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Friday, April 15, 2011
Education: The Hidden Curriculum
Posted by Alan Jay Schwartz, M.D.,MSEd
Alan Jay Schwartz, M.D.,MSEd
When I attended “Teachers’ School”, one of the first things taught and learned were the 3 domains of learning: cognitive, psychomotor and affective. The Page 2 blog has already considered some aspects of cognitive (content) and psychomotor (skill) learning. (I suggest you read these blog entries if you haven’t done so already.) In anesthesiology, content and skill learning are relatively easy to grasp; knowledge and tasks can be defined and evaluated in an objective and unbiased manner, i.e., without hidden meaning. Ask a resident about propofol or how to insert a double lumen endotracheal tube, and the discussion and answers leave little room for interpretation.

Affective learning is a different story. The dictionary tells us that “affective” relates to emotion (i.e., causing or expressing feeling). The affective domain(1) focuses on how we learn with respect to our emotions. There are 5 five categories of behavior in the schema for the affective domain, from the simplest to the most complex: receiving (e.g., hearing), responding (e.g., answering and discussing), valuing (the worth one imparts to an activity), organizing (prioritizing values), and internalizing values (behavior based upon an individual’s value system).

Does affective learning affect medical education? The answer is an unequivocal “absolutely” and via the “hidden curriculum”! Read several poignant examples(2-4) to realize how much of medical education is affected by the hidden curriculum. What about anesthesiology education, affective learning, and the hidden curriculum? There is a hidden curriculum in anesthesiology!(5-8) Professionalism is a pervasive aspect of affective teaching and learning, as well as the hidden curriculum in anesthesiology education.

[Teachers’ and students’] professional values are continuously exemplified and enacted in the course of medical education through role modeling, setting expectations, telling stories and parables, and interacting with the health care environment, not just in courses on ethics and patient–doctor communication.”(9)

While it is true that the vast majority of anesthesiologists are quite professional, consider that lapses may and do occur. Each time a disparaging remark is made about a surgeon by an anesthesiology attending, another anesthesiology resident learns what is the accepted (and implicitly expected) behavior of an anesthesiologist working with a peer surgeon. Any time an indigent laboring obstetric patient receives less attentive analgesic care than that provided a “private” patient, another anesthesiology resident learns what is the accepted (and expected, though unspoken) behavior of an anesthesiologist toward patients of differing socioeconomic status. Whenever a nurse working in the operating room is given instructions about patient care without being provided information about the patient context, another anesthesiology resident learns what is the accepted (and tacitly expected) behavior of an anesthesiologist working in a team mode with paraprofessionals.

Have you thought about how you model anesthesia patient care and professional interactions for residents? My brother, the psychiatrist, says his patients often “open their mouths to change their feet” and he recommends pausing before “putting one’s mouth in gear.” How have you taught anesthesiology without putting all of your effort into gear before considering the implications for the hidden curriculum? Your thoughts and advice about the hidden curriculum are very valuable; please tell us about them.

1. Krathwohl, D. R., Bloom, B. S., & Masia, B. B. (1973). Taxonomy of Educational Objectives, the Classification of Educational Goals. Handbook II: Affective Domain. New York: David McKay Co., Inc.
2. The Hidden Curriculum of Medical School
3. Lempp H, Seale C: The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. BMJ 2004; 329: 770-3
4. Reisman AB: Outing the hidden curriculum. Hastings Cent Rep 2006; 36: 9
5. Gaiser RR: The teaching of professionalism during residency: why it is failing and a suggestion to improve its success. Anesth Analg 2009; 108: 948-54
6. Rhoton MF: Professionalism and clinical excellence among anesthesiology residents. Acad Med 1994; 69: 313-5
7. Tetzlaff JE: Assessment of competence in anesthesiology. Curr Opin Anaesthesiol 2009; 22: 809-13
8. Waisel DB, Lamiani G, Sandrock NJ, Pascucci R, Truog RD, Meyer EC: Anesthesiology trainees face ethical, practical, and relational challenges in obtaining informed consent. Anesthesiology 2009; 110: 480-6
9. Cooke M, Irby DM, Sullivan W, Ludmerer KM: American medical education 100 years after the Flexner report. N Engl J Med 2006; 355: 1339-44

Additional references
1. Gaufberg EH, Batalden M, Sands R, Bell SK: The hidden curriculum: what can we learn from third-year medical student narrative reflections? Acad Med 2010; 85: 1709-16
2. Karnieli-Miller O, Vu TR, Frankel RM, Holtman MC, Clyman SG, Hui SL, Inui TS: Which experiences in the hidden curriculum teach students about professionalism? Acad Med 2011; 86: 369-77
About the Author

J. Lance Lichtor, M.D
J. Lance Lichtor, M.D. is a professor of anesthesiology and pediatrics at The University of Massachusetts Medical School. He is the web editor and an associate editor for Anesthesiology.

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