Secondary Logo

The Hidden Curricula of Medical Education: A Scoping Review

Lawrence, Carlton; Mhlaba, Tsholofelo, MBChB, MMed; Stewart, Kearsley A., PhD; Moletsane, Relebohile, PhD/MsC; Gaede, Bernhard, MBBCh, MMed, PhD; Moshabela, Mosa, MBChB, MMed, PhD

doi: 10.1097/ACM.0000000000002004
Reviews
Free
SDC

Purpose To analyze the plural definitions and applications of the term “hidden curriculum” within the medical education literature and to propose a conceptual framework for conducting future research on the topic.

Method The authors conducted a literature search of nine online databases, seeking articles published on the hidden, informal, or implicit curriculum in medical education prior to March 2017. Two reviewers independently screened articles with set inclusion criteria and performed kappa coefficient tests to evaluate interreviewer reliability. They extracted, coded, and analyzed key data, using grounded theory methodology.

Results The authors uncovered 3,747 articles relating to the hidden curriculum in medical education. Of these, they selected 197 articles for full review. Use of the term “hidden curriculum” has expanded substantially since 2012. U.S. and Canadian medical schools are the focus of two-thirds of the empirical hidden curriculum studies; data from African and South American schools are nearly absent. Few quantitative techniques to measure the hidden curriculum exist. The “hidden curriculum” is understood as a mostly negative concept. Its definition varies widely, but can be understood via four conceptual boundaries: (1) institutional–organizational, (2) interpersonal–social, (3) contextual–cultural, and/or (4) motivational–psychological.

Conclusions Future medical education researchers should make clear the conceptual boundary or boundaries they are applying to the term “hidden curriculum,” move away from general musings on its effects, and focus on specific methods for improving the powerful hidden curriculum.

C. Lawrence is researcher, Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa, and medical student, Harvard Medical School, Boston, Massachusetts; ORCID: http://orcid.org/0000-0001-7507-5582.

T. Mhlaba is public health medicine specialist, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; ORCID: http://orcid.org/0000-0002-0178-2652.

K.A. Stewart is associate professor, The Practice in Global Health and Cultural Anthropology, Duke Global Health Institute, Duke University, Durham, North Carolina.

R. Moletsane is professor and J.L. Dube Chair of Rural Education, Department of Rural Education, University of KwaZulu-Natal, Durban, South Africa; ORCID: http://orcid.org/0000-0002-8493-7479.

B. Gaede is chair, Discipline of Family Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.

M. Moshabela is chair, Centre for Rural Health, and Discipline of Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa, and Wellcome Trust fellow, Africa Centre for Population Health, Mtubatuba, South Africa; ORCID: http://orcid.org/0000-0002-9438-7095.

Editor’s Note: An Invited Commentary by F.W. Hafferty and M.A. Martimianakis appears on pages 526–531.

Funding/Support: This study was supported by the South Africa National Research Foundation (grant number 90394) and the United States National Institutes of Health (grant number 5R24TW008863).

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Previous presentation: “Deconstructing the Hidden Curriculum in Medical Education: A Scoping Review.” Oral Presentation (delivered by Mosa Moshabela), Medical Education Partnership Initiative Symposium; August 2–4, 2016; Nairobi, Kenya.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A497.

Correspondence should be addressed to Carlton Lawrence, Centre for Rural Health, 4th Floor, George Campbell Building, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa; telephone: +27312601569; e-mail: carlton_lawrence@hms.harvard.edu.

Since its initial description in the 1960s and its application to medical education in 1994, the reach of the so-called “hidden curriculum” in medical education has continuously expanded.1–3 Frederic Hafferty originally defined the term with respect to medical education as the “set of influences that function at the level of organizational structure and culture.”4 He described the hidden curriculum generally as the “‘understandings,’ customs, rituals, and taken-for-granted aspects of what goes on in the life-space we call medical education” and viewed the hidden curriculum in medical education as an institutional-level concept best visible in “(1) policy development, (2) evaluation, (3) resource allocation, and (4) insti tutional slang.”4(p404) In the 20 years since this original conceptualization, researchers across the medical education spectrum have used the term to expose and explain a number of “hidden” facets of learning and teaching.5–8 The effects of what is described as the hidden curriculum are rarely innocuous and in fact, are, in many ways, more influential than the formal curriculum.4,9–11

According to recent studies, the hidden curriculum is responsible for any number of ills, from discouraging medical students from pursuing surgical specialties and encouraging inappropriate student mobile device use, to increasing medical school admissions biases.12–14 This vast and expanding use of the term has led some to doubt its continued utility in medical education. For instance, MacLeod questions the benefit of labeling the diversity and breadth of issues now categorized as hidden curriculum as such, writing: “What are the consequences of ‘lumping’ together a series of related but clearly disparate issues? What is brought to light and what is left invisible?”15(p540) MacLeod suggests that the medical education community shift from repeatedly identifying what she sees as no longer “hidden” issues to, instead, actively addressing these now-visible practices. She goes so far as to question the continued use of the term within medical discourse, writing that while the hidden curriculum has historically been a powerful tool for curricular innovation, now may be the time to retire it in favor of more actionable concepts.15 Also, Martimianakis and colleagues16 recently conducted a scoping review and explored the link between the hidden curriculum and humanism in medicine. Their valuable results show that the hidden curriculum is responsible for much of future physicians’ professional identity formation.16 Given this finding and MacLeod’s concerns, we believe that it is essential for researchers to understand how the hidden curriculum is defined and applied within the literature to enable more effectively categorizing or analyzing its effects. Thus, we conducted this scoping view to systematically analyze the definitions and uses of the term “hidden curriculum” in the medical education literature. Our ultimate goal was to provide a strategic and deliberate framework for using the term “hidden curriculum” in the future.

