Debunking the “Hidden Curriculum”

As a second-year medical student, I sat in a crowded auditorium for a lecture on how to successfully manage the upcoming clinical rotations. It was the first time I heard the phrase "hidden curriculum" – a term referring to the informal lessons on social norms and medical culture imparted during medical education. However, I cannot say that I really understood it then. As a third-year medical student, it was something I unconsciously embraced – navigating the different subcultures of my various specialty rotations like a chameleon changing colors. On my vascular surgery rotation, we would burst into patients' rooms in the early hours of the morning, stripping the bedcovers from their lower extremities and declaring that "things looked good." When dressings needed to be changed, we handed scissors, gauze and tape in the right order at the right time directly into the resident's hand. Expedience was key. I have always considered myself an efficient person, but flinging blankets off someone's feet before dawn is not something I would have ever considered doing before I began my medical life.

In order to survive from both a professional and personal standpoint in these rotations, my classmates and I had to tolerate a degree of cognitive dissonance. Perhaps I would not have normally behaved in a way that seemed to be valued on certain teams, but I could adjust for a few weeks at a time. When I found my home in internal medicine, I knew it immediately. "These are my people," I thought.

The hidden curriculum was something that I accepted as a student and, to some degree, even embrace now, taking pride in the special club of medical culture to which I belong. However, while attending one of ACC's Women in Cardiology Section sessions at this year's Annual Scientific Secession and Expo – "Women Leading the Way Throughout Cardiovascular Specialties" – I reexamined what the hidden curriculum might be teaching us about how to be a cardiologist. At this event, highly accomplished women in cardiology discussed strategies for career development. While discussing the session afterwards with other attendees, we began talking about styles of communication with our male colleagues. One physician shared an anecdote regarding her preparation for an important meeting, stating concerns that in order for her agenda to be received effectively, "sometimes I feel like I can't be me." This was a reference to her communication style – which is thoughtful, articulate and assertive, without being aggressive.

As a person with a similar communication style, this advice gave me pause. How could I find a balance between learning to communicate effectively while remaining true to my personality? Was there no room for me and others like me, who might look or sound different from the traditional view of the cardiologist, but have a lot to offer?

This issue is not necessarily one of women in cardiology (although it arose in that context) as there are diverse communication styles amongst all women. However, I think it reveals something about a hidden curriculum for what it means to be a cardiologist, and this is a challenge for increasing diversity in our field. If we subscribe to one idea of what a cardiologist looks or sounds like, we either force people to conform to an uncomfortable standard or out of the field entirely, which is a waste. In the book called Quiet: The Power of Introverts in a World that Can't Stop Talking by Susan Cain, the author discusses a learning tool used in the curriculum of Harvard Business School, in which groups of students must develop a consensus for the tools needed to survive in a hypothetical "stranded in the wilderness" situation. In one example, to the team's detriment, the student with the most knowledge on the subject was ignored because he was quieter than the rest. The students were embarrassed upon review of the discussion to find that they aligned themselves with the loudest voice rather than the most informed. I submit that if the coronary care unit is in the wilderness, you want a team that knows how to navigate it – not a team that looks or speaks a certain way. It is time for an update to the hidden curriculum.

This article was authored by Katie Rose Clapham, MD, Fellow-in-Training (FIT) at Yale University in New Haven, CT.