hidden curriculum

Original Article

Stunting professionalism: The potencyand durability of the hidden curriculumwithin medical education

Barret Michaleca,* and Frederic W. Haffertyb

aDepartment of Sociology University of Delaware, Newark, DE 19716, USA.bMayo Clinic Rochester, MN 55905, USA.*Corresponding author.

Abstract Despite an extensive literature within medical education touting the necessityin developing professionalism among future physicians, there is little evidence thesecalls have thus far had an appreciable effect. Although various researchers have sug-gested that the hidden curriculum within medical education has a prominent role instunting the development of professionalism among future physicians, there has beenminimal discussion of how the content of the hidden curriculum actually function to thisend. In this article, we explore: (i) how the hidden curriculum may function withinmedical education as a countervailing force to medicines push for professionalism and(ii) why the hidden curriculum continues to persist within medical training and particularaspects so difcult to dilute. We conclude by proposing mechanisms to assuage elementsof the hidden curriculum, which may, in turn, allow the principles of professionalism toblossom among medical students.Social Theory & Health (2013) 11, 388406. doi:10.1057/sth.2013.6;published online 1 May 2013

Keywords: professionalism; hidden curriculum; medical education

Introduction

Calls for a recommitment to principles of professionalism1 have been widespreadwithin organized medicine since the early 1990s (Hafferty and Levinson, 2008;AAMC, 2011; Boudreau et al, 2011). Extensive research and policy statementshave highlighted the charge for and by medical professionals to renew theirsocial contract with the public, express compassion, empathy and connected-ness with their patients, promote and practice teamwork within health caredelivery, rid themselves of their political and nancial drives, and pursue thehighest levels of clinical competence and ethical standards (Institute of Medicine,

2013 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health Vol. 11, 4, 388406www.palgrave-journals.com/sth/

2003; Arnold and Stern, 2006; Veloski and Hojat, 2006; Cruess and Cruess, 2008;Wynia, 2008; Camp et al, 2010; Dyrbye et al, 2010).Evetts (2011) notes that groups can utilize the discourse of professionalism in

composing their occupational identity and promoting its image with clientsand customers (p. 407). In this sense, the clamor for professionalismwithin themedical profession can be seen, in part, as a response to shifts in the socio-political and economic context of health care with the rise of consumerism,increased commercialism within the medical eld in general, the proletarianiza-tion of the health care workforce, the rise in available medical information asushered by the information age and increased specialization leading to fragmen-tation in the delivery of care (Light and Levine, 1988; Relman, 2003; Hafferty,2006a,b; Woodruff et al, 2008).2 Organized medicine, once touted as theprototypical profession, has seen its public image battered and bruised, andalthough many of the spotlighted issues and noxious elements appear to be tiedto the arena of clinical practice, remedial calls have targeted medical education asthe battleground in bringing about a needed shift in professional behaviors,duties and attributes.Numerous medical education institutions have implemented various courses,

programs and standards designed to provide students with extensive learningopportunities steeped in promoting professionalism (Baernstein et al, 2009;Rabow et al, 2009; Branch, 2010). The Liaison Committee on Medial Education(LCME), the body that accredits the United States and Canadian medical schools,has an accreditation standard (MS-31-A) that requires schools to account for theprofessional attributes of their students. The Accreditation Council of GraduateMedical Education (ACGME) has identied professionalism as one of its six CoreCompetencies (along with patient care, medical knowledge, practice-based learningand improvement, interpersonal communication skills and systems-based practice)(Swing, 2007). There are similar efforts in other countries. Parallel reports in bothCanada (CanMEDs, The Canadian Federation of Medical Students and so on) andthe United Kingdom (the General Medical Council, the Royal College of Physiciansand so on) also stand as socio-political testimonies to a broad and sustained effort byorganized medicine to re-establish its principles of professionalism (Frank et al,1996; GME, 2009; Bridgewater et al, 2011; Mondoux, 2011).At the practice level, various medical specialty bodies have developed

professionalism codes and charters. For example, the American Board of InternalMedicine Foundation, the American College of Physicians, the American Societyof Internal Medicine Foundation and the European Federation of InternalMedicine have created a physician professionalism charter, now endorsed byover 125 medical organizations worldwide (ABIM Foundation, ACP-ASIMFoundation, and European Federation of Internal Medicine, 2002). Furthermore,the American Board of Medical Specialties, the organization that sets standards

