In this issue of Academic Medicine, Lawrence and colleagues provide a thought-provoking scoping review of hidden curricula and medical education.1 They address the hidden curriculum (HC), which for the past quarter century,2,3 has been deployed as an analytic tool across the full range of clinical and nonclinical contexts and processes that make up the learning environments of health professions education. In this Commentary, galvanized by Lawrence and colleagues’ data and conclusions, we address four issues. First, we tackle the review’s finding that “the term seemed to lack a distinct and universal definition,” along with related concerns as to the impact of such “ambiguity” on a variety of methodological and conceptual issues—all leading to a remedial call for more definitional uniformity regarding the HC, a conclusion we challenge on particular grounds. Second, we document the existence of a hidden HC literature and ask how best to deal with work that uses an HC-like analytic framework or that examines HC effects, yet never directly mentions the term. At minimum, the existence of this hypogean literature has implications for what is “scoped” in scoping reviews. Third, we touch on two publications closely linked to Lawrence and colleagues’ review. The first, a critique of the HC by MacLeod,4 is the self-identified raison d’être for Lawrence and colleagues’ scoping review. The second, an HC scoping review by Martimianakis and colleagues,2 is mentioned early in Lawrence and colleagues’ review only to disappear without further mention. This early disappearance is regrettable because both reviews explore the same concept, but from different vantage points and with somewhat different conclusions—differences we seek to accentuate. Finally, we tackle issues of “theoretical fidelity” and how a theoretical framework developed within one scholarly tradition or paradigm (such as the HC) might undergo conceptual mutation when imported into another domain of scholarly work, and what such transmutations might say about (and how they may benefit) the culture that generates these alterations.
A Rose by Other Names
The conclusion that the HC suffers from “ambiguous and seemingly ubiquitous use,” along with recommendations to curb such lexiconic excesses by moving to a more uniform definitional foundation, is central to Lawrence and colleagues’ review. We support, yet also take issue with, different aspects of their underlying findings. We concur with Lawrence and colleagues’ conclusion that learning environments are composed of a multiplicity of hidden curricula, which, together with the formal curriculum, form a complex web of interactions and influence. We also agree that use of the singular (“hidden curriculum”) may obscure this important structural fact. Nonetheless, and now speaking theoretically, we believe the concept does not, and never has, implied singularity. Instead, its ontological roots demand an epistemological approach that specifically assumes temporal and spatial diversity. Thus, while the phenomenon of the HC is ubiquitous and can be referred to in the singular, its manifestations are expected to be numerous and dynamic. A similar conclusion, generated around measurement issues, has been noted repeatedly by Haidet and colleagues.5,6
We also agree that scholarship employing the HC concept (singular or plural) needs to define what is being examined. As such, we were encouraged (not discouraged) to discover that only (our “only”) 21% of the articles in Lawrence and colleagues’ review (41 of 197) “did not include a direct definition for the term ‘hidden curriculum’” and that even less, 17% or 33, of the included articles used the concepts (hidden and informal) as synonyms. Given the article’s conclusions, we thought the percentages would be higher. We also did not locate data in Lawrence and colleagues’ scoping review supporting the conclusion that this 17% was due to an “increasingly blurred” line between these two concepts.
Third, we agree with Lawrence and colleagues that the landscape of medical education scholarship is littered with HC nomenclature. One of us (F.W.H.) keeps a running log of terms encountered in his HC work. To date, this list includes 9 terms that are used to refer to the “formal” curriculum (e.g., “official,” “manifest,” “codified”) along with a breathtaking 29 covering the other-than-formal aspects of learning environments.7 The central issue for us, however, is not the proliferation of terms but, rather, (1) how they are applied; (2) what issue(s) they address; and (3) whether the term(s) in play is adequately defined. Although we see no real definitional distinctions among the 9 formal terms (and thus have little issue with their interchangeable use), we do see substantial differences among the 29 “other-than-formal” framings. As noted by Lawrence and colleagues, there are important distinctions between the informal curriculum and the HC—as well as additional dissimilitudes across other concepts, including, for example, the null curriculum.2
In contrast to Lawrence and his colleagues, however, we find the use of alternate or alternative HC framings to be conceptually energizing and enriching. Also, importantly, we believe the other framings have important implications for scoping reviews. In speaking to both points, we turn to two studies: one that “made it” into Lawrence and colleagues’ scoping review and one that did not. The former, a study by Balmer and colleagues,8 sought to understand how “medical students navigate the interplay of explicit curricula, implicit curricula, and extracurricula to learn curricular objectives.” The latter, an equally provocative study by Ginsburg et al,9 sought to understand how the “disavowed curriculum” influenced students’ reasoning in professionally challenging situations.