Back to Top | Article Outline

Method

We employed a rigorous scoping review methodology17 to map medical education’s “hidden curriculum” literature. Scoping reviews are used for a variety of purposes, including to examine the extent, range, and nature of research activity; to determine the value of undertaking a full systematic review; to summarize and disseminate research findings; or to identify gaps in the existing literature.17 This scoping review focuses on conceptual mapping, the process of establishing how a particular term—in this case “hidden curriculum”—is used in the literature. We observed that within the medical education literature the term seemed to lack a distinct and universal definition; this ambiguity and its effects on curricular understanding prompted us to adopt this “concept mapping” approach, which we felt would allow for more systematic interventions based on specific meanings, knowledge, and learning encompassed by the hidden curriculum.

The particular approach to and level of rigor of a scoping review is important, as the technique is not standardized.18,19 To ensure the reliability of our methods, we used the five-step approach originally described by Arksey and O’Malley17 and later refined by Levac and colleagues20: (1) identifying the research question; (2) identifying relevant studies; (3) selecting the studies; (4) charting the data; and (5) collating, summarizing, and reporting the results.

Back to Top | Article Outline

1. Identifying the research question

Our scoping review focused on answering the question, How is the term “hidden curriculum” understood within medical education? After conducting background research, we discovered that the terms “informal curriculum” and “implicit curriculum” are often used in conjunction with, or as synonyms for, “hidden curriculum.” Thus, we decided to include these terms in our analysis.

Back to Top | Article Outline

2. Identifying relevant studies

After considering our project goals and consulting our university-affiliated librarian, we drafted the following Boolean search query for our database search: (“hidden curriculum” OR “implicit curriculum” OR “informal curriculum” OR “hidden curricula” OR “implicit curricula” OR “informal curricula”) AND (“medicine” OR “medical”). Scoping reviews that aim to map global concepts such as the hidden curriculum must be comprehensive; thus, we scanned seven databases: PubMed, Scopus, Web of Science, ProQuest, ScienceDirect, JSTOR, and EBSCOhost (filtered to relevant results from ERIC, WorldCat, Academic Search Complete, OCLC ArticleFirst, and PsycINFO). We conducted the initial search on October 20, 2015, and a follow-up search on March 21, 2017. In addition, because of our placement in South Africa and the failure of some of the larger databases to include local journals, we decided to conduct direct searches of the African Journals Online database and the African Index Medicus. We did not limit the results by publication date, language, or study type at this stage.

Back to Top | Article Outline

3. Selecting the studies

We imported all the titles our search uncovered into EndNote software and deleted duplicates. Two of us (C.L. and T.M.) independently applied a screening tool to all retrieved article titles and abstracts to determine their eligibility for full article review. We used a kappa coefficient reliability test to determine the reliability of our screening tool. Because the initial test of 50 articles resulted in a kappa value of 0.78 (standard deviation [SD] = 0.151), which was below our goal of 0.90 (“almost perfect”),21 we refined the screening tool and conducted a second test on 100 new articles. That test yielded an acceptable kappa coefficient of 0.96 (SD = 0.0332), and given the new high level of reliability, we (C.L., T.M.) each independently reviewed all nonduplicative titles and abstracts for inclusion. After this review, all of us discussed any discrepancies and came to a consensus on which articles to include for full review.

Next, each of us read a designated number of the articles selected for full review. We each applied strict inclusion/exclusion criteria to determine eligibility. To be included in the data extraction sheet, each article needed to

  1. focus on and explicitly name the hidden, implicit, or informal curriculum,
  2. involve medical school curricula—not solely curricula from other disciplines such as nursing, science, pharmacology, or the like, and
  3. focus on students obtaining their medical degree, as that is understood in various countries (i.e., undergraduate medical education [UME] in the United States), and not exclusively on residents or fellows.

We excluded books, book reviews, commentaries, and letters to the editor, as well as non-English articles.

To confirm selection process rigor, we searched the bibliographies of 10 selected articles for the terms “hidden” and “informal.”22–31 The search recovered no new articles, providing further support of the rigor and comprehensiveness of our search protocol.

Back to Top | Article Outline

4. Charting the data

We employed Arksey and O’Malley’s17 “descriptive-analysis” approach to data extraction, summarizing information from the selected articles and recording the data in an Excel sheet (Microsoft, Redmond, Washington). This allowed us to analyze the selected articles through a common framework. We also followed Levac and colleagues’ recommendations for the data charting process.20 First, we collectively developed the data extraction form to include both demographic data (e.g., year of publication, location of publication) and thematic categories (e.g., definitions of key terms, effects of curricular reforms, conclusions). The review process was iterative; that is, we added and edited columns on our spreadsheet as necessary throughout the process.