Professionalism and the hidden curriculum

389 2013 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health Vol. 11, 4, 388406

for the 24 of the 27 approved medical practice specialty boards, has just (as of2011) established a standing committee on professionalism.Nevertheless, and in the face of all this progress, critics have argued that

medical school administrators and faculty have been overly eager to advanceprofessionalism as an educational enterprise and have therefore rushed toconceptualize and operationalize an overly nostalgic version of professionalism(Wear and Kuczewski, 2004; Hafferty, 2006c; Prasad, 2011). Moreover, theyargue that this call to arms fails to address the issues related to professionalismpresent at the systemic and organizational levels both in training and in medicalcare settings, and suggest that if medical education truly is committed to reformthen education and practice leaders will need to address not only factors at theindividual level, but also the overarching culture and organizational climate ofmedicine that seeps into the teachings of future doctors (Hafferty, 2006d; Westand Shanafelt, 2007; Lesser et al, 2010; Cunningham et al, 2011).Further complicating this picture, medical students have expressed consider-

able dismay with and resistance to the ways in which faculty have producedaddendums and supplements to an already saturated curriculum in the name ofinculcating professionalism characterizing such curricular appendages aspedantic, harassing and even insulting, and thus turning them off to the wholecall for professionalism (Reddy et al, 2007; Baernstein et al, 2009; Finn et al,2010). Moreover, students consistently have pointed out that they are not seeingthe values, behaviors and attributes touted in the classroom being actualized byclinical faculty and supposed role models (Brainard and Brislen, 2007; Leo andEagen, 2008). In short, medical students do not see these explicit teachings ofprofessionalism as a useful addition to their training, nor do they see medicalschool faculty and shadowed physicians as fully practicing what they appear tobe preaching.In these respects, critics argue that there is a hidden curriculum nested within

medical training (for example, cultural mores transmitted through formal andinformal training processes that reect the norms and values upheld by theinstitution of medicine (Haer et al, 2011)) and that this more invisible andtacitly transmitted curriculum functions as a perpetual culprit in burdening and/or dampening the cultivation of professionalism among medical students3

(Chuang et al, 2010). As Hilton (2004, p. 71) argues, the hidden curriculum is probably the most important factor inuencing development of profession-alism. Nonetheless, research has yet to dissect how and why this usual suspectimpedes the blossoming of professionalism. Therefore, it is important to betterunderstand the ways in which the hidden curriculum affects the teachings ofprofessionalism within medical education, as well as why this dimension ofmedical training continues to persevere despite its hiding in plain sight (Gairand Mullins, 2001; Wear and Skillicorn, 2009).

Michalec and Hafferty


This present article offers a discussion of how the hidden curriculum mayfunction within medical education to stunt the growth of professionalism amongmedical students. More specically, this article examines how the teachings ofthe authority and autonomy (particularly via the privileged nature of medicalknowledge) nested within the hidden curriculum actually serve to contradict andcounteract explicit formal instruction in the principles of professionalism. Con-versely, although the hidden curriculum can be viewed as detrimental tostudents professionalism (or at least how professionalism has been discussedin the medical education literature), we suggest that the hidden curriculum alsoserves as a vehicle for protecting the embattled medical profession by providingsubterrestrial lessons in authority and autonomy which have been viewed,both within medicine and by sociology, as markers of any true profession. Putsimply, we argue that although elements of the hidden curriculum, such as theteachings of authority and autonomy, may have detrimental impact on studentsdevelopment of professionalism, these same elements of the hidden curriculumare actually essential to the perpetuation of medicines status as a profession andtherefore protected and promoted by both cultural practices within medical andby other-than-formal pedagogical strategies within medical education.

