculum, medical educators have parsed components of the curriculum between those intended to be communicated and those that have crept into the student's experience because of interpersonal dynamics or covert institutional forces. These elements have been defined as follows: the formal, explicit curriculum consists of a medical school's schedules, syllabi, and course formats; the hidden, implicit curriculum includes influences functioning at the level of organizational structures3; and the informal curriculum includes the philosophy and behaviors of instructors, medical staff, and fellow trainees that students might emulate.2,3 Although they seem to operate at the margins, the hidden and informal curricula exert significant influence over professional formation and are key determinants of what students will consider acceptable behavior in their professional lives.10
By definition, the provision of the required clerkship in clinical ethics and palliative care in both Doha and New York represents an attempt at a single explicit curriculum to help realize curricular uniformity between the two campuses of the medical college, a goal of the University since the inception of the Doha campus. Although there are minor logistical differences, the readings are virtually identical and the expectations are equivalent. Students in New York and Doha attend the same seminars, do the same opioid conversions and read the same texts. At both sites, our students engage in participant observation—assuming the role of novice anthropologist to observe patterns of care—and keep a journal to record their observations and reflections. In each setting, students have no direct clinical responsibilities, which allows them to pay full attention to the development of their skills as reflective practitioners.
In New York, students rotate at New York Weill Cornell Medical Center and Memorial Sloan-Kettering Cancer Center. This is replicated in Doha by sending students to Al-Amal Hospital (translated as “The Hope Hospital”), an oncology center, and to Rumeillah Hospital, a geriatric and chronic care hospital. At both campuses they attend rounds and spend time talking to an assigned patient and his or her attendings, nurses, and family. Students are encouraged to find out and discuss their patients' personal histories and incorporate them into their narratives.
What is different across the venues are the contexts in which the course is offered, the implicit interpersonal influences between students, teachers, and patients, and the hidden institutional forces both within each venue's medical school and affiliate hospitals. This becomes apparent through the voices of the students who keep journals of their experiences.
Two narratives, from our students' journals, pertaining to breaking bad news—in both cases an adenocarcinoma of the colon—illustrate the direct approach seen in a low-context society versus the more elliptical suggestive discourse of a high-context encounter. A narrative from a student in Doha:
I happened to be with the patient, when the physician broke the [bad] news that she is having a recurrence [of her small bowel carcinoma]. It was impressive how the bad news was delivered to the patient. It was a thorough, well-thought process. First, the physician came to the room with a serious look already setting up the patient for a serious diagnosis. The first thing the patient asked was, “It's bad news, right?” The physician replied by saying, “Well, it depends on how you look at it, but it's not what I hoped for.” Here the patient was given a few moments of silence. Then she asked her physician, “I was expecting this could happen, a recurrence, right?” Here the physician was the one who practiced silence. The patient went on to say, “It's OK, you can tell me.” The physician said, “Of course there are many options on the table still for us, but yes, unfortunately there has been a recurrence.”
Note the initial observation of the physician's nonverbal demeanor prompting an explicit question from the patient and an evasive response from the physician: “It's not what I hoped for.” The patient rephrases the question and the physician sidesteps the response, speaks about possible options, and only finally concedes that there has been a recurrence of disease.
Contrast this with the explicit narrative of an intern in New York who shares a new cancer diagnosis with an octogenarian on rounds. Not only is the task delegated by the attending as a routine teaching exercise, it is delivered frankly and without finesse:
This morning during rounds the team had to break bad news to a patient. The patient is an 88-year-old woman with dementia and a past medical history of colon cancer, diagnosed and treated with resection and chemotherapy 20 years ago…. The pathology was not back at this point, confirming a new malignancy, but the team was fairly certain this was, in fact, cancer. While discussing the patients in the morning rounds, prior to physically rounding on them, the attending asked the intern how he would like to break the news to the patient…. The intern said he would tell her the news today on rounds.
When we went to see the patient, she was sitting up in bed eating breakfast and her 60-plus-year-old son was sleeping in the chair next to her bed, wearing a winter hat and a Mickey Mouse T-shirt, in the same clothes and position as he had been in when we rounded on her yesterday. The intern asked how she was feeling and she said, “Fine.” He then said, “So the results of your colonoscopy are not officially back yet, but the doctors saw a mass and it looks like it is cancer again.” The patient responded, “What?! Speak up!” The intern repeated the information and asked if she had any questions. She responded that she did not and the team said they would be back to speak with her later in the day. On leaving the room, I happened to be the last one to exit, and noticed that her son had not been sleeping at all and as I said good-bye to her, he just looked down at his hands and said, “S—t.” The attending later said to me and another medical student that he thought the intern did a decent job of breaking the news.