Back to Top | Article Outline

5. Collating, summarizing, and reporting the results

We synthesized and collated various themes that emerged from the data extraction sheet. The extraction sheet informed both quantitative and qualitative results and became a platform for synthesizing various definitions and effects of the hidden curriculum. We used qualitative thematic analysis, based in the grounded theory process of descriptive coding,32 to generate the four conceptual boundaries (see Results). We extracted all the definitions of “hidden curriculum,” “informal curriculum,” and “implicit curriculum,” directly from the data on our extraction sheet. We generated open descriptive codes (i.e., organizational, institutional, interpersonal, interactions, norms, experiences, behaviors, socialization, outside formal, location, implicit, unintentional, culture, value) directly from the definitions in the articles. Next, as outlined by Saldaña,32 we synthesized these primary descriptive codes into coherent axial codes, grouping similar definitions (i.e., organizational/institutional/structure, interpersonal/interactions/socialization, location-based/outside of formal/settings related, intention-determined/implicit). The theoretical codes, presented below in the Results as the four conceptual boundaries, emerged from each of these axial codes. Next, we coded the selected articles a final time to examine them for the presence of any conceptual boundaries (nonexclusively) and to gather final frequency statistics.

Back to Top | Article Outline

Results

Descriptive summary

Our initial search uncovered 3,747 titles, of which 749 were duplicative. After applying our screening tool to the remaining 2,998 titles, we identified 197 articles to include in our final analysis (see Figure 1 and Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A497). Of these 197 articles, 121 (61%) were published after 2010, and only 14 (7%) were published between 1980 and 1999 (Figure 2). The bulk of the articles were either qualitative studies (n = 84; 43%) or perspective pieces (n = 71; 36%). Literature reviews (n = 17; 9%), mixed-method studies (n = 13; 6%), and quantitative studies (n = 12; 6%) each constituted less than 10% of the total.

Figure 1

Figure 1

Figure 2

Figure 2

Of the 109 empirical studies, over two-thirds (n = 76; 70%) were conducted in the United States or Canada or in Central America. Other settings included Europe (n = 18; 16%), Asia (n = 8; 7%), and Oceania (n = 5; 5%). Our search produced only two empirical studies from Africa (2%), despite including the continent-specific databases—African Journals Online and the African Index Medicus—in our search (see Table 1). The hidden curriculum is understood as deeply context and culture dependent, making this geographic gap problematic.26,33

Table 1

Table 1

Although much of the literature speaks generally of the hidden curriculum within UME, some authors focused special attention on certain topic areas, including the hidden curriculum in relation to palliative and end-of-life care,34–40 the surgical rotation,41–44 postmortem exercises,22,45–47 and attitudes toward marginalized or underrepresented groups.48–51

Back to Top | Article Outline

Identifying the hidden curriculum

Systematic techniques for identifying or categorizing the hidden curriculum were rare.52 Through this scoping review, we compiled a list of research methods used to study the hidden curriculum. The most commonly used quantitative tools were the Communication, Curriculum, and Culture (C3) Survey and the Patient–Provider Orientation Scale.53–56 Both of these tools, however, measure the hidden curriculum solely with respect to the patient centeredness of care and do not extend to other elements of UME.55 We noted that additional study- or site-specific surveys were employed in the three remaining quantitative studies,34,57,58 but we identified no other standardized measurement tool for assessing the hidden curriculum. This lack of standardization is likely due to the ambiguity of the definition of “hidden curriculum” across settings and among authors, which we discuss in depth below.

The majority of qualitative studies employed interviews and focus groups of medical students to explore their self-identified understanding of the hidden curriculum; however, some studies used non-institution-specific surveys such as Australia’s Critical Reflection Tool to analyze the informal elements of their curriculum.59 A number of investigators plumbed student and faculty reflections—written on paper and online—to find information relating to the hidden curriculum11,41,60–62; however, the effectiveness of these methods for identifying the hidden curriculum is dependent on the definition of the term itself, something that is up for debate.

Back to Top | Article Outline

Addressing the hidden curriculum

Through our review, we extracted any methods cited as effective in changing or preserving the hidden curriculum. The most common recommendation was that schools make the hidden curriculum explicit to both faculty and students.63–68 “Painful feedback,” one author’s term for the process of making the hidden curriculum visible, encourages presenting direct evidence of the harmful elements of the hidden curriculum to students and other stakeholders.69 Open discussion and self-reflection were also often encouraged.24,31,70–74 Chuang and colleagues75 state that separating curricular analysis at the individual, departmental, and institutional levels is necessary to ensure multilevel interventions. Encouraging small-group learning, patient-centered curricula, humanities education, and better integration of marginalized groups also had positive effects on the hidden curriculum.31,62,76–78

Back to Top | Article Outline

Ambiguity in hidden curriculum

We noted ambiguity in both the definition and application of the term “hidden curriculum.” Hafferty and Franks2 first described the term “hidden curriculum” in relation to medical education in 1994, and Hafferty4 later (1998) distinguished it from the “informal curriculum.” As mentioned, Hafferty4(p404) delineated the “hidden curriculum” as “a set of influences that function at the level of organizational structure and culture”; he felt the “hidden curriculum” included “the commonly held ‘understandings,’ customs, rituals, and taken-for-granted aspects of what goes on in the life-space we call medical education.” Informal curriculum for him, on the other hand, is an “unscripted, predominantly ad hoc, and highly interpersonal form of teaching and learning that takes place among and between faculty and students.”4(p404) In his understanding, the two terms are overlapping and influence one another but are not synonyms.