The Hidden Curriculum and Tenets of Professionalism: AnApparent Contradiction

Although the term often is attributed to the education scholar Philip Jackson(1968), the notion that there is a hidden dimension to curricula practices rstappeared in the writings of sociologist, Fred Strodtbeck (1964), a student ofTalcott Parsons. Frequently referenced in reviews of primary and secondaryeducation, the hidden curriculum represents an undercurrent of norms, valuesand regulations embedded within the training process that students are toassume and embrace in order to function effectively in a social role (Wren,1999). Apple (1979) suggests that the internalization of these rules, codes andvalues actively creates and reinforces the boundaries of institutional legitimacythat students will come to represent in their occupational pursuits. Previousresearch on the hidden curriculum has addressed how the structure andprocesses of education perpetuate inequalities, foster ideologies and practicesof particular social groups and facilitate individual disempowerment (Giroux,1985). In turn, professional education has been shown to reproduce hierarchies,degrees of marginalization, ways of thinking and other values of that particularoccupational sector (Margolis et al, 2001). These properties and practices ofdifferential legitimization have been noted to exist in medical training and areargued to be found in customs, rituals and everyday experiences that replicate



ideologies regarding inequality and stratied relationships (Hafferty and Franks,1994; DEon et al, 2007; Chuang et al, 2010; Manhood, 2011).In medical education, the hidden curriculum reects the ethos of medical work

and has the potential to reverberate degrees of separateness and distinctionwithin health-care delivery, thereby fostering distance between doctors-to-beand laypersons (Michalec, 2011a), and further strengthening a status hierarchyamong health professionals. This promotion of stratication, however, is in clearopposition with the tenets of professionalism cited earlier (for example, teamorientation, patient-centeredness, empathy and so on). Yet, despite this apparentcontradiction, elements of the hidden curriculum continue to subsist withinmedical training. We argue this is in part because lessons embedded within thehidden curriculum also function to support two fundamental/traditional char-acteristics that are essential to the preservation of medicines professional status:authority and autonomy.

Authority and Autonomy: Essential Elements of the Profession ofMedicine

Autonomy and authority are extensively intertwined within the medical profes-sion, and it has been argued that autonomy, or a professions degree of controlover its area of work and clientele, stems from its degree of cultural authority,which sprouts from the attainment and promulgation of an esoteric body of(medical) knowledge. Moreover, and as argued by Freidson (1970a, 2001) andAbbott (1988), medicine maintains professional autonomy not only through itsdevelopment and transference of that body of clinical knowledge, but alsothrough its control over its own work, the division of labor (boundaries ofspecializations) and newmember entry. Similarly, medicine asserts its autonomyand professional control by staving off interference and regulation from outsideforces such as other health workers and the government. In addition, and as icingon the cultural authority cake, medicine also controls the work of other health-care occupations (Freidson, 1970b). In sum, the degree of control and autonomyenjoyed by medicine stems from its ability to control a body of esoteric knowl-edge, maintain a sense of legitimacy in the public eye, and sustain a certaindegree of power granted by governmental entities.According to Latham (2002, p. 367), the physician profession is grounded in

the expert authority that accompanies their clinical/medical knowledge. It is thisauthority that asserts and relates the necessity of their profession. Put simply,They know something that neither their patients nor society at large can know.Medical knowledge is perhaps the integral element to the role of the physician.Doctors claim the knowledge and mastery of the intricacies of the human body,



of particular medical technologies and procedures, as well as the diagnosis andtreatment of disease (Fainzang, 2002), with this knowledge being gatheredthrough years of training. Wear and Castellani (2000) argue that the currentculture of medicine reected in the medical school curricula touts science,scientic methods and the knowledge gleaned from medical education as thetrue knowledge, and therefore something much more valuable than thepatients knowledge. the existing medical curriculum, aligned as it is almostexclusively with science and its methods, results in doctors, not patients, who arethe real knowers (p. 606).According to Parsons (1951), physicians serve as agents of social control,

empowered to regulate what behavior is deemed normal (healthy) or deviant(sick) because of their knowledge and expertise. It should be made clear,however, that the authority that physicians maintain is not just over laypersons(that is, patients) but involves other health-care workers as well, such as nurses,physical and occupation therapists, psychologists and those involved in holisticcare. Studies have shown that a status hierarchy exists in medicine that isconsistently reinforced through daily interactions in the health-care setting, andis transferred through education (Waring and Currie, 2009). This hierarchy isbased, in part, on differences in medical knowledge and the asymmetrical powergranted to those higher up on the medical hierarchy because of this knowledge what Friedson (1970b) referred to as professional dominance.In the following sections, we address how authority and autonomy are taught

through the hidden curriculum, and suggest why these elements of the hiddencurriculum (authority and autonomy) may continue to circulate through thelearning environment of medical education. We will rst address the how byexploring key vehicles and arenas within which the hidden curriculum functions.

