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
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
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.
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
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.
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
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.
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)
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.”
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