Balmer, Dorene F. PhD; Hall, Emily MD; Fink, MaryJo MD; Richards, Boyd F. PhD
If boundaries remind us that our journey has a destination, openness reminds us that there are many ways to reach that end.
—Parker Palmer, The Courage to Teach, 1998
Today’s focus on core competencies in medical education draws attention to the role of boundaries in guiding and shaping learning. The boundaries, established within the competencies mandated for residency programs by the Accreditation Council for Graduate Medical Education (ACGME)1 and widely adopted by medical schools, identify domains of abilities expected of all physicians entering practice. Furthermore, the accreditation standards of the Liaison Committee on Medical Education (LCME)2 require medical schools to define and use curricular objectives to drive students’ learning experiences so as to achieve desired outcomes, regardless of clinical venue.
In contrast to this focus on boundaries, several recent studies call attention to the openness inherent in the learning process, particularly from a constructivist view of medical education, which purports that every learner has a unique professional journey toward becoming a skilled and compassionate physician.3 For example, Balmer and colleagues4 described powerful learning in residents’ implicit curriculum that converged with, but was not constrained by, boundaries imposed by the explicit curriculum. Wear and Skillicorn5 and Murinson and colleagues6 described variability in medical students’ takeaway from their experience with the “other than explicit” curriculum.
This study offers insight to the tension between boundedness and openness at a curricular level by sharing data from Columbia University College of Physicians and Surgeons (P&S) as a case example. As part of a curriculum reform in 2008, groups of faculty and students worked together over six months to enhance the existing curricular objective domains, which were based on the ACGME’s core competencies. The new curricular objectives, written as 10 statements of aspiration, encompassed the ACGME competency domains but highlighted things like self-awareness, peer teaching, and teamwork, thus more closely aligning with our institution’s culture and goals7 (see Table 1). Educators involved in the process attempted to comply with LCME standards by deconstructing the 10 statements into measurable behaviors that would be required of all students. However, they struggled to balance the notion of prescribed behaviors (boundedness) with the meaningful, idiosyncratic learning (openness) they experienced themselves as students and as teachers.
As one of several strategies to explore the tension between boundedness and openness, we conducted a study designed to examine students’ perceptions of their learning journey within the interplay of curricula at P&S. To be as inclusive as possible of all learning experiences, we delineated three curricula: The explicit curriculum includes learning activities that are specified in the course syllabi, both required courses and selectives; the implicit curriculum includes learning activities (also referred to as the hidden or informal curriculum) that occur in the shadow of explicit curriculum but are beyond direct control of curriculum leadership, such as the modeling of behaviors of residents; and the extracurriculum includes learning activities that occur away from the explicit curriculum, such as participation in clubs or volunteering in New York City. In the decision to use the terms implicit and explicit, we drew on the work of Eisner,8 who distinguishes the explicit curriculum as what the school “advertises” (e.g., printed course materials) and the implicit curriculum as what is taught through institutional culture and organization as well as through interpersonal interactions with instructors. Here, we report initial results of this study and discuss their implications to encourage educators at other institutions to remember the openness of the learning process.
In May and June 2011, we (meaning the research team unless otherwise specified) invited fourth-year medical students to participate in the study. We invited students (n = 49) who we had reason to believe would be available and/or interested in participating in our study (i.e., students who assisted with a doctoring course for underclassman or took time off to do research or pursue a dual degree) and who had completed the required clerkships of the major clinical year. We e-mailed these students, asking about their interest in participating in a study about their learning experience at P&S and informing them of how study results might be used in the implementation of the new curricular objectives. Students who agreed to participate were among the last to journey through the “old” curricula and, hence, provided an ideal group to serve as a baseline for comparison.
Two of us (D.B., B.R.) conducted all the interviews, which ranged from 30 to 150 minutes. All interviews, conducted individually and face-to-face, were audio-taped and transcribed verbatim. In the interviews, we asked the students to read the newly written curricular objectives described above and to explain what the objectives meant in their own words. After students interpreted the objectives, we asked them to complete two tasks, which required them to make judgments about the interplay of explicit curricula, implicit curricula, and extracurricula in their own learning about the knowledge, skills, and attitudes needed to achieve the curricular objectives. We provided students with printed definitions of the curricula and encouraged them to ask for clarification at the start of the interview. All students asserted that they understood the definitions and proceeded through the interview without seeking clarification.