The Teachings of Authority and Autonomy within the HiddenCurriculum

Explicit technical, medical knowledge is clearly imparted to medical studentsthrough a formal curriculum of courses, labs and clinical training. The hiddencurriculum, however, provides an excellent context to inculcate the norms andvalues of separateness, control and power because medical school faculty areconstrained from explicitly stating to students in an open classroom or lab settingYou are better than PT students., or You dont need to listen to nurses. Arecent statement from the Committee on Ethics of the American College ofObstetricians and Gynecologists (2011, p. 401) states, Inherent in the educationof health-care professionals is the problem of disparity in power and authority. Michalec (2011a) found that rst- and second-year medical students report



being taught that medical knowledge carries particular esteemed qualities.During his interviews, students spoke not merely of having trouble communicat-ing with laypersons because of distinctiveness of what they were learning(medical knowledge), but that according to their instructors, what they werelearning was also powerful and accompanied by a high level of authority.Furthermore, these preclinical students sensed teachings (during ceremoniessuch as orientation and the White Coat Ceremony (WCC), as well as with regardto consistent praise and complementation key arenas of the hidden curriculum)of authority nested within their medical training, and that faculty and adminis-tration often suggested in both direct and oblique ways that they (students) weresuperior, smarter and of more social worth than those outside of medicine. WhatMichalecs study highlights is that medical students are being told, (repeatedlyand tacitly) that they are special, a veritable best and brightest.Moreover, a variety of structural elements within medical education continu-

ously reinforce these teachings of authority and autonomy. Several reports haveindicated that less curriculum hours are actually allocated to the teaching andlearning of the social and ethical issues as compared with bioscience and clinicalaspects of medicine and health care (Hafferty, 1998, 2000; Michalec, 2011b).Such disparities in the formal curriculum may lend to less exposure to learningand practice opportunities for medical students in these specic elds, therebyshowcasing, and perhaps even enhancing, the presence and value of theauthority of clinical knowledge over other forms of knowledge. Moreover, inspite of decades of touting the importance of teamwork and team-based practice,medical students experience the overwhelming majority of their training in solecompany of other medical students (Michalec, 2011b), with interprofessionaltraining remaining more of a pedagogical mirage than an active practice(Baldwin, 2007). Similarly, Whitehead (2007) explains that because doctors areexpected to bear the onus of medical decision making (compared with otherhealth care professionals), the assumption of this responsibility must beincorporated in their training, and it is through this training (explicit andimplicit) that medical students conrm the legitimacy of their autonomousdecision-making ability.Much like ceremonies, persistent adulation and curriculum design, role

modeling represents yet another medium for conveying the hidden curriculum(of authority and autonomy) as students learn various aspects of physiciansprofessional identity and responsibilities (Reuler and Nardone, 1994; Batlle,2004; Lempp and Seale, 2004). Role modeling remains one crucial areawhererepeated negative learning experiences may adversely impact the developmentof professionalism in medical students and residents (Kenny et al, 2003,p. 1203). Although the role modeling of behaviors, values and ethical standardscan lend to positive professionalization of future physicians (Wessel, 2004;



