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The hidden curriculum of medicine

In the interest of experimentation (and because we’re big fans of his), onboardMD is re-posting a blog from our friend Reza Fakhraei, who runs the Med Student Gunner blog. Reza is currently a first-year medical student at the University of Toronto. He started blogging about his med school journey “to provide straightforward and comprehensive advice to anyone looking to get into medical school”. He has since expanded his focus, writing more and more about what medical school is really like from the inside, both for the enjoyment and interest of his audience, and because blogging is an enjoyable hobby that keeps him balanced.

There is an aspect of medicine you may or may not be aware of, known as the hidden curriculum (HC). What is the HC? It is all of the aspects of medicine that are not formally taught to you but are part of the practice. Learning all aspects of the HC are essential to becoming a successful medical student, clerk, resident and physician, but you are not explicitly taught them at any point in your training.

To give you an extremely simple example of the HC that most, if not all, medical students pick up on either before entering medical school or within the first few months: there is a “pecking order” in the hospital.

When you are in third and fourth year of most four-year medical school programs (or second and third year in a three-year programs), you enter what is known as clerkship. Essentially, you are working in a hospital in a specific specialty in order to gain more skills in an actual medical setting as opposed to an academic one. When you are a clerk you work long hours and have a lot of responsibilities. You are also at the bottom of the previously mentioned “pecking order”. You are there to learn, so you are a burden to others - you need to try to make everyone else’s life easier in order to leave a positive impression. You report to the residents who are above you in the chain; above them are the fellows and the staff physicians. Disrespecting the pecking order by complaining to a staff physician about an instruction from a resident without first running it by the resident might lead to quite the interesting discussion and work environment, for example. This is a huge oversimplification, but it is an example of an aspect of the HC that is definitely important to be aware of in order to succeed in medicine.

Hopefully that example was sufficient to give you a brief understanding of the HC in medicine, but how do you learn these aspects of medicine if they are not covered in the classroom? This is where mentorship comes into play. A lot of the negative aspects of medicine are not openly discussed in large group settings or lectures and might not even be that easily found online. In order to get the real perspective of what medicine is like, speak with some clerks, residents, and staff physicians. Do not stop at one mentor - try and get a large number of mentors who have different experiences and perspectives. In my experience, in one-to-one or small group setting, professionals are more open with you and will give you the real truth about the profession - they want to assist you the best way they can. By reaching out to several physicians and residents, I can say that I have learned a lot about medicine that I never knew about, providing me with more perspective and awareness about what I am getting myself into.

While I have learned some ugly aspects about medicine, I can also share that the HC is not all negative. There are a lot of unofficial positive aspects of medicine that I learned about from various mentors. For example, as physicians, you can advocate for your patient, and this advocacy can lead to tremendously improving not only their care, but the care of others.

"Many of us are born in hospitals and die in hospitals with physicians bringing us to life and easing our way to whatever lies past death."

Based on everything I have learned, I can, without a doubt, say that I would choose this field ten times over. Medicine might be a very tough field that requires a lot of sacrifice in other aspects of your life, but the work you do in medicine really is amazing. Through just half a year in medical school I have done about 50 hours of shadowing in various fields from forensic pathology to psychology to OB/GYN. I have seen so many different corners of medicine already, and I have seen the various ways that this career rewards those that are a part of it. People are so trusting of medical professionals, even medical students who are just learning, and it honestly warms my heart to see individuals so open with me. The trust that is afforded to health care providers has to be one of the most valuable assets presented to us. One of the amazing aspects of medicine that I have learned, about and gained a greater appreciation for, is the value of this trust and the importance of maintaining it.

I imagine that if you are reading my blog, you are most likely considering a career in medicine, and I would commend you and tell you to continue. In no other career will you have such a direct impact on so many people’s lives. At the end of the day, almost every single person will be a patient of a health care system at one point in their life. Many of us are born in hospitals and die in hospitals with physicians bringing us to life and easing our way to whatever lies past death. In no other career are you afforded the ability to be as dynamic as a physician. You can practice and do research, own a start-up, work as a consultant, the list goes on and on. You are constantly improving your knowledge-base and learning from some of the smartest minds, while interacting with professionals from all fields.

You might be a bit lost in this post. It is not as structured as my usual posts. This is not an advice piece. This is a narrative of what I believe are some of the most important aspects of medicine I have learned in the four months I have studied so far. Sure, I have learned some clinical decision-making skills, genetics, microbiology, and how to take a thorough patient history, but these are skills that can be taught to anyone that is motivated enough to learn them. The HC needs to be sought out, and you need to choose what aspects of it you decide to learn since you will never be tested on it. You can go through medical school and pretend that you are there to help patients, while really just seeking out money and prestige. You can ignore the vital importance of trust. And you might never face any repercussions from this approach, becoming a successful physician that never encounters any roadblocks. But I truly believe that if you are in medicine for the right reasons, take your training very seriously, and perform to the best of your abilities, you will provide better care than someone who is equivalent in all other ways, except their motivations. You will also be representing other physicians by shaping our workplace with not only our interests at heart, but the interests of those for whom we care.

This blog has been re-posted on onboardMD with the permission of the author. Minor edits have been made for length and clarity. Check out more of Reza’s blog posts at Med Student Gunner.