Each participant completed two tasks during the interview. For Task 1, we asked students to assign 100 points to each curricular objective according to the quantity of their learning that occurred across the three types of curricula: explicit, implicit, extracurricula. For example, in considering a particular objective, a participant could assign 50 points to explicit curricula, 30 points to implicit curricula, and 20 points to extracurricula, indicating that most of the learning for that objective occurred as a result of explicit curricula. We asked students to think aloud while determining their point assignments. For Task 2, we asked them to assign a total of another 100 points across all 10 objectives, again thinking aloud while determining the relative quantity of learning that occurred for each objective. We queried students at regular intervals during both tasks about their level of confidence in how they assigned points. At the end of the interview, we asked students to speculate and explain how similar or different their point assignments would be to their classmates’.
The study was reviewed and approved by the Columbia University Medical Center institutional review board. We provided no incentive to participate, obtained written informed consent, and assured students that their participation and comments would remain confidential, having no bearing on grades.
A research assistant entered point assignments into Excel (Microsoft, Redmond, Washington) and calculated means and standard deviations across all three curricula within each objective (Task 1) and for each of the 10 objectives (Task 2).
One of us (D.B.) managed qualitative data in the form of interview transcripts via ATLAS.ti (ATLAS.ti, Berlin, Germany). D.B. created an initial list of codes from key concepts within each objective (e.g., teamwork, self-care). In the first pass, D.B. applied these codes to the first five interviews and created inductive codes as other concepts emerged (e.g., role modeling, student-run clinic). In the second pass of analysis, we met over the course of several months to refine the code list and consider the utility of the codes in better understanding students’ perceptions of their learning journey within the interplay of curricula. Then, D.B. applied the refined and final code list to all transcripts. She shared clusters of coded data with the research team so they could immerse themselves in the data and corroborate the application of codes (e.g., quotes from transcripts to which specific codes had been applied). In the third pass of analysis, we met several times to scrutinize the data, both quantitative and qualitative, in search of explanatory insight. At this point, we had a series of conversations with two experts in the concept of the hidden curriculum to refine and expand our thinking through peer review.
Eighteen students (13 female) participated in this study, representing approximately 11% (18/164) of the eligible student body. Twelve participants were in the class of 2011 preparing to graduate, and six had taken a year off to do research or pursue a dual degree. Participating students subsequently matched into diverse specialties: medicine, 7; surgery, 3; anesthesia, 2; psychiatry, 2; neurology, 2; pediatrics, 1; and physical medicine and rehabilitation, 1.
Figure 1 provides a visual display of two types of variability in learning experiences, based on the quantitative data gathered from Task 1. First, patterns of students’ estimates of learning in explicit curricula, implicit curricula, and extracurricula varied substantially across objectives, as manifest in the relative differences in the lengths of the bars. Second, students’ estimates of learning in the three types of curricula within each objective also varied, as manifest in the size of the standard deviations. Specific to the first type of variability, by looking more at extremes than middle ground, we observed three patterns:
1. Predominance of the Explicit Curriculum: Average estimates of learning were noticeably greater for the explicit curriculum than for the other two curricula for the objective Build Patients’ Stories and Know Sciences.
2. Predominance of the Extracurriculum: Average estimates of learning were noticeably greater for the extracurriculum than for the other two curricula for objectives Demonstrate Self Awareness and Participate in New Knowledge.
3. Predominance of the Implicit Curriculum: For the remaining objectives, differences in average estimates of learning tended to be greater for the implicit curriculum than for the other two curricula. This occurred for objectives Be Aware/Committed–Health Systems, Communicate, Generate Hypotheses, Support Team, Teach, and Understand Patients Deeply.
With respect to the second type of variability for Task 1, we observed that standard deviations across objectives tended to be larger for the implicit curriculum and extracurricula than for the explicit curriculum, except for Build Patients’ Stories, Participate in New Knowledge, and Understand Patients Deeply.
Figure 2 provides a visual display of variability in the relative quantity of learning experiences for each curricular objective, based on the quantitative data gathered from Task 2. We observed that students perceived a substantially greater quantity of learning for Build Patients’ Stories and Know Sciences compared with the other objectives.
Although Figures 1 and 2 provide a helpful bird’s-eye view, the think-aloud task generated rich qualitative data. These data, when coded, enhanced our understanding of the remarkable variability in students’ learning experiences.
Insights about Observation 1: Predominance of the explicit curriculum
A major finding from Task 1 and Task 2 was the predominance of learning about medical knowledge (Know Sciences) and clinical skills (Build Patients’ Stories) in the explicit curriculum. Taken together, these objectives were typically understood as “what medical school is.” Speaking about building his fund of medical knowledge, one student observed, “I think a huge part of medical school is knowing the facts. I think, explicitly, the most time has been to teaching us the facts.”
Concerning the acquisition of basic clinical skills, such as taking a history, doing a physical examination, and performing basic procedures, another student said, “The history and physical, Imean, this is just how you’d be a doctor with a patient. I think that was the bulk of the training.”