Janssen et al, 2008; Baernstein et al, 2009; Helmich et al, 2011), previousresearch featuring students accounts of their training have shown that studentsdo witness physicians openly mock and put down patients, disrespect otherhealth care workers, put patients at risk and blatantly ignore hospital proceduresand ethical standards and face no signicant sanction or punishment fromwithin, or outside, their institution (Ginsburg et al, 2002; Brainard and Brislen,2007; Michalec, 2012).Feudtner et al (1994) presented medical trainees observations of physicians

overtly exercising their authority over patients, such as sedating a patient withHaldol in order to give them medications intravenously (simply because thepatient did not desire to take her medications), and performing unnecessaryforceps deliveries for practice. Hinze (2004) provides narratives that highlighthow the teachings of authority and a rigid status hierarchy are alive and wellwithin medical training especially concerning gender differences in professionalmedicine, offering rst-person accounts of how male practicing physiciansexplicitly and implicitly demean and vitiate female medical students andpracticing female physicians in front of medical trainees without recourse orsanction. In their exploration of the effects of the teachings of hidden curriculumin medical education, Lempp and Seale (2004) found that 21 out of 36 students intheir study reported numerous instances of humiliation (from practicing physi-cians) either through observation or through personal experience. The authorssuggest that One of the principle ways in which students learnt about theimportance of hierarchy in medicine is through teaching that involved humilia-tion. (p. 771). These studies, and others, provide direct evidence of howmodeled behavior, as a veritable lecture hall for the teachings of the hiddencurriculum, can project lessons in the authority (of medical knowledge andspecic status characteristics) and autonomy of the medical profession ingeneral. Consequentially, these teachings can have detrimental impact on thedevelopment of students professionalism.Therefore, why would organized medical education turn a blind eye to a

mechanism that has been shown to not only be disadvantageous to thecultivation of acclaimed characteristics among future physicians, but also hasbeen spotlighted by extant research? Why do the teachings of authority andautonomy (through the hidden curriculum) persist?

Authority and Autonomy as Elements to Conserve and Protect

Authority and autonomy not only are outcomes/by-products of becoming aprofession, but are also viewed within traditionally framed organized medicineas pillars of the profession itself (Parsons, 1951; Friedson 1970b, 2001). In these



ways, authority and autonomy are key to preserving medicines perception ofitself as a profession. Therefore, these elements that contribute to both the selfimage and even its actuality not only must be protected and closely guarded, buttheir value and importance also must be fostered and passed along to the nextgeneration of those in the profession (medical students). The hidden curriculumserves both of these purposes.In the case of medicine, the same events, movements and challenges that have

spawned the call for professionalism (that is, consumerism, proletarianization,complementary and alternative medicine and so on) have threatened medicineand led the embattled profession to question the stability and durability of itsauthority and autonomy (Hess, 2004; Cohen, 2006; Lowrey and Anderson,2006). In addition, whereas medical school faculty and administration have touteda range of attributes such as compassion, teamwork and patient-centeredness intheir push for professionalism (Boudreau et al, 2011), the actuality is that in orderto sustain medicines professional status (and all that comes with it) medicinealso must seek to safeguard its domain-based authority and autonomy. Asdiscussed earlier, this is accomplished through the hidden curriculum bymechanisms such as the consistent reinforcement of hierarchical boundariesbetween doctors and patients and other health professionals, differentiatedpraise for particular behaviors and even a general talking-up of the value andsignicance of medical knowledge (over other forms and loci of knowing). AsLatham (2002, p. 367) states, The physicians authority over the patient is thusalso authority over the patients community. He [sic] must therefore retain thetrust of both, or else render his authority suspect and his expertise useless.Similarly, when authority is questioned, autonomy and control are threatenedand weakened (Abbott, 1988). Hence, despite hiding in plain sight, the hiddencurriculum has yet to be dissolved, and particular teachings, such as thoseinvolving authority and autonomy, have yet to be stymied or hindered. Rather, inhighly strategic ways, the hidden curriculum is being nurtured and harboredbecause it assists in the defense of the traditional medical powers and privileges.Timmermans and Oh (2010) outline how the medical profession has been

extremely resilient and unyielding throughout the past decades, consistentlyconfronting its challenges. The authors suggest that the medical profession hassurvived numerous threats to their status and power through strategic takeovers(that is, the absorption of the least radical features of complementary andalternative medicines (CAM)), tightening their grip on clinical knowledge (thatis, their engagement with evidence-based medicine (EBM)) and establishingtactical partnerships (that is, their symbiotic relationship with the pharmaceu-tical industry). We suggest that the hidden curriculum has also served aprominent role in this set of strategic defenses and realignments by protectingand conserving the professions core resources (authority and autonomy) and by



ToddHighlight

imparting these resources in a range of tacit and often times implicit ways to thenext generation of physicians during medical training. Furthermore, perhaps thisis why the recent calls for professionalism, as well as the programs and coursesthat have been established to increase professionalism among trainees, havebeen referred to as mere window dressing and/or lackluster, and why medicalstudents continue to see behavior among their preceptors and shadowedphysicians that is not in-line with tenets of professionalism behavior that isunprofessional (Reddy et al, 2007; Baernstein et al, 2009).