While these examples contrast communication styles of clinicians within high- and low-context societies, the discourse of the attending and intern speaks neither to the reaction of the first patient in Doha (who seeks more information) nor to the silence of the second patient (and the expletive of her son), which suggests that the conveyance of information was too stark. These caveats underscore the importance of individualizing communication strategies, in whatever context one might be, to minimize the iatrogenesis that may occur with breaking bad news. Our point here is that to do this, the student needs to be aware of the cultural forces that compel him or her to adopt degrees of transparency or opacity to achieve the most effective communication. Students learn these lessons about implicit communication from creating narratives as part of the explicit curriculum.
It is reassuring to note that in the above narratives the students have actually developed an anthropological stance that allows them to infer the methods of communication—and their strengths and weaknesses—in each of the contexts they encountered. We see these cultural insights emerging as students assess patients and their contexts. Consider a student's description of a New York patient who was fully informed about his circumstances and reflective about his prospects:
I met this 70 yo gentleman whose primary CNS lymphoma had returned after almost 20 years in remission. He was all alone in his room when I first met him; his family had brought him into the hospital earlier to be admitted, but then had to leave for home in NJ. The man appeared tearful. He described how he had been so lucky and so happy that his last chemotherapy had prolonged his life and how he had gotten to see the birth of his three grandchildren. But he also now described feeling alone, scared, and frightened. He missed his wife and recounted how they had not slept apart from each other in almost 20 years, basically since his last hospitalization. He described feeling anxious and worried about his further treatments, wondering what difficulties and hardships they would surely entail. He said that he was content with the life that he had lived, but felt demoralized that the cancer had come back. He said that he did not know if he could handle the treatments again, now that he was 20 years older. He wondered out loud if his time had simply come; whether it was now time to die gracefully rather than trying to fight the cancer again.
Or, consider a different student's comments about another patient in New York, who, fully informed of her illness, was defiant in her hope for cure:
After we felt comfortable with the patient's medical history, we entered the room to hear her own personal take on it. I was struck by her poise. I'd expected a tired, defeated cancer patient, waiting for Death to deliver her from such a hellish predicament. But this was no morose pity-monger. This patient was hopeful, almost defiant of her disease. She had decided she'd conquered difficult problems in her life before and this was simply one more battle she would march, as though she'd done it a thousand times before.
I couldn't help but be impressed with her grasp of the situation. She did not naively pray to the gods of false hope, and yet she did not allow this sudden confrontation with her own mortality to define her life. She was simply going to take it in stride, have faith in her physicians, and have the strength to carry on.
In each of these narratives, we encounter patients who are not only completely aware of their situation but frank and explicit in their feelings. The first patient “wondered out loud”—explicitly using words to share his feelings and doubts, a mode of communication consistent with the low-context societal norms of the United States. The overtness and desire to be transparent and communicative is even more obvious in the comments of the medical student in the second narrative, who describes seeking out the patient “to hear her personal take on it [her illness].”
Contrast these student–patient encounters with the reflections of their counterparts in Doha. In these narratives, students turn to the context for information and consciously avoid direct engagement with the patient. Instead, it is analysis by inference, a reliance on visual clues and context to understand the patient. As one student put it:
It is essential to identify the patient's environment in order to understand his life in the hospital. The message delivered by the patient's appearance and surroundings can be more truthful than any words. It is the most honest representation of the patient's true life in the hospital. It tells you the extent of family care, social support, patient's mood and level of education.
The student continued:
Within a few seconds of looking at the patient, we were able to come up with many facts that, along with the patient's history, draw the big picture of his hospital stay. He was obviously a well-educated man who loves to read and is aware of what's going on locally and internationally. This was easily given away by the pack of newspapers that he spends most of his time reading. He was well groomed, nicely shaved, with good hygiene, which indicated to us that he was being taken care of. The bag of gum and chocolate, obviously not everyday hospital food, pointed to the care he might be getting from the outside world. [There were] creams, lotions, and shampoos with different odors and colors, none of which were present next to his roommates. Pictures of the two young girls smiling over his bed, his nieces, were the only family able to stay back after the family's weekly visit.
Students consistently made references to the use of contextual clues, not only to understand the patient but also to deliver information to patients.
The starkness of the differences between our explicit curriculum taking place in high-context Doha and low-context New York was made explicit to us by three medical students from Doha we recently encountered in New York. Fresh from their rotations and with fast-food soft drinks in their hands, we met them one night near our medical center.