Why did Balmer et al employ the terms “explicit,” “implicit,” and “extra,” and why did Ginsberg and colleagues turn to “disavowed?” Although we do not pretend to speak for the authors, we assume that the respective concepts allowed the authors to explore optimally the issue(s) they wished to investigate and, in so doing, best express what they thought the data revealed. The issue before us, however, is whether, in selecting the terms they selected, the authors took us down a garden path of bewilderment. We think not. Instead, we believe that these authors enriched our collective understandings of the “systematic side effects”10 and the “unanticipated consequences”11 of highly institutionalized and routinized educational practices. Insisting that Balmer et al and Ginsberg et al draw from a more restricted set of concepts is not an answer we would endorse. There can never be a singular understanding or truth about HC phenomena.
Finally, in spite of the fact that Balmer and colleagues’ study8 was captured in this scoping review (because of its use of “implicit” as a category label) and Ginsburg and colleagues’ study9 was not (because it eschewed all of the three trigger terms: hidden, implicit, informal), we consider both to be “HC studies”—a conclusion which not-so-incidentally makes Ginsberg and colleagues’ study a false negative in terms of Lawrence and colleagues’ review.
The preceding paragraph brings us to two important qualifications and related arguments. First, not all studies of HC phenomena need to use the term “hidden curriculum” (or curricula) to fall within this general theoretical and methodological framework. For example, we would consider it appropriate, as well as conceptually enriching, to imagine a study on workarounds to be an HC study, even when it is abundantly clear (from the study) that all participants share understandings that their alternative solution to a group problem stands outside the boundaries of what the formal rules say should be taking place. The intersubjectivity generated from the pursuit of this type of deviancy relates to implicit understandings of how far and in what contexts social actors can bend the rules without compromising their social standing. All we would ask, in this hypothetical example, is that the fictional authors refer to the micro social interactions of executing the workaround as “informal” rather than “hidden.”
Second, and related, we, like Lawrence and his colleagues, have encountered studies of social practices that are more informal than hidden even though the investigators have marqueed the project as an “HC study”3; however, this practice does not change the fact that the concept—as noted above—can function as a general organizing framework and a heuristic devise for thinking about and methodologically exploring the potential for disjunctures between formal and other-than-formal social processes.3 How this exploration takes place and how particular nuances of the phenomenon are labeled, we argue, should be varied. The complexity of social dynamics warrants such disparateness and diversity.
The Hidden HC Literature
Given our preceding discussion, we invite readers to consider the case of hidden HC studies—and to do so along three vectors. First, and illustrated by Ginsberg and colleagues’ study,9 pertinent studies might not be included in a given scoping review by virtue of having used an aberrant, alternative, or preternatural concept. The call by Lawrence and colleagues to restrict the range of concepts deployed would, in our view, fuel a loss of conceptual richness. We believe a field’s conceptual growth is facilitated—rather than limited—by an ongoing comparison of theoretical constructs, including the articulation of their limits and applicability in different contexts.
A second type of hidden HC literature has been mentioned elsewhere3 and consists of work that for all apparent purposes stands outside the genre altogether. Campbell and colleagues’ national survey of professionalism in medicine12 is an example. Among their findings, the authors note that although physicians “generally agree with proposed professional norms,” their “reported behavior … did not always conform to those norms.”12 Although this finding has direct HC implications, the authors did not deploy the HC as a concept, nor did they extend its discussion to issues of medical education, to role modeling as a form of cultural transmission, or to related issues such as professional identity formation, socialization, and the learning environment. Might they have legitimately done so given their data? Absolutely. Nonetheless, they did not, and this is why this study is a “hidden” HC study. It also is a study, along with others,13,14 that would not be captured by a traditionally organized (i.e., keyword-based) HC scoping review.