Through this scoping review, we found that the literature extends well beyond Hafferty’s original definitions. The search tool uncovered articles variously referencing the “hidden,” “implicit,” or “informal” curriculum. Specifically, of the 197 articles we fully reviewed, 156 included at least one of our key terms (see Table 1): “hidden” (n = 184; 93%), “informal” (n = 76; 39%), and “implicit” (n = 4; 2%). Using the extracted definitions from the articles, we were able to compare definitions across articles and map how each concept is defined in reference to the others. The most common and perhaps most alarming finding from this process was the ambiguous and interchangeable use of the terms “hidden” and “informal.” Of the 197 articles we reviewed, 17% (n = 33) included both the terms “hidden curriculum” and “informal curriculum” without providing distinct definitions; that is, the authors of these articles often treated the two phenomena as equivalent (we included these 17 articles both in our count for articles citing the “hidden curriculum” and in our count of articles citing the “informal curriculum). Four articles included the term “implicit curriculum,” and in 2 articles,23,26 the term was also used interchangeably with “hidden curriculum.” Some authors clearly see the hidden and informal curriculum as interchangeable, while others see them as distinct concepts.

Back to Top | Article Outline

Conflicting connotations of hidden curriculum

The term “hidden curriculum” is ambiguous and generally non-neutral.16 By extracting the effects of the hidden curriculum from the articles we reviewed, we found the literature often portrays the hidden curriculum as negative or intrinsically in conflict with the formal curriculum. Balboni and colleagues’ comments79 illustrate this sentiment: “We refer to the [hidden curriculum] as the process … which instills behaviors, attitudes, and values among trainees in tension with the ideals of the medical profession” [emphasis added]. Further, the literature cites the hidden curriculum as a major factor in the erosion of idealism63 and the increase in cynicism80 and bias81 that occur during medical school.

We found far fewer insights depicting the hidden curriculum as a positive element within UME, although they do exist. For example, some elements of the hidden curriculum, such as rural health placements or medical clerkships, seem to have an overall positive effect on students’ experiences and their developing professionalism.30,82,83

Back to Top | Article Outline

Conceptual classification of hidden curriculum

As noted, we observed that the approach to and application of the “hidden curriculum” varies widely across the literature. To better understand the ambiguity, we attempted to map the use of the term. Using definitions extracted from all included articles and grounded theory methodology, four different but overlapping conceptions emerged (see Table 2). We propose that the term is understood, depending on the article, as (1) an institutional–organizational concept, (2) an interpersonal–social concept, (3) a contextual–cultural concept, and (4) a motivational–psychological concept. As shown in Table 2, each conceptual boundary lends itself to a distinct disciplinary lens—retrospectively, policy, sociology, anthropology, and psychology.

Table 2

Table 2

Once we delineated the four classifications, we worked to understand their frequency of use and overlap. We noted that the various uses or conceptions of the term are not exclusionary or necessarily distinct; instead, authors have used them in tandem. Among the 197 articles we reviewed, the hidden curriculum as an institutional–organizational concept, applied in 82 articles (42%), was the most common. The interpersonal–social conception, applied in 57 articles (29%), was the second most common, followed by contextual–cultural (applied in 40 articles [20%]), and, finally, motivational–psychological (applied in 20 articles [10%]). Notably, a full fifth of the articles (n = 41 [21%]) did not include a direct definition for the term “hidden curriculum.” Additionally, another 20% of the articles (n = 40) used a definition that included more than one conceptual boundary. The most common overlap, used in 35 articles (18%), was between the institutional–organizational and interpersonal–social conceptions. Gaufberg et al71 exemplify this cross-concept application when they write,

we use the term “hidden curriculum” to refer to learning that occurs by means of informal interactions among students, faculty, and others [interpersonal–social] and/or learning that occurs through organizational, structural, and cultural influences intrinsic to training institutions [institutional–organizational]. (italicized words in brackets added for illustration)

Back to Top | Article Outline

Researcher positionality in hidden curriculum studies

Importantly, the conceptual boundary used in hidden curriculum studies is not arbitrary but, instead, is likely informed by the researcher’s (or researchers’) reflexivity, expertise, and/or fields of study—and, in turn, the boundaries chosen by individual researchers directly affect their study methods, outcomes, and recommendations. Table 2 highlights the discipline most associated with the various conceptions. For instance, researchers who view the hidden curriculum as an interpersonal–social concept are likely to use sociological methods to explain or uncover its effects. The methods of these studies often involve eliciting self-reflection from individual students, and the results focus on individual- or departmental-level interventions. On the other hand, research that examines the hidden curriculum as solely an institutional–organizational concept must extend beyond the individual learner to the culture of the medical school as an organization; thus, the unit of analysis for these studies is almost always the medical institution. Proposed interventions from these studies often entail changes to policy, programs, or curricula, and they usually differ in scope from those using other conceptual boundaries.

Back to Top | Article Outline

Discussion

Use of the term “hidden curriculum” in the literature is clearly on the rise: Nearly half of the articles we included have been published since 2012. Further, although originally understood as distinct phenomena,2 “hidden” and “informal” curricula have become increasingly blurred, as shown in the 17% of articles that use the terms synonymously. Thus, we believe that it is essential for scholars to effectively describe what they mean by the hidden curriculum and where they see its influence within UME.

Back to Top | Article Outline

Recommendations for scholars investigating the hidden curriculum in UME

Recommendation 1: Specify the conceptual boundary and the context.

The conceptual boundaries outlined here may provide clarity to a term that has garnered criticism from some15 because of its ambiguous and seemingly ubiquitous use. The widespread application of “hidden curriculum” as a term may make researching and evaluating the efficacy of various hidden curriculum reforms difficult. In addition, UME operates in many contexts—whether these are formal classroom teaching, medical clerkships, electives, or other spaces. Although many norms and values span learning environments, hidden curricula and their impact are context dependent and should not be viewed as a monolith spanning all settings. Therefore, education policy would benefit greatly if authors explicitly addressed the following in publications regarding the hidden curriculum: (1) the conceptual boundary or boundaries they are applying to the term, and (2) the specific learning environments in which they see the hidden curriculum acting (i.e., is the hidden curriculum bounded or unbounded by certain spaces?). Recommendations to address the hidden curriculum will vary according to the conception used, so the efficacy and efficiency of curricular reforms may depend on employing the proposed conceptual framework outlined in Table 2.

