Decoding the Learning Environment of Medical Education: A Hidden Curriculum Perspective for Faculty Development
Hafler, Janet P. EdD; Ownby, Allison R. PhD; Thompson, Britta M. PhD; Fasser, Carl E.; Grigsby, Kevin DSW; Haidet, Paul MD, MPH; Kahn, Marc J. MD; Hafferty, Frederic W. PhD
Dr. Hafler is associate professor, Yale School of Medicine, Yale University, New Haven, Connecticut.
Dr. Ownby is director of educational programs and assistant professor, Department of Pediatrics, University of Texas Medical School at Houston, Houston, Texas.
Dr. Thompson is assistant professor, Department of Pediatrics, assistant dean for medical education, and director, Office of Educational Development and Support, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma.
Mr. Fasser is professor, Department of Allied Health Sciences and Department of Family and Community Medicine, and director, Department of Allied Health Sciences, Baylor College of Medicine, Houston, Texas.
Dr. Grigsby is senior director, Organizational Leadership Development, Association of American Medical Colleges, Washington, DC.
Dr. Haidet is director of medical education research and professor of medicine and humanities, Pennsylvania State University College of Medicine, Hershey, Pennsylvania.
Dr. Kahn is senior associate dean for admissions and student affairs and professor of medicine, Tulane University School of Medicine, New Orleans, Louisiana.
Dr. Hafferty is professor of medical education and associate director, Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota.
Please see the end of this article for information about the authors.
Correspondence should be addressed to Dr. Hafler, Yale University School of Medicine, Edward S. Harkness Hall, 367 Cedar Street, ESH 315, New Haven, CT 06510; telephone: (203) 737-5952; fax (203) 737-4199; e-mail: email@example.com.
First published online February 21, 2011
Medical student literature has broadly established the importance of differentiating between formal-explicit and hidden-tacit dimensions of the physician education process. The hidden curriculum refers to cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational endeavors. The authors extend the concept of the hidden curriculum from students to faculty, and in so doing, they frame the acquisition by faculty of knowledge, skills, and values as a more global process of identity formation. This process includes a subset of formal, formative activities labeled “faculty development programs” that target specific faculty skills such as teaching effectiveness or leadership; however, it also includes informal, tacit messages that faculty absorb. As faculty members are socialized into faculty life, they often encounter conflicting messages about their role. In this article, the authors examine how faculty development programs have functioned as a source of conflict, and they ask how these programs might be retooled to assist faculty in understanding the tacit institutional culture shaping effective socialization and in managing the inconsistencies that so often dominate faculty life.
It is, I think, not easy to exaggerate the importance of the informal social element in the promotion of science and learning. - Abraham Flexner, 1930
As Flexner1 suggests, the learning process includes both formal and informal elements. In recent years, medical educators have acknowledged the importance of differentiating between formal-explicit and hidden-tacit dimensions in the process of becoming a physician. The hidden curriculum refers to cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational endeavors.2–4 Many leaders and educators now recognize the necessity of accounting for and helping faculty learn to decode and understand the hidden curriculum that is operational in their institutions. To date, the hidden curriculum literature mostly positions students as the receivers and faculty as the deliverers of the hidden curriculum. We explore whether a tacit dimension similarly exists for faculty members' learning.
In this article, we define “hidden curriculum” for the purposes of exploring its role in faculty development, and we examine how institutions might help faculty to understand and manage the hidden curriculum as it pertains to their own development. We use the term “faculty development” in a broad sense, referring to the inclusive range of learning that socializes faculty to their role, including professional and identity development, instructional development, leadership development, and organizational development. These areas of learning often entail both explicit and tacit learning experiences related to how a faculty member should think, act, and be. We end the article by identifying possible implications that can guide faculty development programming and research with the aim of addressing the hidden curriculum as it pertains to faculty.
What Is the Hidden Curriculum?
All learning involves both formal-explicit and informal-tacit elements. For at least the past century, educators have shared this view of learning. Examples include John Dewey's5 concept of collateral learning as well as more contemporary concepts such as workplace learning,6 situated/cognition learning,7 peripheral participation,8 and communities of practice.9 Although educators have used a variety of terms to differentiate between the formal (e.g., explicit, written, curriculum on paper) and the informal (e.g., hidden, implicit, unwritten, meta, latent, shadow, tacit, tested) dimensions of medical learning, the basic distinction all of them make is that social life in general is governed by a complex interplay of formal laws and/or cultural traditions and informal norms, stereotypes, and social practices.10 Whereas medical educators and others tend to view or describe the learning environment as a simple dichotomy between the formal and hidden curricula, the reality is that social learning is a more complex phenomenon.11,12 Regardless of the labels used, three critically important arenas of influence remain: (1) those social activities formally structured and intended, (2) those social activities that are more informal, unplanned, and unscripted, and (3) those influences, such as organizational culture and place, that are more invisible and ethereal in their presence and impact.1,12,13 We suggest that these three arenas exist not only for students but for faculty as well, and we will use the term “hidden curriculum” to globally capture all of the nonformal influences including those that are hidden (i.e., those captured in arenas 2 and 3), and to discuss how these influences affect faculty in their development as members of a distinctive social group.
