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Exposing the Hidden Curriculum Influencing Medical Education on the Health of Indigenous People in Australia and New Zealand: The Role of the Critical Reflection Tool

Ewen, Shaun DEd; Mazel, Odette; Knoche, Debra MPPM

doi: 10.1097/ACM.0b013e31823fd777
International Medical Education

The disparity in health status between Indigenous and non-Indigenous people in Australia and New Zealand is widely known, and efforts to address this through medical education are evidenced by initiatives such as the Committee of Deans of Australian Medical Schools' Indigenous Health Curriculum Framework. These efforts have focused primarily on formal curriculum reform. In this article, the authors discuss the role of the hidden curriculum in influencing the teaching and learning of Indigenous health (i.e., the health of Indigenous people) during medical training and suggest that in order to achieve significant changes in learning outcomes, there needs to be better alignment of the formal and hidden curriculum. They describe the Critical Reflection Tool as a potential resource through which educators might begin to identify the dimensions of their institution's hidden curricula. If used effectively, the process may guide institutions to better equip medical school graduates with the training necessary to advance changes in Indigenous health.

Dr. Ewen is interim director, Onemda VicHealth Koori Health Unit, deputy director, Centre for Health and Society, Melbourne School of Population Health, and associate dean (Indigenous Development), Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.

Ms. Mazel is program manager, Leaders in Indigenous Medical Education (LIME) Network, Onemda VicHealth Koori Health Unit, Centre for Health and Society, Melbourne School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.

Ms. Knoche is research fellow, Centre for Excellence in Indigenous Tobacco Control and Onemda VicHealth Koori Health Unit, Centre for Health and Society, Melbourne School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.

Correspondence should be addressed to Ms. Mazel, LIME Project, Melbourne School of Population Health, The University of Melbourne, Level 4 / 207 Bouverie St., Carlton, Victoria, Australia, 3010; telephone: (61) 3-83449160; e-mail:

First published online December 20, 2011

Medical schools' hidden curricula, as opposed to their formal or informal curricula, comprise the set of influences that stem from the structure and culture of the institutional environment. Such influences are underpinned by the understanding that medical schools are, as Hafferty1 describes them, “cultural entities and moral communities intimately involved in constructing definitions about what is good and bad medicine.” These are seen to have an impact on what is learned at medical school rather than what is taught. In this article, we have used the conceptual framework of the hidden curriculum2 (1) to better understand the influences that shape the teaching and learning about the health of Indigenous people (hereafter, “Indigenous health”) in medical education in Australia and New Zealand and (2) to stimulate discussion of the influence of the hidden curriculum in Indigenous health education by analyzing medical schools' feedback from the Critical Reflection Tool (CRT), described later in this article.

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The disparity in health status between Indigenous and non-Indigenous people in both Australia and New Zealand3 8 is a gap that, in Australia, sees an Indigenous person have a life expectancy that is, on average, 12 years fewer than that of a non-Indigenous person9 and, in New Zealand, approximately 9 years fewer.10 Both Indigenous populations, constituting 2.5% of the Australian population11 and around 15% of New Zealand's population,12 bear a grossly disproportionate burden of disease compared with their non-Indigenous counterparts.13,14 Whilst this disparity is a result of the complex interplay of historical, social, and environmental factors, a disparity also exists in the quality of care provided to Indigenous patients by health professionals.3 7 Broad curricular reform in medical education in the two countries, therefore, has the potential to advance the effectiveness of the health care provided.3,15,16 Australian and New Zealand schools of medicine and medical specialist training colleges, then, have an important role to play in developing solutions for educating a health workforce that is effective and responsive to the needs of Indigenous people.17

Efforts to address the disparity in health care outcomes through education have focused primarily on formal curriculum reform.18,19 Students have been exposed to lessons about Indigenous histories and cultures and to exercises that teach about communication, self-reflection, and issues of personal biases.20,21 Teaching approaches that include traditional didactic lectures and tutorials, Indigenous simulated patient sessions, case based learning, and teaching in Indigenous contexts have been used to try and optimize learning in Indigenous health.22 27

In tandem with formal curricular development, strategies for the recruitment and retention of Indigenous medical students have also been implemented to varying extents and play an important role in developing a health workforce that meets the needs of Indigenous people.28 30 In 2010, there were 161 Australian Indigenous medical students, making up 1.3% of the total of 12,785 Australian medical students.31 This contrasts with the total number of Australian Indigenous medical graduates, which was estimated to be 100 (0.2%) in 2006.32

There is little empirical evidence to support the claim that increased understanding by clinicians of the issues affecting the health of Indigenous people will contribute to improved health outcomes.23,33,34 We, however, argue that recognizing the influence of the hidden curriculum in Indigenous health education is essential to support formal curricular initiatives, and for lasting and systemic change. Through resources such as the CRT, medical schools have the opportunity to engage with and reflect on the influence of institutional structures and norms on their Indigenous health teaching and learning. We wrote this article to open up the discussion about the influence of the hidden curriculum by analyzing feedback from the implementation of the CRT.