Back to Top | Article Outline

Recommendation 2: Clarify research methodologies and results.

We argue that UME is filled with hidden curricula—not blanketed by a singular hidden curriculum. We believe that, moving forward, authors should make explicit the what, where, and how of their hidden curriculum as they see and are investigating it—within both the Methods and Results sections of their research reports. Explicitly specifying will allow policy makers and curriculum developers to better identify literature related to their own particular needs and initiatives. Using a more systematic framework for discussing the hidden curriculum will also better inform the teaching practices of medical educators themselves. Asking students to reflect generally on the “hidden curriculum” they experienced during their years in medical school is akin to asking them to reflect on the complete formal curriculum: Both tasks are daunting and likely to yield unspecific or incomplete and possibly unhelpful results.

Back to Top | Article Outline

Recommendation 3: Remember the positive.

To better understand and therefore harness the power of the hidden curriculum, however defined, researchers may also need to focus on its positive effects. By better studying and publicizing these positive examples, the medical education community may find ways to blunt the broader harmful effects.

Back to Top | Article Outline

Recommendation 4: Consider other settings.

Research into hidden curricula in UME has so far been limited mostly to the United States and Canada. Two-thirds of the empirical studies in this review involved U.S. and/or Canadian medical schools. The medical education community’s understanding of hidden curricula is based on a very specific medical education system. For instance, U.S. and Canadian medical schools award medical degrees solely to physicians in training who have completed their undergraduate (baccalaureate) education, whereas many medical schools in Africa and Europe employ a UME system through which trainees earn both their baccalaureate and medical credentials. These two approaches likely differ in many aspects, including goals and expected competencies. Additionally, as Fins et al26,33 point out, the hidden curriculum varies among cultures or locations, even if they employ a similar curricular format. We believe, therefore, that any new research must examine medical schools in these understudied regions (Africa, South America) to avoid creating a sense of homogeneity among what may be very different hidden curricula.

Back to Top | Article Outline

Recommendation 5: Develop more quantitative tools for studying hidden curricula.

We noted a paucity of quantitative studies examining the hidden curriculum. This deficit is likely due, at least in part, to the inherent difficulty in measuring much of what is bounded by this term. The hidden curriculum is deeply contextually and culturally dependent and thus does not lend itself well to quantifiable measurement26,33; however, some quantitative measurement tools do exist. The most commonly used quantitative tools cited in the articles we reviewed are the C3 Survey and Patient–Provider Orientation Scale.53–56 These tools are limited in that they measure the hidden curriculum only with respect to the patient centeredness of care. Developing new quantitative measurement tools to evaluate the hidden curriculum in relation to other topics (e.g., standardized exam performance, student mental health, specialty choice) would be of benefit.

Back to Top | Article Outline

Study limitations

Although we sought to be as thorough as possible, the study is limited to the articles uncovered by the nine literature bases we searched. We believe our inclusion/exclusion criteria were clear and effective—and multiple independent reviews and the results of our kappa coefficient tests support the reliability of the article selection process—yet we may have inadvertently excluded some relevant studies. Also, per the scoping review approach, we did not consider the quality of the studies we included; this lack of discrimination should also be considered when extrapolating results.

Back to Top | Article Outline

Conclusions

As of now, the term “hidden curriculum” in medical education remains shrouded in a fog of vague definitions and widespread application. This scoping review illuminates the various ways the term is used, and we encourage future authors to move away from general musings on its ill effects toward, instead, studies that consider context and conceptual boundaries, clarify investigators’ positions, consider the positive, evaluate diverse settings, and lead to new tools for measuring hidden curricula. These efforts might help improve the powerful hidden curriculum of medical education.

Back to Top | Article Outline

Acknowledgments:

The authors wish to acknowledge the College of Health Sciences and Medical Education Partnership Initiative at the University of KwaZulu-Natal (UKZN), the Duke Global Health Institute, and the U.S. Fulbright Fellowship program. This publication is part of a broader UKZN research initiative entitled “Transformation in Medical Education (TiME) study.”

