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Mindful EM: The Impact Factor of the Hidden Curriculum

Hazan, Alberto MD; Haber, Jordana MD

doi: 10.1097/01.EEM.0000515684.60294.83
Mindful EM

Dr. Hazan is an emergency physician with EmCare in Las Vegas and the author of the medical thriller Dr. Vigilante and the preteen urban fantasy series The League of Freaks. Find out more about his novels at He is also a board member with . Follow him on Twitter @Dr_Vigilante. Dr. Haber is an emergency physician and the director of clinical education at University Medical Center in Las Vegas. She has a master's degree in medical education. Follow her on Twitter @JoJoHaber. Read their past articles at

residency, teaching

residency, teaching





One of our favorite attendings used to take a moment before every intubation to ask his patients a critical but often neglected question: “If you were to die, would you like me to relay any message to your family?”

The answers were mixed. Some patients wanted him to contact their families and tell them that they loved them. Some wanted him to convey their regret over things that were said or unsaid. Some wanted him to make sure their pets were well taken care of.

For the past 10 years, we have asked our patients the same question and have honored their wishes every time we intubated a patient who has the mental clarity to answer appropriately. And we think about this stellar attending and remember how compassionately he behaved at the bedside. The example he set for us has conceivably benefited hundreds of patients and family members.

We have an awesome responsibility as educators to teach our medical students and residents. We need to realize that the things we say and teach, the subtle remarks we make, and the actions we take have the potential to be ingrained in our students' consciousness.

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Ingrained in the Brain

That simple action of reaching out to a patient, which the attending took without lecturing about it, was not meant to be a lesson for us. We found this to be unique. He showed compassion, caring, and consideration.

We all have teachers who have inspired us with their humanity and love for their patients, and you will be in that position if you are in a residency program or in charge of medical students, whether you like it or not. Students have a limited amount of knowledge. They have limited interaction with physicians, so it's natural for them to hang on to your every word and action. We need to be extremely mindful of the way we act, what we say, how we teach, and on what we choose to focus.

It may be overwhelming to you, the teacher, to realize that everything you say is being ingrained in some young student-doctor's brain, that what you say and do will forever affect the way the person in front of you practices medicine, and beyond that, will in some way influence the lives of thousands of patients and their family members. We should not shy away from this responsibility. We need to acknowledge that our words and actions have influence beyond the four walls of the emergency department, and we must take this responsibility seriously.

Don't assume things about your students, and don't get frustrated. Don't ever expect a polished history and physical from a medical student or brand-new intern. Rather than having these unreasonable expectations, realize that every student has a different background, different medical education, and different training. Instead of getting frustrated, see your job as an opportunity to shape their careers and the lives of others. Have patience and be mindful that the way you react will forever affect your student's practice.

If you are unkind to a drug seeker, your students are likely to be too. If you blow off a frequent flyer, so will they. If you respond to students' presentations by belittling their knowledge, they are likely to do the same to their future students.

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Sighs and Rolling Eyes

This is the hidden curriculum of which most of us are unaware — the subtle sighs, the rolling eyes. These are not the lectures you plan or the chapters you assign for reading. This is your everyday attitude, your reaction to intoxicated patients, drug seekers, and frequent flyers. Students are likely to forget the difference between peripheral and central vertigo, but they will never forget the way you made them feel when they presented their case to you.

The hidden curriculum is also the extra time spent at the bedside educating patients or going over pearls from each case with a student or resident. It's that extra bit of effort that shows you care.

Sometimes we focus solely on getting through our shift. We are under a lot of stress, but it's important to be mindful about the influence we have on our learners because actions and reactions have consequences beyond our shift. They will potentially influence generations of learners and a countless number of patients and family members.

The things you say and do will be forever ingrained in your learner's mind. Just like we think about our attending every time we intubate someone, your medical students and residents will think of you every time they see something that reminds them of an interaction they had with you.

Wouldn't you rather be remembered for the rest of a medical student's or resident's career as the person who showed empathy, respect, love, and consideration rather than the one who was jaded, disrespectful, and unkind toward someone who sought your help in the ED?

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