Even researchers intimately familiar with the HC concept, including those who have used it elsewhere, can forego its use when they feel their arguments are best served by doing so. In our view, Wear’s analysis15—of how PowerPoint slides, competencies, and screen reading constitute a “perfect cognitive storm” within medical learning environments—is an HC article, particularly given how Wear frames her problem and interprets her data. Like Campbell and colleagues’ study,12 Wear’s analysis would not be captured by a traditionally organized (i.e., keyword-based) HC scoping review—even as other (and more formally tagged) articles by Wear16,17 made the cut for Lawrence and colleagues’ scoping review. We believe that researchers who are interested in the underlying distinction between formal versus other-than-formal dimensions of social life need to keep an open “scoping mind” when encountering “Campbellesque” and “Wear-like” studies, which cannot happen if they believe that the only HC articles that can exist are those formally labeled as such.
Third, there is a wealth of theoretical frameworks and conceptual tools that precede—yet continue to surround—work on the HC. Although the medical education literature tends to trace the HC to earlier work in the field of education, the concept has more proximal linkages to the field of sociology, in particular to the Cambridge (Massachusetts) academic community. The earliest HC reference we are aware of is a 1965 report/publication by Fred L. Strodtbeck,18 a Harvard PhD, whose study of “the hidden curriculum in the middle class home” was followed by a scattering of Harvard theses and dissertations during the early 1970s.3 Meanwhile, a mile and a half down Massachusetts Avenue, Massachusetts Institute of Technology (MIT) professor Benson Snyder19 began collecting data in the 1960s that would form the basis of his comparative analysis of student learning strategies at MIT and Wellesley College—something he titled The Hidden Curriculum. More proximal still are the HC’s ties to sociological works by several Harvard students and faculty, including Robert K. Merton’s (1936) theory of unanticipated consequences11 (published as a Harvard graduate student), his later work on manifest versus latent function,20 and his landmark study on the sociology of medical education (The Student–Physician),21 in which he introduced his concept of role modeling, a vehicle widely identified within contemporary medical HC scholarship as core to the transmission of informal and hidden curricula. In 1961 (and this time three miles to the north), former University of Chicago sociologist Everett C. Hughes arrived at Tufts University. Hughes’ early studies on nursing education,22 which highlighted the gap between “formal instruction” and “ward experience,” would help form the basis for nursing education’s long-standing focus on the “theory–practice gap”23—a concept with strong conceptual linkages to the HC. Not so incidentally, Hughes also mentored the research team that would carry out the second major study of medical education in the late 1950s and early 1960s, Howard Becker and colleagues’ Boys in White.24
Our overall point is one of contextual sensitization and inclusiveness. Although one can learn a great deal about the HC by limiting oneself to works that explicitly identify or expressly label the HC, one also can learn too little. A wealth of work within the social sciences, education, and nursing that is HC-like and HC-informing contributes to our understandings of the dance between formal and other-than-formal dimensions of learning specifically, and social life more generally.25 Although we concur with Lawrence and his team and MacLeod4 that researchers should define their terms and clearly operationalize their variables, we do not feel that restricting the conceptual lexicon is a solution to the problems identified by these authors.