Back to Top | Article Outline

References

1. Jackson PW. Life in Classrooms. 1968.New York, NY: Holt, Rinhart and Winston
2. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861–871.
3. Hafferty FW, O’Donnell JF. The Hidden Curriculum in Health Professional Education. 2014.Hanover, NH: Dartmouth College Press
4. Hafferty FW. Beyond curriculum reform: Confronting medicine’s hidden curriculum. Acad Med. 1998;73:403–407.
5. Azzarito L. Gender, the hidden curriculum and physical education through girls’ eyes. Res Q Exerc Sport. 2014;82:A–33.
6. Moss DM. The hidden curriculum of legal education: Toward a holistic model for reform. J Dispute Resolut. 2013:1–13.
7. Van Puymbroeck M, Austin DR, McCormick BP. Beyond curriculum reform: Therapeutic recreation’s hidden curriculum. Ther Recreation J. 2010;44:213–222.
8. Pitts SE. What do students learn when we teach music? An investigation of the “hidden” curriculum in a university music department. Arts Humanit High Educ. 2013;2:281–292.
9. Murakami M, Kawabata H, Maezawa M. The perception of the hidden curriculum on medical education: An exploratory study. Asia Pac Fam Med. 2009;8:9.
10. Mahood SC. Medical education: Beware the hidden curriculum. Can Fam Physician. 2011;57:983–985.
11. White CB, Kumagai AK, Ross PT, Fantone JC. A qualitative exploration of how the conflict between the formal and informal curriculum influences student values and behaviors. Acad Med. 2009;84:597–603.
12. Robbé IJ. Revealing the hidden curriculum and reducing cultural reproduction: Small steps on a long road. Med Educ. 2014;48:846–848.
13. Ellaway R. The informal and hidden curricula of mobile device use in medical education. Med Teach. 2014;36:89–91.
14. White J, Brownell K, Lemay JF, Lockyer JM. “What do they want me to say?” The hidden curriculum at work in the medical school selection process: A qualitative study. BMC Med Educ. 2012;12:17.
15. MacLeod A. The hidden curriculum: Is it time to re-consider the concept? Med Teach. 2014;36:539–540.
16. Martimianakis MA, Michalec B, Lam J, Cartmill C, Taylor JS, Hafferty FW. Humanism, the hidden curriculum, and educational reform: A scoping review and thematic analysis. Acad Med. 2015;90(11 suppl):S5–S13.
17. Arksey H, O’Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol. 2005;8:19–32.
18. Davis K, Drey N, Gould D. What are scoping studies? A review of the nursing literature. Int J Nurs Stud. 2009;46:1386–1400.
19. Pham MT, Rajić A, Greig JD, Sargeant JM, Papadopoulos A, McEwen SA. A scoping review of scoping reviews: Advancing the approach and enhancing the consistency. Res Synth Methods. 2014;5:371–385.
20. Levac D, Colquhoun H, O’Brien KK. Scoping studies: Advancing the methodology. Implement Sci. 2010;5:69.
21. McHugh ML. Interrater reliability: The kappa statistic. Biochem Med (Zagreb). 2012;22:276–282.
22. Anders S, Fischer-Bruegge D, Fabian M, Raupach T, Petersen-Ewert C, Harendza S. Teaching post-mortem external examination in undergraduate medical education—The formal and the informal curriculum. Forensic Sci Int. 2011;210:87–90.
23. Balmer DF, Hall E, Fink M, Richards BF. How do medical students navigate the interplay of explicit curricula, implicit curricula, and extracurricula to learn curricular objectives? Acad Med. 2013;88:1135–1141.
24. Chretien K, Goldman E, Faselis C. The reflective writing class blog: Using technology to promote reflection and professional development. J Gen Intern Med. 2008;23:2066–2070.
25. Dobie S. Viewpoint: Reflections on a well-traveled path: Self-awareness, mindful practice, and relationship-centered care as foundations for medical education. Acad Med. 2007;82:422–427.
26. Fins JJ, Rodríguez del Pozo P. The hidden and implicit curricula in cultural context: New insights from Doha and New York. Acad Med. 2011;86:321–325.
27. Hafferty FW, Gaufberg EH, O’Donnell JF. The role of the hidden curriculum in “on doctoring” courses. AMA J Ethics. 2015;17:130–139.
28. Hattab AS. Current trends in teaching ethics of healthcare practices. Dev World Bioeth. 2004;4:160–172.
29. Ioana C. Hidden influences on the moral growth of medical students—Lessons from the medical English classroom. Procedia. 2014;116:3619–3623.
30. Karnieli-Miller O, Vu TR, Frankel RM, et al. Which experiences in the hidden curriculum teach students about professionalism? Acad Med. 2011;86:369–377.
31. Mullangi S. The synergy of medicine and art in the curriculum. Acad Med. 2013;88:921–923.
32. Saldaña J. The Coding Manual for Qualitative Researchers. 2013.Los Angeles, CA: SAGE Publications
33. Fins JJ, Gentilesco BJ, Carver A, et al. Reflective practice and palliative care education: A clerkship responds to the informal and hidden curricula. Acad Med. 2003;78:307–312.
34. Billings ME, Engelberg R, Curtis JR, Block S, Sullivan AM. Determinants of medical students’ perceived preparation to perform end-of-life care, quality of end-of-life care education, and attitudes toward end-of-life care. J Palliat Med. 2010;13:319–326.
35. Block SD. Medical education in end-of-life care: The status of reform. J Palliat Med. 2002;5:243–248.
36. Rabow M, Gargani J, Cooke M. Do as I say: Curricular discordance in medical school end-of-life care education. J Palliat Med. 2007;10:759–769.
37. Fernandes R, Shore W, Muller JH, Rabow MW. What it’s really like: The complex role of medical students in end-of-life care. Teach Learn Med. 2008;20:69–72.
38. Horowitz R, Gramling R, Quill T. Palliative care education in U.S. medical schools. Med Educ. 2014;48:59–66.
39. Barnard D, Quill T, Hafferty FW, et al. Preparing the ground: Contributions of the preclinical years to medical education for care near the end of life. Working Group on the Pre-clinical Years of the National Consensus Conference on Medical Education for Care Near the End of Life. Acad Med. 1999;74:499–505.
40. Olthuis G, Dekkers W. Medical education, palliative care and moral attitude: Some objectives and future perspectives. Med Educ. 2003;37:928–933.
41. Rogers DA, Boehler ML, Roberts NK, Johnson V. Using the hidden curriculum to teach professionalism during the surgery clerkship. J Surg Educ. 2012;69:423–427.
42. Hill E, Bowman K, Stalmeijer R, Hart J. You’ve got to know the rules to play the game: How medical students negotiate the hidden curriculum of surgical careers. Med Educ. 2014;48:884–894.
43. Hundert EM, Douglas-Steele D, Bickel J. Context in medical education: The informal ethics curriculum. Med Educ. 1996;30:353–364.
44. Gofton W, Regehr G. What we don’t know we are teaching: Unveiling the hidden curriculum. Clin Orthop Relat Res. 2006;449:20–27.