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Formal Curricular Advances

In 2003, an audit of existing Indigenous health content in core medical curricula across all 12 medical schools in Australia (there are currently 18 in Australia and 2 in New Zealand)35 was undertaken through the Committee of Deans of Australian Medical Schools' Indigenous Health Curriculum Development Project (hereafter, “Indigenous Health Project).”36 The audit informed the development of a binational Indigenous Health Curriculum Framework,19 which focuses on key subject areas, learning objectives, and key pedagogies, touching on the institutional reforms and approaches needed to support them. The suggested subject areas for Indigenous health teaching in the framework are history; culture, self, and diversity; Indigenous societies, cultures, and medicines; population health; models of health service delivery; clinical presentations of disease; communication skills; and working with Indigenous peoples—ethics, protocols, and research.

The framework was endorsed in August 2004 by the Committee of Medical Deans, later named Medical Deans Australia and New Zealand (MDANZ); and was the first of its kind to be endorsed across schools in the health sciences in those countries. In 2006, the Australian Medical Council (AMC) embedded the framework within its set of standards for basic medical school accreditation for both Australia and New Zealand.37 Frameworks similar to this have since been developed, adopted, and implemented in Canada38,39; also, in both the United States and Canada, the Liaison Committee of Medical Education's standards for accreditation of medical education programs include standards on cultural competency.40 Whilst our focus in this article is on Indigenous health specifically, there is often an overlap between Indigenous health and issues of cultural competency that might apply to other minority groups.33

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The Hidden Curriculum

Formal curriculum developments are an important part of improving and strengthening the training of medical professionals in the health and well-being of Indigenous peoples, yet there are a number of challenges that educators face in effectively achieving these goals that stem from the overarching culture of medicine and medical schools.1 Increasingly, research has focused on the need to consider the wider “educational, structural and cultural processes” that have an impact on educational outcomes, of which changes to the formal curricula contribute only one part.41 43 Below, we consider one of the most important of these wider processes, the hidden curriculum.

Hafferty and Franks44 applied the examination of complex curricula to medical education, identifying three influential dimensions in the learning environment: the formal curriculum, the informal curriculum, and the hidden curriculum. The formal curriculum represents the “stated, intended, and formally endorsed curriculum,” the informal curriculum is “an unscripted, predominantly ad hoc, and highly interpersonal form of teaching and learning that takes place among and between faculty and students,” and the hidden curriculum is the “set of influences that function at the level of organizational structure and culture.”1,45 It is the latter set of influences that we will explore in relation to the teaching and learning of Indigenous health because, as Hafferty and Franks44 describe:

what students learn about the core values of medicine and medical work takes place not so much in the content of the formal lectures but rather between the blackboard and the pen, not so much at the bedside but via its more insidious and evil twin, “the corridor.” It is time medicine started claiming ownership of both realms.

In practical terms, the hidden curriculum can be defined as the unwritten “rules, regulations and routines” of the institutional environment.46 It draws our attention to the commonly held understandings, rituals, and taken-for-granted aspects of the overarching environment of medical education and medical institutions as both cultural entities and moral communities that are constantly defining what is important and what is not.44 As Martin47 identifies it, “[a] hidden curriculum is not something one just finds; one must go hunting for it.”