Two Key Articles
As noted above, the MacLeod4 article stands as the authors’ self-identified raison d’être for their scoping review. We thus revisit this article to better outline why and how we depart from the conclusions drawn by Lawrence and coauthors. In seeking to problematize the concept, MacLeod raises a number of provocative issues, including the following: (1) how a once “radical” and “revolutionary” concept may have become “commonplace” over time; (2) whether a phenomenon once hidden, but now “handily recognized,” should be categorized as either “informal” or perhaps even part of the formal educational landscape; (3) how the singular (hidden curriculum) is a misnomer, and that what we seek to analyze is best conceptualized as multiple “hidden curricula”; and (4) what she identifies as her most important issue, “the consequences of naming a particular practice ‘hidden’”—including how such a label might “allow us to disavow ourselves of responsibility” for action. We agree with all of the above. We are particularly intrigued by the last issue, how the labeling of something as “hidden” might elevate it to the status of untouchable or even nonexistent. In addition to the issues MacLeod raises, we also ask, Who has the power to label something “hidden” as out-of-bounds, and who benefits from such practices? What kinds of privilege and power are (re)produced in this process? Indeed, we would argue that the act of rendering something “untouchable” through micro processes can be studied as an HC effect. In line with her other arguments, MacLeod concludes that “we in medical education have done a superb job in identifying the problematic [HC] practices,” and thus, she continues, today’s need is to address the long list of “pervasive educational issues—the things that really aren’t so hidden.” Alternatively, we wonder if what has been targeted thus far, along with related remedial efforts, reflects privilege? Do the more fundamental issues of power and privilege within health professions education continue to lie undisturbed and unchallenged?
A conclusion that the pervasive use of the HC concept signals the need to deconstruct how the term is implicated in broader sociopolitical relations (rather than a call to banish the term altogether) might have allowed the Lawrence team to bridge the MacLeod4 article and Martimianakis and colleagues’ scoping review.2 The Martimianakis team2 identified 200 articles published in six medical education journals that explicitly or implicitly linked the HC construct to physician humanism. In contrast to the Lawrence team, however, they included articles that referenced the phenomenon of the HC even if the authors did not deploy a specific HC definition. By moving beyond a traditional taxonomic approach (which is consistent with scoping reviews), and by applying critical discourse analysis and thematic analysis techniques, Martimianakis and her coauthors were able to treat the texts in their review as data, and thus chart the educational effects of linking the construct of HC to ideas of humanism. In the process, they identified a strong preoccupation with the moral erosion of physician teachers that results in negative role modeling. These perceived attacks to humanistic care resulted in the privileging of certain types of interventions/responses over others—namely, reforms targeting problematic behaviors of medical students and faculty members—but with very little consideration for how organizations, institutions, and broader sociopolitical relations might give rise to such problematic behaviors. This overemphasis on regulating the behaviors of students, other trainees, and faculty has contributed to the conflation of professionalism and humanism26 along with an underappreciation of how and why workplace interests reflected in health economics, politics, and practices become misaligned with(in) educational ideals. In conclusion, Martimianakis and colleagues2 challenge health professions educators to consider how the deliberate disentanglement of professionalism issues from humanism issues might contribute to a different kind of HC study and educational reform, one that begins by acknowledging that medical training does not happen in a sociopolitical vacuum.
The Challenge of Theoretical Conversion(s)
This brings us to our concluding point. The scoping review by the Martimianakis team2 makes visible how the HC construct has undergone a degree of conceptual mutation as it has become increasingly deployed within medical education research. What once (within education) focused predominantly on social structural and systems-level interventions underwent a relatively undetected remodeling as remediation efforts within medical education began focusing on individuals and their ability to manifest resilience to pernicious influences. This transmutation is similar to one reported by Ng and colleagues27 on how the discourse of reflection within medical education has become “divorced from original theories of reflection and reflective practice.” Similarly, Ritz and coauthors28 document not only how the concept of social accountability has undergone a “marked diversification” in its meaning (including a conflation with terms like “social responsiveness” and “social responsibility”) but also how it has become elevated “to a realm of discourse where it appears to have an independent existence … beyond the realm of critical analysis.” Finally, in a broadly framed argument, Varpio and colleagues29 detail how keeping a methodological framework or theoretical concept intact when it is being expropriated from one discipline to another is nigh impossible.
In raising this issue of transmutation, we again reach back to MacLeod,4 first to her distillation of the HC concept as a problem, and then to her “therefore” concern that HC has “run its course.” Although we unabashedly endorse MacLeod’s predilection to problematize, our concern is with the possibility (as suggested by Martimianakis and colleagues2) that what is problematic is the concept’s biased-by-privilege application rather than the concept itself. That is, medical educators are more likely to focus on regulating behaviors of learners and teachers rather than exploring how structural or institutional arrangements such as health resourcing issues, including how physician remuneration is set up in relation to other professions, may contribute to unprofessional behaviors in the workplace.