45. Bamber AR, Quince TA. The value of postmortem experience in undergraduate medical education: Current perspectives. Adv Med Educ Pract. 2015;6:159–170.
46. Burton JL. The autopsy in modern undergraduate medical education: A qualitative study of uses and curriculum considerations. Med Educ. 2003;37:1073–1081.
47. McNamee LS, O’Brien FY, Botha JH. Student perceptions of medico-legal autopsy demonstrations in a student-centred curriculum. Med Educ. 2009;43:66–73.
48. Robertson WJ. The irrelevance narrative: Queer (in)visibility in medical education and practice. Med Anthropol Q. 2017;31:159–176.
49. van Ryn M, Hardeman R, Phelan SM, et al. Medical school experiences associated with change in implicit racial bias among 3547 students: A Medical Student CHANGES study report. J Gen Intern Med. 2015;30:1748–1756.
50. Kenison TC, Madu A, Krupat E, Ticona L, Vargas IM, Green AR. Through the veil of language: Exploring the hidden curriculum for the care of patients with limited English proficiency. Acad Med. 2017;92:92–100.
51. Murphy M. Hiding in plain sight: The production of heteronormativity in medical education. J Contemp Ethnogr. 2016;45:256–289.
52. Tekian A. Must the hidden curriculum be the “black box” for unspoken truth? Med Educ. 2009;43:822–823.
53. Krupat E, Pelletier S, Alexander EK, Hirsh D, Ogur B, Schwartzstein R. Can changes in the principal clinical year prevent the erosion of students’ patient-centered beliefs? Acad Med. 2009;84:582–586.
54. Al-Bawardy R, Blatt B, Al-Shohaib S, Simmens SJ. Cross-cultural comparison of the patient-centeredness of the hidden curriculum between a Saudi Arabian and 9 US medical schools. Med Educ Online. 2009;14:19.
55. Haidet P, Kelly PA, Chou C; Communication, Curriculum, and Culture Study Group. Characterizing the patient-centeredness of hidden curricula in medical schools: Development and validation of a new measure. Acad Med. 2005;80:44–50.
56. Haidet P, Kelly PA, Bentley S, et al; Communication, Curriculum, and Culture Study Group. Not the same everywhere. Patient-centered learning environments at nine medical schools. J Gen Intern Med. 2006;21:405–409.
57. Johnston WF, Rodriguez RM, Suarez D, Fortman J. Study of medical students’ malpractice fear and defensive medicine: A “hidden curriculum?” West J Emerg Med. 2014;15:293–298.
58. Zhang J, Peterson RF, Ozolins IZ. Student approaches for learning in medicine: What does it tell us about the informal curriculum? BMC Med Educ. 2011;11:87.
59. Ewen S, Mazel O, Knoche D. 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. Acad Med. 2012;87:200–205.
60. Plack MM, Driscoll M, Marquez M, Greenberg L. Peer-facilitated virtual action learning: Reflecting on critical incidents during a pediatric clerkship. Acad Pediatr. 2010;10:146–152.
61. Shorey JM 2nd.. Signal versus noise on the wards: What “messages” from the hidden curriculum do medical students perceive to be importantly meaningful? Trans Am Clin Climatol Assoc. 2013;124:36–45.
62. Cheng LF, Yang HC. Learning about gender on campus: An analysis of the hidden curriculum for medical students. Med Educ. 2015;49:321–331.
63. Doja A, Bould MD, Clarkin C, Eady K, Sutherland S, Writer H. The hidden and informal curriculum across the continuum of training: A cross-sectional qualitative study. Med Teach. 2016;38:410–418.
64. Cribb A, Bignold S. Towards the reflexive medical school: The hidden curriculum and medical education research. Stud High Educ. 1999;24:195–209.
65. O’Callaghan A. Emotional congruence in learning and health encounters in medicine: Addressing an aspect of the hidden curriculum. Adv Health Sci Educ Theory Pract. 2013;18:305–317.
66. Hundert EM, Hafferty F, Christakis D. Characteristics of the informal curriculum and trainees’ ethical choices. Acad Med. 1996;71:624–642.
67. Wilkinson TJ. Stereotypes and the hidden curriculum of students. Med Educ. 2016;50:802–804.
68. Martimianakis MA, Hafferty FW. Exploring the interstitial space between the ideal and the practised: Humanism and the hidden curriculum of system reform. Med Educ. 2016;50:278–280.
69. Austin JP. Trickle-down professionalism: Hidden curriculum and the pediatric hospitalist. Hosp Pediatr. 2015;5:352–354.
70. Rabow MW, Remen RN, Parmelee DX, Inui TS. Professional formation: Extending medicine’s lineage of service into the next century. Acad Med. 2010;85:310–317.
71. 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;85:1709–1716.
72. Baker M, Wrubel J, Rabow MW. Professional development and the informal curriculum in end-of-life care. J Cancer Educ. 2011;26:444–450.
73. White CB, Perlman RL, Fantone JC, Kumagai AK. The interpretive project: A creative educational approach to fostering medical students’ reflections and advancing humanistic medicine. Reflective Pract. 2010;11:517–527.
74. Bandini J, Mitchell C, Epstein-Peterson ZD, et al. Student and faculty reflections of the hidden curriculum: How does the hidden curriculum shape students’ medical training and professionalization? Am J Hospice Palliat Med. 2017;34:57–63.
75. Chuang AW, Nuthalapaty FS, Casey PM, et al; Undergraduate Medical Education Committee, Association of Professors of Gynecology and Obstetrics. To the point: Reviews in medical education—Taking control of the hidden curriculum. Am J Obstet Gynecol. 2010;203:316.e1–316.e6.
76. Russell C, O’Neill D. Ethicists and clinicans: The case for collaboration in the teaching of medical ethics. Ir Med J. 2006;99:25–27.
77. Senior T. Writing the hidden curriculum. Br J Gen Pract. 2015;65:261.
78. Fallin-Bennett K. Implicit bias against sexual minorities in medicine: Cycles of professional influence and the role of the hidden curriculum. Acad Med. 2015;90:549–552.
79. Balboni MJ, Bandini J, Mitchell C, et al. Religion, spirituality, and the hidden curriculum: Medical student and faculty reflections. J Pain Symptom Manage. 2015;50:507–515.
80. Christianson CE, McBride RB, Vari RC, Olson L, Wilson HD. From traditional to patient-centered learning: Curriculum change as an intervention for changing institutional culture and promoting professionalism in undergraduate medical education. Acad Med. 2007;82:1079–1088.
81. Turbes S, Krebs E, Axtell S. The hidden curriculum in multicultural medical education: The role of case examples. Acad Med. 2002;77:209–216.
82. Ozolins I, Hall H, Peterson R. The student voice: Recognising the hidden and informal curriculum in medicine. Med Teach. 2008;30:606–611.
83. Roberts C, Daly M, Kumar K, Perkins D, Richards D, Garne D. A longitudinal integrated placement and medical students’ intentions to practise rurally. Med Educ. 2012;46:179–191.
Back to Top | Article Outline