Re-examining the Stalled Promulgation of ProfessionalismPrinciples

In a 1988 issue of the Journal of Health and Social Behavior, Samuel Bloom(1988) presented a powerful argument that medical educations manifesthumanistic mission is little more than a screen for the research mission which isthe major concern of the institutions social structure (p. 294). Interestingly, 24years later, we are faced with similar set of stealth-related activities withinmedical education a covert push for authority and control while explicitlysounding the call for professionalism. However, whereas Bloom was exploringa history of reform without change, we are arguing that medicine actually isghting for its professional livelihood, and that the hidden curriculum has beenactivated as a vital weapon for medicine in this battle.These front- and backstage maneuverings present medicine with a substantial

conundrum: In order to maintain its professional status, medicine must sustainsome degree of authority and autonomy. Yet, the promulgation of suchnecessities (through the hidden curriculum) is somewhat antithetical to thispush for professionalism. The notions of authority and autonomy withinmedicine are not necessarily negative side-effects of medicine achieving ormaintaining professional status. Rather, it is their reection and translationthrough the hidden curriculum that appears to lend to the detriment. Hence,whereas a great deal of attention and effort to cultivate principles in profession-alism among medical students has been directed toward developing, offering andassessing professionalism-laden programs, we suggest that focus should shifttoward the mechanism(s) nested within medical education that appear to beantithetical to these principles and could very well be stunting their developmentamong medical students toward the tempering of the hidden curriculum andthe teachings of authority and autonomy.As noted earlier, the hidden curriculum within medical training reects and

reinforces hierarchies, status inequalities and overarching differences in healthand health care. Therefore, a key to enfeebling aspects of the hidden curriculum



and their effects is by muting the notion that medicine is the profession withinhealth care. Although interprofessional training within medical education circleshas been somewhat of a straw dog over the past several decades (Baldwin, 2007),there is evidence that medical education institutions are taking signicant stridestoward emphasizing a more interprofessional, team-oriented approach tohealth care. A number of medical schools have recently constructed andimplemented elaborate, multi-year Interprofessional Education (IPE), programsaimed at bringing together students from multiple health care disciplines duringtheir years of training to breakdown the hierarchy within health care delivery,increase patient-centeredness from a team approach, and foster communicationand respect among the various health professions (Clark, 2004; Thistlethwaiteand Moran, 2010). These programs are integrated into preclinical and clinicaltraining agendas for these institutions, but given the novelty of these programs,research is currently underway to assess to what messages and values are beingtranslated to the students of the various disciplines through these programs.These programs are not slated as programs in professionalism per-say, ratherthey are geared toward bringing together each of the health disciplines under theumbrella of improving health care delivery, the experiences of health careprofessionals, and patient outcomes in general. Another important element ofIPE programs is that they often include members of the local patient population/general public to serve as a guide to the pre-professionals through the illnessexperience. IPE, with its focus on team-based care, patient-centeredness, andinclusion of the public in the education process, has the potential to havesignicant impact on the hidden curriculum and lay the groundwork for aspectsof professionalism to take root.Another manner in which the medical education community can assuage the

potentially injurious profession dominating teachings of the hidden curriculum isto transform the WCC. Often held during the rst year of medical training, theWCC is a ritual in which students are draped with the quintessential regalia of aphysician. The white coat has been described as a magical cloak that protectsthe medical student and doctor from the suffering of their patients (Druss, 1998),and as a symbol of science and technology, and a reection of life and purity(Blumhagen, 1979). Although it may seem to occupy a relatively negligiblefootprint with the overall process of medical education, and while ofcials withinmedicine have argued for its benets and appropriateness (as outlined in Branch,1998; Huber, 2003), others such as Wear (1998) and Russell (2002), havesuggested that the white coat actually functions as a source of the hiddencurriculum and thus transmits messages of power, authority, elitism and thedominance of science that it symbolizes.Whatever the issue, it is important that medical educators be willing and