Hidden Curricula for Both Students and Faculty
Much of the literature on the hidden curriculum has traditionally focused on students.2–4 This literature usually casts faculty, including advanced learners, such as residents and fellows, as conduits of both formal and hidden curricula to their subordinates. Peer-to-peer transmission, be it at the student, resident, or faculty level, has received little attention. Rare are analyses of peer-to-peer interactions even in situations in which individuals have dual responsibilities, such as during graduate medical education when resident physicians play the conflicting role of both student (to faculty) and teacher (to medical students).14 Residents are submerged within their own tacit learning environments, and they must navigate networks of hidden, often peer-based, learning processes.15 The rather extensive hidden curriculum literature focusing on graduate medical education and faculty tends to emphasize how senior group members impact their subordinates, rather than how they might influence one another.16,17
Faculty, residents, and other teachers are both subject to, and active participants in, their own hidden curriculum. Faculty are not born faculty. “To be faculty” is both to take on a specific social identity and to follow a set of social roles. Faculty learn this identity and its related roles over time. Both the identity and the attendant roles are infused with social expectations including those held by in-group members (i.e., other faculty) and out-group members (e.g., students, administrators). Learning the rules governing “faculty life” involves formal and informal, direct and tacit, learning processes. For example, faculty may have “protected” time for educational activities, but may find themselves called for clinical work. Accordingly, the individual faculty may begin to learn or understand that the policies of protected educational time may not actually translate into real hours of protected time. The message is that his or her department values clinical service more than educational service. Whereas faculty are important drivers of the hidden curriculum as it pertains to students, the hidden curriculum as it pertains to faculty may be more driven by the institution itself, and it may be translated and transmitted to individual faculty members by their peers.
The literature has depicted faculty members as deliverers of pedagogy, role models, and/or repositories of institutional power, but rarely, in terms of their development, as objects of critical inquiry in their own right. This lack of acknowledgment as learners has become so routine that, when studies of “medical school socialization” are published, the peripheral status of faculty as learners often slips by unnoticed. In this way, faculty learners have become bit players in a provocative drama about development and the formation of future physicians.
Although a vibrant body of literature focuses on the socialization of graduate students to academic life,18,19 and a separate body of scholarship focuses on the socialization of occupational newcomers,20 including the role of tacit knowledge in organizational (including medical) learning,21 virtually no studies are specific to the training and/or maturation of medical school faculty. Exceptions are Blankenship's22 early edited work on “colleagues in organizations” and two more recent works by Trowler and Knight23 and by Pololi and colleagues.24 Some publications provide focused examinations of scientific collaboration and faculty productivity,25–27 including the impact of teaching scholar28 and faculty development programs,29 but these studies are not designed to answer particular questions about the hidden curriculum. Similarly, a burgeoning body of literature examines career development and advancement within academic medicine,30,31 with a particular focus on faculty discontent and burnout,32,33 faculty retention,34 and the particular case of women and minorities in academic medicine,35,36 but, once again, most of these studies answer specific empirical questions about the prevalence of certain trends or phenomena, or they call for changes without an underlying theoretical framework or reference to the impact of the hidden curriculum.
We believe that a better understanding of the hidden dimensions of faculty formation will allow organizations to become more sensitive to the tacit and more informal dimensions of organizational culture. For example, faculty and administration may be well able to list the teaching awards and recognitions given out each year. However, they may be less able to articulate the characteristics of those awards relative to core school values. Further, they may not be aware of the school's entire universe of awards or of the larger picture of meaning that this universe conveys to the institutional community about core organizational values. Indeed, a school that has purposefully reviewed its universe of awards is rare. For example, the Arnold P. Gold Foundation provides a Humanism in Medicine Award, but not all schools receive it. What is the message for the schools that do not receive this award? Is humanism less important to those schools?
Understanding the hidden curriculum can sensitize faculty and administrators to the existence and impact of such meta-messages, even if—perhaps especially important if—these messages are previously unseen and unintended by the sender or unrecognized and misinterpreted by the audience. Knowing the meta-messages is important because such knowledge provides the foundation for leveraging positive messages and minimizing negative messages and their unintended outcomes (e.g., high rates of faculty turnover, low faculty morale, decreased faculty productivity, decreased student satisfaction [with faculty], and ultimately poor organizational performance).32–36
Reconstructing Faculty Development From a Hidden Curriculum Perspective
The medical education literature often employs the term “faculty development” to indicate a particular set of educational activities, typically aimed at building skills in specific areas, such as grant and manuscript writing, curriculum development, and teaching.37–39 In terms of the hidden curriculum, faculty development exists not only as specific, formal skill-building experiences but also as generic processes tied to the broader concept of socialization. In other words, becoming a faculty member is a process of occupational enculturation that involves a broad range of social practices infused with both formal/explicit and informal/implicit learning dimensions. From this perspective, efforts to improve the instructional value, impact, and/or relevance of formal faculty development programs will be dictated in part by the broader array of cultural messages that faculty encounter as they go about learning what being a “good faculty member” means and what they really need to attend to in order to advance their careers.