Hafferty and Franks44 suggest that what students internalize in terms of the “values, attitudes, beliefs, and related behaviors deemed important within medicine” takes place through this more latent curriculum, which is more “concerned with replicating the culture of medicine than with the teaching of knowledge and techniques.” Bourdieu48,49 identifies the concept of the habitus, which in this context represents the social structure that students inhabit (the medical school) and, through their engagement with it, gradually adopt its values. Roberts et al50 extend the idea of the hidden curriculum. In a study of barriers to learning about culture, race, and ethnicity, they found that students recognize that conformity raises the chance of success and nonconformity slows progress and might lead to exclusion or failure.50 Although those students thought that cultural diversity was important, they believed medical schools marginalized and failed to adequately support effective teaching in the area. However, students also claimed that medical school was an inappropriate place for teaching about culture and that it was not of central relevance to biomedicine.50 A similar finding was published by Phillips36 in a national audit of Indigenous health curricula in medical schools in Australia. These varying standpoints might be understood through the concept of habitus, or the influence of the hidden curriculum, where students, in order to succeed, conform to what they experience as the dominant values of the institution. Resistance to learning about some issues occurs because students value only curricular content that is supported by the institution's dominant tacit values, to which they must aspire in order to achieve.

Although formal learning is important, it is the hidden curriculum that provides insight into the influences on student behavior.50 Potential for learning is optimized when the two are aligned; however, the problem is that this is not always the case.44 Hafferty1 suggests four areas for researchers to explore when examining the presence, or analyzing the impact, of the hidden curriculum: institutional policies, evaluation activities, resource allocation, and institutional “slang.” In the next section, we will first describe the development of the CRT51 and then analyze its relevance as an instrument for explicitly identifying the four areas used by Hafferty to explore the hidden curriculum in Indigenous health education.

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Following the development of the Indigenous Health Curriculum Framework, and building on the work of the Australian Indigenous Doctors' Association's Healthy Futures Report28 and the AMC accreditation guidelines,37 the CRT was developed, piloted, and trialed in 2007 by the staff of the Indigenous Health Project at the Onemda VicHealth Koori Health Unit with the assistance of a working party on behalf of MDANZ.51

The purpose of the CRT is to support Australian and New Zealand medical schools as they internally review their efforts to implement their Indigenous health curricula and initiatives for the recruitment and retention of Indigenous medical students.51,52 It was designed to address the broader contextual issues that have an impact on these areas, and it aims to encourage critical reflection and stimulate discussion. The CRT consists of eight categories, or areas for reflection: the context of the medical school, the outcomes of the medical course, the medical curriculum, teaching and learning, assessment of student learning, the curriculum—monitoring and evaluation, Indigenous students, and implementing the curriculum.

Through encouraging a whole-school engagement—including the dean, faculty managers, curriculum developers, teachers and tutors, and academic, professional, and administrative staff—and the use of practical examples, the CRT supports medical schools to identify the drivers for and barriers to change in Indigenous health education. The CRT takes into account the divergent medical school structures and the need to engage schools at various stages of development with respect to Indigenous health. Without explicit reference, the CRT provides an opportunity for medical schools to reflect on the elements and influence of the hidden curriculum. A similar tool has since been developed in Canada,53 and, in the United States, the tool for Assessing Cultural Competence Training is used to measure the impact of cultural competence education in the health sciences.54,55

A trial of the CRT was undertaken from October 2007 for quality assurance, to evaluate the effectiveness of the content of the tool, and to assist with its future development. All medical schools in Australia and New Zealand were invited to participate and provide feedback via survey. The surveys were sent to the dean of each school. Twelve out of a possible 20 medical schools participated in the trial, and the results were collated in late 2008. Responses were generally from those working in the Indigenous health stream. Subsequent to the trial, all medical schools were sent a follow-up survey in 2011, with six schools responding, one of which had not previously used the CRT. A number of the participants in the follow-up survey were involved in the trial in 2008.

We thematically analyzed the written comments from the 2007 trial and the 2011 follow-up survey. The interpretation of results was assisted by the ongoing input from a broader reference group of the Indigenous Health Project, composed primarily of medical educators in Indigenous health. A selection of deidentified responses, as they pertain to and inform the understanding of the hidden curriculum, are included in the following section.

Ethical approval to seek views of participants in the trial and subsequent survey about their reflections of the utility of the tool was granted by the Melbourne School of Population Health, Human Ethics Advisory Group, University of Melbourne.

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The CRT is a tool that supports medical schools to “[c]reate structures that allow individuals to reflect on the larger structural picture of which they are a part.”1 Emergent themes from the trial and subsequent survey were consistent, with overall feedback being positive and supportive of its purpose, content, and use. Comments consistently highlighted the tool's use in revealing the elements of the hidden curriculum that Hafferty identifies, but they also provided insight into the limits of Hafferty's approach. Hafferty's four areas of influence in relation to the hidden curriculum were used to analyze the results, discussed below.