We asked them how their subinternships were going, and one volunteered that coming to New York was like coming home because the school had prepared them well for practice in an American context. Here, he noted you can talk with patients and they are very informed. But he added that when they returned to Qatar, they would have to revert back to local norms and customs and talk differently with patients or families. This is a fascinating suggestion, indicating that even as an implicit societal influence exists that tilts discourse to nondisclosure (consistent with a high-context society), the explicit and hidden institutional curricula—which are usually thought of as antithetical—in this case coalesced to help prepare students for postgraduate training and/or practice in the United States. This powerful alignment of an explicit educational mission with a strong hidden curriculum (i.e., low-context norms about explicitly communicating informed consent in the West), coupled with the implicit interpersonal clues of mentors and instructors, allowed students trained in high-context Doha to also develop “bilingual” skills to enable practice in low-context Manhattan or high-cotext Doha.
The Many Hidden Curricula
Beyond the differences in how a standard explicit curriculum might be viewed by students in differing contexts, there are more fundamental observations about the hidden curriculum that emerge from our transcontinental educational efforts. Although we speak of the hidden curriculum as if it were one entity, the hidden curriculum must be understood as a plural phenomenon: the hidden curricula. Its description actually depends on the context in which it operates. Consider the differences we have described between our medical schools' settings in Doha and New York. In a high-context society such as Doha, much more is hidden than in low-context New York. Because of this, much more of the curriculum is outside the realm of the structured curriculum and hence implicit, by virtue of the society in which it is delivered.
There are a number of implications. While we are teaching the same explicit curriculum in New York and in Doha, the percentage of the educational message in each venue that will be either implicit or explicit is quite different. By this line of argument, the explicit curriculum in Doha is proportionally less important pedagogically than is the same curricular experience in New York. Relying on the explicit curriculum across venues can become problematic if the influence of the hidden curriculum is disproportionate in one setting versus another. Beyond undermining the explicit curriculum, the hidden curriculum can overshadow what is taught in the classroom and the bedside.
Given these dynamics, we would assert that failure to appreciate and respond to the influence of high- or low-context societal dynamics on the curricular experience amounts to educational malfeasance. Educators who teach abroad need to know the relative strength of their explicit curricula, given prevailing cultural norms, much like the tourist needs to appreciate the exchange rate for the dollar against the euro or the Qatari riyal. In high-context societies, the explicit—curricular or otherwise—is discounted and undergoes the equivalent of a currency devaluation.
In the extreme, there might even be an occasion where educational currencies cannot be exchanged when commensurability between cultures is so distant that conversion of a curriculum might be impossible, such as between very low and high contexts. It is useful to look at these outlier cases because they also illustrate a supposition at the heart of the very implicit/explicit curricular argument.
The very notion of a hidden curriculum must come out of a low-context society, where the standard is one of being overt and explicit. In that context of full disclosure and transparency, the implicit elements of an interaction—that which is hidden—come as a surprise, something that raises one's suspicion. In that setting, informed consent takes on the shape of a legal contract.
In a context like Doha, which is high context, explicitness—by contrast—comes as a departure from the norm. This is a context marked by trust and the sort of homogeneity of shared values that once made paternalism possible in the United States, where it was a vestige of a more high-context society where the doctor's views could serve as a proxy for the patient. In that context, one might imagine an Academic Medicine article entitled, “Medical education and the value of the hidden curriculum: How to overcome the challenge of the explicit or formal curriculum.”
Having made the argument for the impact of high or low context on the hidden, or implicit, curriculum through the prism of international medical education, it should not be lost on the U.S. reader that the effect of context on the hidden curriculum can be more subtle when comparing one U.S. medical school with another. As the extreme case of the two Weill Cornell campuses illustrates, there is no such thing as a single hidden curriculum. It is dependent on context, whether between New York and Doha or Georgetown and UCSF.
What is implicit is contextualized, and we suspect that, for example, schools with a religious mission might have more inherent norms and values shared by leadership, clinicians, students, and alumni. Although this should be studied empirically, we would imagine that religious-mission-driven institutions and their constituencies operate under an unspoken code and share a sense of comportment and behaviors that implicitly direct care and influence pedagogy.
Academic leaders in medicine need to appreciate the variation within this hidden variable and come to understand the dynamics between the hidden and implicit within their own institutions, much less that between schools separated by oceans and time zones. To borrow a phrase from the philosopher John Rawls,11 which seems apt here, we need to lift this “veil of ignorance” to apprehend all the pedagogical variables that can affect educational outcomes. To do otherwise is to mistake an important normative boundary between the implicit and explicit, forces that shape our behaviors and ultimately inform the care we provide and the lessons we impart—knowingly or not—on the next generation of physicians entrusted to our pedagogy.
The authors gratefully acknowledge the insights of Weill Cornell Medical College students in Doha and New York whose journal entries and comments have contributed to the authors' understanding of the hidden curriculum across cultural contexts.