When the “TALK” and “WALK” are not Aligned: Helping Faculty Identify and Embrace “The Hidden Curriculum” Donald Woolever, MD Deborah Taylor, PhD Central Maine Medical Center FMR

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Pre-Test We will present some abbreviations or slang to you, please shout out what you know/think it means? – Abbreviation: GOMER – Abbreviation: FTD – Slang: Doorknob Rounds – Slang: Frequent Flier – Slang: + Suitcase Sign

Objectives for The Next Hour 1.Delineate and define components of “the hidden curriculum“ 2.Recognize the impact of “the hidden curriculum“ in medical education 3.Create a plan to assess and teach about “the hidden curriculum“ in your own FM department and/or residency

The “Hidden Curriculum” the intangible skills and attitudes that were not explicitly taught in textbooks, lectures, labs and course objectives Chuang A, Nuthalapaty F, Casey, P To the point: Reviews in medical education – taking control of the hidden curriculum. AJOG. 2010:10:316e1-6.

The “Hidden Curriculum” Often not admirable Often does not support core values of honesty, integrity, caring, compassion, altruism and empathy Contributes to ↑ cynicism toward patients, teachers and the profession Hafferty, FW, Franks, R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994;69:

The “Hidden Curriculum” Impacts perception of the Dr-Pt relationship Affects interactions with teachers (black humor sets in) Influences approach to dz mgmt Negatively steers priorities in healthcare settings Arnold RM. Formal, informal and hidden curriculum in multicultural medical education: the role of case examples. Acad Med 2002;77:209-16

Exercise Make a list of messages you remember (hearing or intuiting) from your medical school or residency experience about Medicine in general or Family Medicine in particular – Positives – Negatives

Our Story Annual long range program planning retreats (two 1 day session 1 month apart) First morning is Faculty Team Building Outside facilitator to lead our Hidden Curriculum discussion (flipped classroom technique) – Proposed idea of asking learners – Were we ready for what we heard? – Would you be?

Intended Messages Explicit – The ability to practice preventative medicine and provide patient education – The benefits of patient continuity – Family Docs say they enjoy delivering babies and taking care of those children – FM offers flexibility to do many things (e.g. ED, OB, hospital med, procedures) – Some of the doctors walk over to the hospital to see one of their patients who is in (caring)

Intended Messages Implicit – It seems like they get a lot of satisfaction from their job – Passionate about what they do – Provided an excellent example of how we should care for our elderly patients in the context of their lives and not just based on EBM/text book medicine – Going the extra mile for pts – It is a privilege to care for patient and family through compassionate, responsible care – Practicing medicine is a great opportunity to make a significant difference in someone's life – I now feel that family medicine is much more exciting than I ever thought in the past

Unintended Messages Explicit – Some docs will roll their eyes and say "Oh god, I have to see that patient again!" – Never hear any good things about being a family doc – I do hear many negative comments from specialist and community preceptors about FM – I have heard faculty mention many times what they wish they had done instead of family medicine. – More focus in medicine on meeting pt numbers, billing, the business of medicine. Less focus on patient relationships. Less time for patients. More demand on doctors. Less respect of doctors. – Negative messages about problematic patients, work load and reimbursement for services.

Unintended Messages Implicit – Most of the physicians I come in contact with do not seem "happy" in their chosen field. – Family physicians feel like they are on the low end of the totem pole – I don't like that dynamic of feeling like there's a power differential between family physicians and specialists. – Can count on one hand the number of docs I have met in my life that enjoy what they do. – If you speak poorly about a patient, it reflects poorly on you.

Time for Conversation

Share messages you had written down in the “solo” exercise earlier Have some conversation about your experiences (common themes, impact on you, how that informs your practice of medicine now?) What is one thing you would commit to changing about your explicit or implicit “hidden curriculum” messages when you go back to your home program? Report out to the large group

Keeping Us Grounded “What I truly need at this point in my career is excellent mentors of great doctoring. I want attendings that I look at and say….that's exactly the kind of doctor I want to be - that is the kind of patient relationships I want to have - that is how I want to live my life - that is who I want to be ‘when I grow up’. Not - wow that person is timely and punctual with paperwork. Yes, those things are important too, but they are not nearly as important.”

Questions? Comments? Thanks for coming!

References Anderson, D. The hidden curriculum. American Journal of Radiology 1992;159: Chuang, AW, Nuthalapaty, FS, Casey, PM et al. To the point: reviews in medical education – taking control of the hidden curriculum. AJOG 2010;10:316.e1-e6. Coulehan, J & Williams PC. Vanquishing virtue: The impact of medical education. Academic Medicine 2001;76(6): Glicken AD & Merenstein, GB. Addressing the hidden curriculum: Understanding educator professionalism. Medical Teacher 2007;29: Gofton, W & Regehr, G. What we don’t know we are teaching. Clinical Orthopaedics and Related Research 2006;449: Hafferty, F. Beyond curriculum reform: Confronting medicine’s hidden curriculum. Academic Medicine 1998;73(4): Phillips, J, Weismantel, D, Gold,K, Schwenk, T. How do medical students view the work life of primary care and specialty physicians. Family Medicine 2012;44(1):7-13.