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Institutional policies

The values and culture of an institution are expressed throughout medical school policies. They are evident in faculty and student handbooks, procedure manuals, and admission and recruitment brochures.46 They are also expressed tacitly in the ways schools are structured, their modes of operation, and how they convey key messages about what is valued by the institution and what is not.1 The CRT provides schools with the opportunity to critically analyze factors such as the aspirations of the medical school as articulated through mission statements, relationships with Indigenous health units (if they exist), relationships with local Indigenous communities, and the details of the curriculum and Indigenous student recruitment strategies.

An important element of the CRT is that it is designed to encourage the coordination of a whole-school engagement (explained earlier). In this way, it seeks to engage all of those people involved in making the decisions and developing policies that have an influence on the Indigenous health agenda and, in so doing, considers the social structures of the institution.45 However, the guidelines for the use of the tool are not prescriptive, and, in many instances, the CRT was completed by an individual or the Indigenous health unit rather than through the suggested whole-school approach. In those schools that demonstrated limited buy-in, many found it arduous, with responsibility falling to those who already have expertise in the area or who are already doing the majority of the work. A faculty member at one of the schools told us that

getting broader school engagement and ownership is a significant barrier. Whilst there is some utility for individual reflection, the CRT is more appropriate as a shared experience—There is enough solo action in Aboriginal health education!

Our main finding was that the utility of the tool was contingent on the process undertaken. The most positive responses aligned with processes that were executive-led and whole-school in approach—for example, through negotiation between faculty executives and the medical education unit, joint review involving the director of the medical education unit and senior Indigenous health staff, or a whole-school planning day. In these circumstances, a strong commitment was expressed about the future use of the tool. As one staff member stated,

I have been extremely fortunate that the associate dean of teaching and learning is 100% on board and the expectation clear that all staff will follow suit. It is also helpful that we have our commitment to the CRT as part of our mission statement.

Another remarked:

We have found the CRT invaluable. It has given us clear direction and at this stage there are no barriers as the key staff are on board.

Both the positive and negative comments reveal the importance of institutional policies and the structures needed to support curriculum reform. The breadth of comments included factors such as staffing, level of commitment from the faculty, effective communication, and the relationship between the Indigenous health unit and the broader faculty.

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Evaluation activities

Evaluation tools are not just instruments of assessment, as Hafferty1 notes, but are also vehicles for conveying what is and what is not important within the organization. The implication of the absence of evaluation activities, which include issues of staff promotion and tenure, accreditation reviews, and areas of research foci,25,41 is that Indigenous health has become marginalized or devalued and other areas of knowledge deemed more important, thus contributing to a negative shift in student attitudes.50

The CRT was seen as useful in identifying the importance of evaluating activities associated with Indigenous health and guiding the processes necessary to achieve this. A staff member of a medical school noted that the CRT

provided a framework for a more detailed focus on key aspects of developing, implementing and evaluating our school's approach to Indigenous health.

Others commented that the tool was useful in planning the curriculum in a strategic way. For example,

It was a [whole-school] exercise, useful in terms of plotting a way forward, based on what had, or had not, worked in the past. It was a useful rallying point, in terms of gathering together sometimes disparate interests in terms of constructing a curriculum.

The CRT engages the medical school to consider whether it has a process to ensure that the coordinated design, delivery, and evaluation of the Indigenous health curriculum is currently being undertaken.51(sections 3A, 5A, 6A)

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Resource allocation

The availability and distribution of resources shapes what faculty and students learn about institutional mission and organizational values, especially in an environment where “needs always outstrip resources.”1 Teaching of Indigenous health requires adequate human resources and coordination and must be assumed as part of the core responsibility of the school and reflected as such in budget allocations.19 The CRT helps to identify the need for adequate resources to implement and evaluate Indigenous health. Also, a faculty member stated that

assuming dedicated, ongoing resources are allocated to developing, implementing and evaluating an Indigenous health strategy within the school, the CRT could become a useful barometer of progress, and highlight key areas requiring more progress.

