1. 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

2. ACTIVITY DISCLAIMER The material presented at this activity is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, method or procedure appropriate for the medical situations discussed but, rather, is intended to present an approach, view, statement or opinion of the faculty that may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual attending this program and for all claims that may arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented at these activities. Physicians may care to check specific details such as drug doses and contraindications, etc. in standard sources prior to clinical application. These materials have been produced solely for the education of attendees. Any use of content or the name of the speaker or AAFP is prohibited without written consent of the AAFP. FACULTY DISCLOSURE The AAFP has selected all faculty appearing in this program. It is the policy of the AAFP that all CME planning committees, faculty, authors, editors, and staff disclose relationships with commercial entities upon nomination or invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

3. 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

4. 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

5. 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.

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;69:861-71.

7. 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

8. 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

9. 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?

10. 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)

11. 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

12. 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.

13. 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.

14. Time for Conversation

15. 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

16. 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.”

17. Questions? Comments? Thanks for coming!

18. References Anderson, D. The hidden curriculum. American Journal of Radiology 1992;159:21-22. 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):598-605. Glicken AD & Merenstein, GB. Addressing the hidden curriculum: Understanding educator professionalism. Medical Teacher 2007;29:54-57. Gofton, W & Regehr, G. What we don’t know we are teaching. Clinical Orthopaedics and Related Research 2006;449:20-27. Hafferty, F. Beyond curriculum reform: Confronting medicine’s hidden curriculum. Academic Medicine 1998;73(4):403-407. 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.