References cited in Table 2 only

84. Baingana RK, Nakasujja N, Galukande M, Omona K, Mafigiri DK, Sewankambo NK. Learning health professionalism at Makerere University: An exploratory study amongst undergraduate students. BMC Med Educ. 2010;10:76.
85. Bernard AW, Malone M, Kman NE, Caterino JM, Khandelwal S. Medical student professionalism narratives: A thematic analysis and interdisciplinary comparative investigation. BMC Emerg Med. 2011;11:11.
86. Schein EH. Organizational Culture and Leadership. 1985.San Francisco, CA: Jossey-Bass Publishers
    87. Kommalage M. Hidden and informal curricula in medical schools: Impact on the medical profession in Sri Lanka. Ceylon Med J. 2011;56:29–30.
    88. Lindberg O. Undergraduate socialization in medical education: Ideals of professional physicians’ practice. Learn Health Soc Care. 2009;8:241–249.
    89. Pingleton SK, Davis DA, Dickler RM. Characteristics of quality and patient safety curricula in major teaching hospitals. Am J Med Qual. 2010;25:305–311.
    90. Rosenbaum ME, Axelson R. Curricular disconnects in learning communication skills: What and how students learn about communication during clinical clerkships. Patient Educ Couns. 2013;91:85–90.
    91. Shapiro J, Lie D, Gutierrez D, Zhuang G. “That never would have occurred to me”: A qualitative study of medical students’ views of a cultural competence curriculum. BMC Med Educ. 2006;6:31.
    92. Kahn P. The informal curriculum: A case study on tutor reflexivity, corporate agency and medical professionalism. Teach High Educ. 2013;18:631–642.
    93. Ratanawongsa N, Teherani A, Hauer KE. Third-year medical students’ experiences with dying patients during the internal medicine clerkship: A qualitative study of the informal curriculum. Acad Med. 2005;80:641–647.
    94. Adler SR, Hughes EF, Scott RB. Student “moles”: Revealing the hidden curriculum. Med Educ. 2006;40:463–464.
    95. Hall P, Byszewski A, Sutherland S, Stodel EJ. Developing a sustainable electronic portfolio (ePortfolio) program that fosters reflective practice and incorporates CanMEDS competencies into the undergraduate medical curriculum. Acad Med. 2012;87:744–751.
    96. Hafler JP, Ownby AR, Thompson BM, et al. Decoding the learning environment of medical education: A hidden curriculum perspective for faculty development. Acad Med. 2011;86:440–444.
    97. Thiedke C, Blue AV, Chessman AW, Keller AH, Mallin R. Student observations and ratings of preceptor’s interactions with patients: The hidden curriculum. Teach Learn Med. 2004;16:312–316.
    98. Brainard AH, Brislen HC. Viewpoint: Learning professionalism: A view from the trenches. Acad Med. 2007;82:1010–1014.
    99. Wong JJ, Di Loreto L, Kara A, et al. Assessing the change in attitudes, knowledge, and perspectives of medical students towards chiropractic after an educational intervention. J Chiropr Educ. 2014;28:112–122.
    100. Aultman JM. Uncovering the hidden medical curriculum through a pedagogy of discomfort. Adv Health Sci Educ Theory Pract. 2005;10:263–273.
    101. Branch WT Jr, Kern D, Haidet P, et al. The patient–physician relationship. Teaching the human dimensions of care in clinical settings. JAMA. 2001;286:1067–1074.

    Supplemental Digital Content

    Back to Top | Article Outline
    © 2018 by the Association of American Medical Colleges