I’m thinking of writing my own hidden curriculum. The hidden curriculum is the set of values that students learn from, no matter what we have decided to teach them. As our trainees go through medical school and then postgraduate training, they watch and learn from a whole range of doctors, something often denied to us later in our careers. This exerts a powerful influence over what behaviour is acceptable as a doctor, usually more powerful than the written curriculum. Sometimes it just takes one small act of compassion, or one example of truly patient-centred care for a learner to realise that those sort of events are allowable in medicine. Just as things seen in clinic are never described in textbooks or lectures, there are some things routinely taught in medicine but almost never seen in real-life clinics. These would form the basis for my written hidden curriculum.
WHAT MY PATIENTS TEACH ME
It is a little strange that we get to decide what being patient-centred means, often without any input from patients. Some medical students can be quite disparaging of non-medical teachers.1 Part of my hidden curriculum will routinely ask patients for advice for myself and the student or registrar: ‘What do you think when we say you’re non-compliant?’ ‘What’s the best way something’s ever been explained to you?’ ‘What’s the best bit of advice you have for us right now?’
Even just asking those questions invites a sharing of expertise. At the end of each week, my curriculum would say, document and discuss what was learnt from the patients that week.
HIDDEN CURRICULUM, HIDDEN SOLUTIONS
Sometimes we see people with problems that don’t have a medical diagnosis or a medical solution. But never do we see case-scenarios without a diagnosis or solution. Every problem we have ever been taught about has an answer that is correct, and there will be an authority somewhere to tell us what the answer is. It may be the teacher at the end of the room, the answer sheet to an exam, or the carefully contrived Medline search to find the recent Cochrane review on just that problem you were given. How many times will you see a rash, not know what it is and it goes away? How many times do you see a cluster of symptoms which, despite investigation, remain biologically elusive but frustratingly present? What’s your plan now, doctor? That wasn’t in your finals exam, was it? So let’s have one or two problem-based learning cases in the course where there is no definitive answer, the patient is sat in front of you and you need to do something safe.
SHOWING THE HUMAN
My proposed hidden curriculum would suggest that teachers show themselves doing strange things normally kept out of sight, like being human. Revealing what happens when we don’t know something: how and where do we look something up? Are we using Medline, a guideline, or the Mail Online? What about if things go wrong or get stressful? How about we demonstrate how we cope with that, how we successfully prevent ourselves from burning out? We would also show how we look out for our colleagues, asking them if they’re OK, making sure we develop fun workplaces, no matter what policy throws at us. Imagine if we were able to instil these activities as routine in future generations.
There are other things I’d put in my written- down hidden curriculum; routinely basing case scenarios on patients from different class and cultural backgrounds so we avoid stereotyping white and middle-class patients as ‘normal’. I’m keen to get on and write it now. So where did I put my paper? And my pen? Hang on. I can’t seem to find them anywhere. This curriculum may remain hidden for a little bit longer.
- © British Journal of General Practice 2015