able to step back and assess just what messages are being created by and within



the very structures they have developed and are responsible for (Hafferty, 1998,p. 404). This means thoroughly evaluating the meanings translated in theseceremonies and the differentiations made between medical students and thosenot within the medical profession, especially given the timing of most WCCs.Even something as celebratory as a WCC may send conating and contradictorymessages. In this sense, medical school administrators interested in mitigatingimpressions of elitism and power, and fostering positive perceptions of inter-professionalism, mutual cooperation and interdependence (among the healthprofessions key elements of professionalism), should look to include profes-sional representatives from the other health care-related disciplines (that is,Nursing, Pharmacology, Physical Therapy, Occupational Therapy, Social Workand so on) in the WCC in some fashion other than just guests and/or spectators.Professionals in these other disciplines could serve as speakers, ofciates orcould even adorn medical students with their white coats, thereby welcomingthem to the health care industry. Another manner in which the same directivescould be achieved would be to host a generic WCC for students of all healthcare disciplines. Each discipline teaches and trains students to heal, why can theynot all join together to celebrate their collective initiation into the healingprofessions? Such recongurations of the WCC could help to dismantle barriersand fences between the health professions and counteract conceptions of a rigidhierarchy within health care delivery, thereby potentially neutralizing certaindeleterious effects of the hidden curriculum.4

Given that the lessons of authority and autonomy through the hiddencurriculum have been shown to also be present within the professional domain(along with the educational domain) of medicine, the efforts of dismantling thehierarchies within health care delivery should also be done from within themedical industry and therefore reected in the attitudes and actions of practicingphysicians. If medicine is truly invested in the promotional of professionalismprinciples among its future workforce then the medical profession would do wellto adopt the motto: It takes a village and acknowledge and embrace the notionthat effective health care is delivered through a team of professionals (that is,nurses, medical social workers, doctors, pharmacists, physical and/or occupa-tional therapists and so on), which includes the patient (Lichtenstein et al, 2004).In stepping down from its crumbling silo, medicine still will maintain a distinct,esoteric body of clinical knowledge, but, in turn, the profession must profess thatits knowledge functions best when working in tandem with the knowledge ofother parties/professionals within the health care delivery team which again,must include the patient. By doing so, medicine will relinquish some degree ofcultural authority and control, yet this will assist in ushering in a new contractwith the public as well as with other health care professionals what some arecalling a new patient-centered professionalism (Irvine and Hafferty, 2011).



Weakening the potency of the hidden curriculum not only entails the practiceof dissolving hierarchies within health care, but also courageously and publicallypurging the bad apples within the profession. If professionalism is to ourish,the attention cannot simply be on pedagogical practices, those practicing withinthe profession must be held accountable as well (Leach et al, 2006; Hafferty,2006b). In order to save itself from its current siege, medicine must become moretransparent in terms of how it handles ethical violations, poor and out-of-datepractices and the adverse pursuits of political and nancial endeavors among itsown members (Hickson et al, 2007).Until this point, we have steered clear of any medically oriented analogies or

metaphors, yet perhaps one must be used to better capture the manner in whichthe medical profession must attack or confront certain aspects of the hiddencurriculum. Radiation therapies are a popular method of treating cancer. Whiledeconstructing the tumor, radiation simultaneously damages healthy cells andtissue the desired effect being a greater sum of damage to the tumor thanhealthy tissue. If we consider the hidden curriculum as having a potentiallytumorous effect within the soma of medical education, then implementing vettedand evaluated IPE programs within the curriculum, reconguring WCCs andfostering transparency within the profession in general may in fact impactmedical trainings healthy tissue (re-organizing curriculum to include IPE,possibly forfeiting the positive side-effects of the WCC and even sacricing somedegree of authority and autonomy). Although some tumors may be eradicatedand others merely controlled, the overall effect is a more sustained andnourishing environment for the seeds of a more modern-day or new profession-alism to be established and ourish (Irvine, 1999, 2006; Working Party of theRoyal College of Physicians, 2005; Coverdill et al, 2010).