The CRT asks schools to look at the allocation of human resources to the coordination and implementation of the Indigenous health curricula as well as student recruitment and retention. It asks whether staff are specifically employed to teach Indigenous health, how those teaching positions in Indigenous health are funded, whether they are adequately resourced, and what scholarships are made available for Indigenous students.51(sections 1C, 1F, 7E)

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Institutional “slang”

Understanding the use of slang as applied to Indigenous people by students and faculty can help overcome stereotyping and help minimize the use of “othering,” where a group is defined as different from the norm and therefore subject to being labeled, marginalized, and excluded.56 Understanding slang involves looking more closely at the use of language in Indigenous-specific cases to see how value is attached to identity and/or behavior.57 The subtle (and sometimes not so subtle) messages conveyed via slang can work either to marginalize or to value Indigenous health issues and to work for or against the efforts made in terms of changes to the formal curriculum.

Institutional slang is an area that is not directly addressed in the CRT, although it does support schools to consider activities that might influence how issues of stereotyping might be overcome51(section 1E) and highlights the need for Indigenous staff that would also have an impact in this area.51(section 1C)

Overall, the responses to the trial and reflections in the interviews indicate the difficulties of navigating complex organizational structures, but they also reveal much about the hidden curriculum, as captured in the following statement by a faculty member:

As experience suggests, the process of developing and implementing an Indigenous health strategy within a medical school requires a “champion” to drive it. Without this, any momentum gained is quickly lost and the entire venture can flounder…. A [whole-school] approach is a great idea in theory but to achieve this in practice requires committed time and resources to develop cultural capacity, knowledge, and awareness, often via a process of continuous education, self-reflection, and “leading by example.” One of the major challenges is sustaining this over time.

Analysis of both positive and negative responses received highlights the importance of the institutional environment, the need for ongoing evaluation activities, and the need for adequate resources for the development and implementation of Indigenous health initiatives within the medical school, all aspects that Hafferty engages in with regard to the hidden curriculum. They show that the CRT can play an important role in uncovering elements of the hidden curriculum and identifying what is working well and where improvements can be made. The greatest barrier, however, remains an essential part of the hidden curriculum, which is how institutions and the leadership within those institutions engage and value Indigenous health.

At its most basic level, the CRT may be illuminating, and, at its best, we believe it can be used as a catalyst for reform to inform the significant changes that schools have to make to ensure that Indigenous health becomes a valued part of the school environment. Whilst a framework for uncovering elements of the hidden curriculum is important, we maintain that more is needed to ensure that actions are undertaken. Consideration of the role of accreditation in further developing and enhancing approaches to Indigenous health may be useful in this respect.

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The Value of the CRT

The CRT provides a structured, systematic approach that supports organizational reflection, creating an opportunity to review and reform not just the formal curriculum but also hidden curricula regarding Indigenous health education. By engaging with the CRT and applying Hafferty's framework, the consistency between the hidden and formal curricula can be analyzed, and steps can be taken to ensure better alignment.

In aiming for excellence in teaching and learning regarding Indigenous health, the challenge for medical schools is to reconfigure their operations, policies, and activities in a way which is consistent with planned teaching and learning outcomes.58 If schools are to recognize and acknowledge their hidden curricula regarding issues of Indigenous health, they will require an approach in which those engaged in developing, implementing, and managing the curriculum come together to do so.

The CRT provides that approach: It is a resource through which educators might begin to identify the dimensions of their institution's hidden curriculum. If the CRT is used effectively, it can guide institutions to foster the advances being made through the formal curriculum by helping ensure that the teachings regarding Indigenous health are, in fact, being carried through to learning, and that the formal and hidden curricula are aligned. In this way, broad curricular reform may start to have an impact on the quality of care provided to Indigenous patients and improve the health status of Indigenous people.

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The authors thank the working party and the members of the Leaders in Indigenous Medical Education (LIME) Network, whose commitment and ongoing input to Indigenous health curriculum and the CRT has contributed to furthering the reform agenda discussed in this article.

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Other disclosures:

The Indigenous Health Project (2004–2007) and LIME Network (ongoing) are projects of the Medical Deans Australia and New Zealand supported by the Australian Government Department of Health and Ageing.

Author Debra Knoche was employed in the Medical Deans Indigenous Health Project in 2007 as the Project Officer responsible for the development, pilot, and trial of the Critical Reflection Tool.

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Ethical approval:

Melbourne School of Population Health, Human Ethics Advisory Group, University of Melbourne. Application number: 1135820.1.

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Previous presentations:

A preliminary version of this article was presented at the ANZAME Conference: Overcoming BARRIERS, RE(E)Forming Professional Practice, Townsville, Australia, July 2010. The findings of the CRT trial were presented at the LIME Connection III Conference, Melbourne, Australia, December 2009.

© 2012 Association of American Medical Colleges