Nevertheless, students seemed to understand that learning, for these objectives, was foundational in the explicit curriculum but eventually subsumed by clinical application in the implicit curriculum. One student explained it this way:
As a first-year or second-year, my sense of doing a history and physical [exam] was very different from what it is now. Back then, I was just worried about doing the maneuvers correctly, whereas now I almost take that for granted. If I’m looking for something, I worry much more if I did all the things I needed to do to help me rule something in or rule something out…. The preclinical years were good for “Here’s how you do it, here’s what you see.” But integrating the [physical] exam happened much more organically in the clinical years.
All but one participant perceived that learning about Know Sciences and Build Patients’ Stories demanded the most time in medical school.
Insights about Observation 2: Predominance of the extracurriculum
For many students, learning about two objectives (Demonstrate Self Awareness and Participate in New Knowledge) occurred largely in the extracurriculum because they were not explicitly or implicitly taught in “medical school proper.” For example, when considering Demonstrate Self Awareness, one student said, “I learned that from my own life.” Another student noted:
People wave their hand at [self-awareness] a lot. It’s talked about very superficially. It’s not something that is part of the formal curriculum, like “We’re going to give you real resources.” It’s more, “Here are all of the resources that are available if you should choose to care about this.”… So it’s mentioned, it’s out there, but it’s not a part of what you do.
According to students, the greater occurrence of learning about Participate in New Knowledge in the extracurriculum compared with other curricula was primarily due to taking time off to do research. Students recognized this as a significant source of variability in learning during medical school. As one student said:
I think it’s variable…. I have friends doing PhDs and they spend a lot of time in the lab. They’ve participated in the generation of new knowledge a lot more than others.
Insights about Observation 3: Predominance of the implicit curriculum
Students tended to perceive that most learning occurred in the implicit curriculum for the remaining six objectives, and they often attributed this learning to observation or, as they said, “watching.” Although such learning was pervasive across all 10 objectives, the pattern of codes suggests that students emphasized learning through observation for these six objectives. Some of the most salient examples pertained to learning to communicate and interact with patients by watching attending physicians and more senior trainees. This type of learning is commonly referred to as role modeling. One student described learning by watching as follows:
As a medical student, you’re allowed to watch a lot. We complain about that, but it is actually quite wonderful…. You really learn the most when you’re sitting back and no one knows that you’re listening to conversations.
Students recounted both positive and negative examples of role modeling. Often the positive and negative were paired together as two sides of a complete learning experience or, as one student said, a “double-edged sword.” Another student recalled:
I’ve seen several residents do things with patients that I was like, “I definitely don’t want to do that when I’m a resident.” Conversely, I’ve seen residents that like I would joke with my friends, “I want to be like them when I grow up.”
Learning by observation tended to be more subtle than “watching” for other objectives; it was a process of socialization into the culture of academic medicine. For example, students commented on working alongside attending physicians and residents at an academic medical center and “picking up” a sense of intellectual curiosity when learning about the objective Generate Hypotheses.
I saw a lot of this on the implicit level just because of the people we are around. There are attendings, fellows, and residents, and they’re so curious. If some med student brings up a pathophys [pathophysiology] thing, and the resident didn’t remember it, everyone says, “Wow, tell me more, I want to hear more about that.”
Although peers also played an important role in the implicit curriculum, the amount of learning attributed to peers varied across objectives. Students reported frequent idiosyncratic learning from peers about the objectives Teach and Support Team. For example, one student talked about learning to motivate teams:
I think class counsel is certainly a team I have to motivate. I’ve learned a lot about group dynamics there. And in the clinical years, you work with the same group of students. It’s not always perfect and rosy; you have to learn how to work together but that’s just life.
Similar to insights gained from Observation 1, students did not discredit explicit learning about objectives in Observation 3. Rather, they perceived that character traits made opportunities for explicit learning about some objectives irrelevant, or because explicit learning was subsumed by more frequent and/or more profound learning in the implicit curriculum. For example, one student said this about learning Be Aware/Committed–Health Systems:
You pick up your patient’s best interest, meaning health care and the broader context of health care, when you’re doing explicit training in the preclinical years. But it’s hard to really understand how many moving pieces there are and what it means to do what is best for the patient. You say, “I am going to fix this guy’s disease,” when you study pathophys [pathophysiology]. But sometimes the person’s problem isn’t their disease. The social system that they’re involved in is their biggest problem; learning what it takes to do what’s in their best interest is much more implicit.