To quote long-time Speaker of the House Thomas P. “Tip” O'Neil, “all politics is local.”40 In the case of medical education, all learning, be it at the student or faculty level, is context dependent.41 Thus, when a medical school invests in formal faculty development programs to increase the effectiveness of its faculty as teachers,37,38 it must also consider the broader cultural supports for teaching as a valued faculty activity, such as the presence (or absence) of a teaching track that includes tenure. If faculty members are receiving countervailing messages from their work environment that teaching is relatively undervalued, then the formal faculty development efforts to improve teaching skills are being undermined by the broader culture of the institution. For example, one of our home institutions initiated an educators' journal club as part of a formal faculty development program. After a few months, very few faculty were attending the sessions. Faculty members were not able to secure the time away from their clinical and research activities to attend. Furthermore, those junior faculty who attended did not see senior faculty in attendance and may have interpreted the journal club as less valued in the schema of academic life at the institution. In this case, a planned activity created as part of a formal faculty development program was less effective in meeting its objectives because the broader culture, as demonstrated by the behaviors of seasoned teaching faculty, ran counter to the goals of the formal faculty development program.
Review of the faculty development literature41 makes many of the same points we have advanced above, but these works do not reference a hidden curriculum framework. For example, Steinert and colleagues41 note that most faculty development programs target teaching and instructional improvement or they target a particular type of faculty, such as practicing clinicians, primarily those within family medicine and internal medicine programs (basic science faculty members receive far less attention). They further note that faculty development often lacks context and fails to establish “a direct link to teachers' ongoing educational activities.”41 Compounding this problem, many faculty development interventions lack a theoretical (e.g., experiential learning, reflective practice) framework. Studies of impact also focus more on learners' reactions to the experience (e.g., favorable versus unfavorable) and/or changes in learners' attitudes, knowledge, and skills rather than actual changes in the learners' behavior or changes in the systems in which faculty and learners work.42 Reflecting the idea that politics is local, Steinert and colleagues41 conclude that “context is key” and that faculty development efforts must include more attention to organizational culture. More important, these authors41 conclude that whereas formal faculty development is able to address the first two of Kirkpatrick's43 four necessary conditions of change (e.g., a personal desire to change and knowledge regarding the whats and hows of change), it is not able to create a supportive occupational environment or rewards tied to change (the last two of Kirkpatrick's necessary conditions for change).
A Conceptual Model for the Hidden Curriculum With Respect to Faculty Development
Figure 1 constitutes an initial attempt to describe some of the factors that may impact the hidden curriculum as it pertains to faculty (as well as students). Factors that influence the hidden curriculum, as it pertains to students, include the behaviors of faculty and residents, advice from senior students, and feedback and evaluation. Factors such as the processes for granting promotion and tenure, the allocation of space, and salary structure or merit increases are elements of the hidden curriculum impacting faculty. An example of this is mission-based budgeting with respect to education. An institution that pursues this type of budgeting will funnel dollars to its departments based on the time devoted to teaching. This structure, on the surface, may seem to value time spent teaching; however, if the allocation of those funds is left up to a departmental chair who chooses to funnel the money to researchers or other departmental activities, then what does this say to the teaching faculty within that department? Although Figure 1 portrays the hidden curricula for faculty and students as separate entities, they are actually both mechanisms for viewing how the overall institutional culture is operationalized for either students or faculty.
In this article, we have attempted to take the concept of the hidden curriculum, at least as it appears within the medical education literature, and use it to reframe the concept of faculty development, so that faculty development includes not only formal activities but also the broad array of experiences, including those that are tacit and unintentional, influencing faculty life. The likelihood for faculty to encounter a variety of conflicting messages about the nature and goals of their educational undertakings is not well understood, nor is it well documented in either the medical education hidden curriculum literature or the faculty development literature. We suggest a critical need for empirical research to address important questions with respect to institutional culture and faculty development. Faculty face inconsistencies in the culture and structure of their workplaces, ambiguities about the nature of their work, and questions related to their professional identities. How can medical educators design faculty development programs that address these aspects of the hidden curriculum? How can the academic medicine community align faculty development programs with both the culture of the organization and the faculty experience within the organization? How can the community link, integrate, and reconcile the various bodies of literature on faculty life (including how faculty learn to be faculty) so that the formal curriculum of faculty development assumes a meaningful and influential presence within the overall milieu of health science institutions?
The authors would like to acknowledge the organizers and presenters of the 2020 Vision of Faculty Development Across the Medical Education Continuum conference, Baylor University School of Medicine, Houston, Texas, February 26 to 28, 2010.
This work was supported by a writing conference funded by the Medallion Fund and the Josiah Macy Jr. Foundation.
This information was presented in part at the conference mentioned above.
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