In all the examples we have shared thus far, we view medicine as a force field of considerable cultural influence, and thus a field that can “bend,” reshape, or otherwise distort how phenomena unfold inside its boundaries. Furthermore, we see this force field being exacerbated because of medicine’s fanciful belief that it is a “culture of no culture”30 and therefore a form of social practice that resides outside or above the more base, common, and subjective forces of culture. Recalling Ritz and colleagues,28 we see hegemony as self-deluding, self-reinforcing, and ultimately self-perpetuating.
Thus, and in the case of the HC and health professions education, the Marxist roots of the HC (and the corresponding focus on systemic inequities) largely have been invisible to a medical education audience because class struggles rarely have been part of medical education’s postpositivist starting points.31
Nonetheless, and in a point we wish to emphasize—even as the concept has also been “misapplied”—the HC (a product of the lost genealogy) has contributed to the development of a paradigmatic foundation for other critical forms of scholarship to take hold, including Marxist. Ng and colleagues,27 for example, introduce to a medical audience the tenets of institutional ethnography, a feminist methodology with strong Marxist underpinnings because it is grounded in the everyday lives and work of people. They start by explaining the concept of the “problematic” a cornerstone of institutional ethnography. They note that the problematic “is different from a research problem” because it “is not found in the extant literature, but within the social relations underpinning people’s work and experience.”27(p54) They go on to describe how the social relations underpinning people’s work and experiences “are often hidden from immediate view” and are part of a “complex web of local and extra local practices.” The application of institutional ethnography in medical education contexts is clearly comparable with the interests of scholars charting HC effects, for it enables researchers to move beyond the description of culture and structures to understanding how routine day-to-day practices affect curriculum delivery and learning. Combining the use of the HC construct with institutional ethnography signals potential to build and enhance what medical educators and scholars know about tacit and informal influences, a point demonstrated empirically by Webster and colleagues.32
Much of Lawrence and colleagues’ scoping review is admirable. The authors’ underlying methodology and the details they provide on article identification and analyses are a role model for other reviews. Also noteworthy is their discernment of four definitional domains (institutional-organizational, interpersonal-social, contextual-cultural, and motivational-psychological) for the HC, along with their mapping of these domains to four disciplinary lenses (respectively, policy, sociology, anthropology, and psychology). Within this context, we also endorse Lawrence and colleagues’ call for researchers to have some idea of the disciplinary and theoretical roots underscoring the research question(s)—HC focused or not—that they seek to address.
These four domains bring us to a closing enticement—always with an eye toward conceptual heterogeneity. What if the next HC scoping review abandons keywords such as “hidden,” informal,” and “implicit” (the basis for Lawrence and colleagues’ review) and, rather, seeks to explore and map the underlying conceptual landscape by applying disciplinary lenses such as (but not necessarily restricted to) those provided by Lawrence and colleagues? Our brief foray above into the sociological origins of HC thinking was an exciting excursion for us. We think other explorations might be similarly undertaken. Rabbit holes can be mind-expanding habitats. Just ask Alice.
In the end, those of us interested in working within an HC framework or interested in exploring HC phenomena must contend with two problematic words: “hidden” and “curriculum.” The first biases us toward the more implicit, unintended, and tacit sides of learning—even as we know that much of social learning takes place within an interstitial space between the formal and a range of other-than-formal domains of learning. The second restricts us—unduly we think—to the social institution of education. The social dynamics and structural architecture of learning extend far beyond the walls of what commonly comes to mind when we say the word “curriculum.” Perhaps there is a lesson in Strodtbeck’s18 1965 identification of an HC in the middle class home? Strodtbeck was concerned with the social advantages differentially and “almost unconsciously” acquired by children from middle class homes versus “children from the dependent poor.” What Strodtbeck was wrestling with, of course, was the issue of social capital—a term that had not yet made its way into the sociological lexicon. Alice would be pleased to thus observe us wrestling with how yet another construct (social capital) might interface with the HC, and thus how we continuously are challenged to resituate the HC within the magically expansive dance of social relationships, social learning, and social life.
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