Conclusion

We have posited how and why the principles of professionalism (and thedevelopment of these principles among medical students) have struggled toblossom within the current climate of medical education, and, in turn, how thehidden curriculum has been able to radiate within this climate. In return forprotecting aspects of authority (including medical knowledge) and autonomy/control over the other health professions and translating them to futurephysicians, the medical profession has nurtured and sustained the hiddencurriculum, specically the teachings of power differentials, hierarchicalboundaries and overarching inequalities in health care delivery. Althoughappreciable research has identied the presence of a hidden curriculum withinmedical education, argued for its deconstruction and ngered it for the sluggish



growth of professionalismwithin medical students, this specic work highlightshow a function of the hidden curriculum is to conserve the medical professionscritical resources of autonomy and authority, which purportedly lends to itsremarkable perseverance.We agree with other researchers in that professionalism will not thrive until

the culture and climate of medicine (which is currently fostered in part by thehidden curriculum) is fully explored and dissected. In order to do this, wesuggest implementing anti-hierachical rhetoric and structures within medicaltraining such as IPE programs and the signicant modication of WCCs. We alsoargue that altering the education setting alone will not curtail the hiddencurriculum. Therefore, practicing physicians and the profession itself must notonly sacrice degrees of authority, but also levels of their autonomy by makingtheir judiciary practices and political and nancial endeavors more transparent(Bridgwater et al, 2011). These mechanisms will usher in a new contract notonly between the medical profession and the general public, but also between allhealth professions.

Notes

1 Throughout this work, the authors use the term Professionalism to refer to the individual-level traits,behaviors and attitudes similar to those described in the encompassing normative definition offered bySwick (2000). The term Profession, within this work, refers specifically to organized medicine as anoccupational entity and in relation to specific qualities of any true profession (that is, authority andautonomy). Finally, within this work, the term Professionalization refers to the processes andmechanisms by which medical students learn to become professional health care practitioners. Inturn, this work attempts to bridge the importunate cultural divide between the more sociologicallyoriented discourse on the Profession of medicine and the more medically oriented discourse on medicalProfessionalism (Hafferty and Castellani, 2010).

2 Although there remains some considerable opposition to the claim that physicians are becomingdeprofessionalized and/or subordinated to the bureaucratic controls (Pescosolido, 2006; Spalter-Roth,2007), medical insiders remain quite convinced that physicians have suffered serious erosions of theirclinical autonomy and discretionary decision making (Shanafelt et al, 2002; Zuger, 2004).

3 Although writings on the hidden curriculum come largely from within the United States, UnitedKingdom and Canadian medical education literature there are the beginnings of an expandinginternational literature on the hidden curriculum. Similarly, although the concept is universal, particularcontext may differ enough so that what holds for one country in terms of specific findings about contentof the hidden curriculum or the content of the space between the formal curriculum and the hiddencurriculum is particular to place (specific medical education institution). Therefore, although discussionsof the hidden curriculum (in the general sense) offered within this work could be applied to more thanone national context, given that the authors are relating the role of the hidden curriculum to the currentstate of the medical profession in the United States the discussion of the hidden curriculum within in thisparticular work is primarily directed toward US medical education.

4 Although the inclusion of other health professions within the WCC may have a positive impact on theinternal status hierarchy among the health professions, it may do little to address (and may evenexacerbate) the status and power divide between health care providers and patients (laypersons).



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sth20136a.pdfStunting professionalism: The potency and durability of the hidden curriculum within medical educationDespite an extensive literature within medical education touting the necessity in developing professionalism among future physicians, there is little evidence these calls have thus far had an appreciable effect. Although various researchIntroductionThe Hidden Curriculum and Tenets of Professionalism: An Apparent ContradictionAuthority and Autonomy: Essential Elements of the Profession of MedicineThe Teachings of Authority and Autonomy within the Hidden CurriculumAuthority and Autonomy as Elements to Conserve and ProtectRe-examining the Stalled Promulgation of Professionalism PrinciplesConclusionNotesA10

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