Since the P&S curriculum renewal began, we have heard several alumni remark that today’s curriculum is much different from the one they experienced years ago. We wonder if the difference is inclusive of the full interplay across all types of curricula, some of which we can manipulate but much of which is outside the control of curriculum leadership. We also wonder if, from the perspective of the LCME mandate to govern by objectives, we as educational leaders can claim credit for what is perceived as positive change, knowing now that much learning occurs outside the objective-driven curricula. Our findings remind us that curriculum governance is not simply an effort to shape the explicit curriculum and guide students’ learning experience within the boundaries of curricular objectives. Rather, by documenting the relatively large, albeit variable, influence of the implicit and extracurricula on students’ learning experiences, our findings demand that we attend to the openness of “other-than-explicit” curricula. Having students make judgments about the interplay among the types of curricula in their learning and about the relative quantity of learning produced data that helped give form to students’ formless experience of traversing curricula. With form bestowed, we were able to examine the interplay of the curricula and examine what had been relatively elusive.
We surmise that the quantity of learning in the explicit curriculum about knowledge-oriented and skill-oriented curricular objectives, Know Science and Build Patients’ Stories, respectively, may influence how students perceived the relative quantity of learning for other objectives in the explicit curriculum. The curricular objectives that are predominant in the implicit curriculum, such as Generate Hypotheses and Understand Patients Deeply, may be more difficult to address in the explicit curriculum and less likely viewed as key components of medical training. The amount and significance of idiosyncratic learning in the implicit curriculum may be challenging for faculty charged with implementing LCME mandates. However, such learning is consistent with other reports which demonstrate the impact of role models, both positive and negative.5,6,9–12 In our study, the amount and significance of learning in the extracurriculum were notable, particularly for some students. In our experience, student-initiated learning outside of “medical school proper” tends to be relegated to the office of student affairs and, thus, overlooked by medical educators.
Whereas others have touched on learning about professionalism and role recognition in the implicit (hidden) curriculum, our study, which uses curricular objectives as a lens, points to the breadth of learning that occurs outside the explicit curriculum.10,13–17 In spite of frequent references in medical education to the “perils of the hidden curriculum”18 and the need to “confront”19 what students learn therein, our findings suggest that much learning in the “other-than-explicit” curriculum supports what medical schools intend to teach.
Although our curricular objectives, by design, invite a certain degree of openness, truly embracing openness requires institutional transformation. At P&S, our findings support current efforts by clerkship directors to decrease emphasis on learning simply to pass standardized tests and to continue to highlight learning through direct involvement in patient care. We have already used the findings of this study to inform discussions at various curricular committees. For example, when one committee was attempting to map out where students were exposed to explicit learning opportunities around clinical skills, we reminded faculty that powerful learning also occurs in extracurricular venues, such as student-run clinics. We are implementing a learning portfolio to serve as a repository of evidence of such learning. This portfolio is designed to help students reflect on their acquisition of curricular objectives as well as seek external input in interpreting their efforts. Finally, we will continue to share our findings with various faculty and house staff groups, reminding them of their status as role models for medical students.
Several things limit the assertions we can make based on the data. Our study is, by design, a story of a small number of students at one institution. It may speak to an institutional culture that is willing to challenge the status quo of competency-based education. Students who participated had personal interests in education and may not fully represent the opinions and experiences of their classmates. Moreover, the judgments they made about their learning experience may have been different if they had journeyed through a curriculum guided by the new curricular objectives. Given that the new curriculum did not replace but enhanced curricular objectives, it seems likely that differences among students would remain. The terminology used to describe the “other-than-explicit” curricula is inherently messy. Our terminology, borrowed from Eisner,8 may be too broad, especially as it pertains to the implicit curriculum. Is every interpersonal relationship that a student has on the wards, outside of formal lectures, an implicit experience? Some would argue that teaching on rounds is part of the school’s explicit curriculum because it is designed as a formal learning experience. Nonetheless, the role modeling that is exhibited on these rounds is not usually explicit and is subject to variation from attending to attending or resident to resident. Consistent with the findings of Wear and Skillicorn,5 who reported that medical students and residents did not readily distinguish between informal and hidden curricula, we used the term implicit curriculum to encompass both.
In conclusion, this study contributed data to inform ongoing conversations about the tension in curriculum governance between boundedness and openness. These conversations provide insight about how to live with the boundedness of curricular mandates on the one hand and the openness of students’ learning experiences in the other hand. We believe these conversations are a critical step toward designing medical education in a way that positively exploits the explicit curriculum, implicit curriculum, and extracurriculum to maximize students’ overall sum of learning experiences.
Acknowledgments: The authors wish to thank Dr. Fred Hafferty and Dr. Joe O’Donnell for their thoughtful comments on this work, and for their inspiration.
Other disclosures: None.
Ethical approval: The study was reviewed and approved by Columbia University Medical Center institutional review board. The authors obtained written informed consent from participants.