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Variation in the Contemporary Hidden Curriculum in Graduate Medical Education

Variation in the Contemporary Hidden Curriculum in Graduate Medical Education. William Rafelson, MD, MBA Consuelo Cagande , MD Andrew Moore, MD Vijay Rajput, MD, FACP Cooper University Hospital Cooper Medical School of Rowan University . Future of Medical Education .

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Variation in the Contemporary Hidden Curriculum in Graduate Medical Education

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  1. Variation in the Contemporary Hidden Curriculum in Graduate Medical Education William Rafelson, MD, MBA Consuelo Cagande, MD Andrew Moore, MD Vijay Rajput, MD, FACP Cooper University Hospital Cooper Medical School of Rowan University

  2. Future of Medical Education • Integrate knowledge, skills and value through curriculum • Standardize outcome and individualize learning • Develop habits of scholarly inquiry for commitment to excellence • A professional identity formation - essential foundation of clinical competence, communication and interpersonal skills, and ethical and legal understanding, performance excellence, accountability, humanism and altruism

  3. Medical Teacher 2008

  4. Our Definition of Hidden Curriculum “The Hidden Curriculum refers to a concept that has evolved as medical educators have come to understand and recognize that there is a great difference between what is being taught and what is really being learned.  Accordingly, the Hidden Curriculum can be defined as that which creates the difference.” 

  5. “Cognitive Misers” • Residents struggle with time constraints, fatigue, and juggling too many roles and responsibilities • Can make them draw upon stereotypes and biases in making clinical decisions • Frequently rely on automatic heuristic approach • Does not occur out of laziness, but to maintain efficiency, although the outcomes are usually suboptimal, inaccurate, and biased Fiske ST, Taylor SE. Social Cognition. Boston, MA: Addison-Wesley; 1984

  6. What is Happening during Residency?

  7. Physician - Hidden Curriculum • Lack of Accountability towards Patients • Physicians and nurses no longer feel they have a sense of personal accountability towards their patients. • The Effect of Negative Attitudes on the part of Teachers • Attitudes are communicated down the hierarchical chain. • The Effect of the “Work-Life Balance” • Medicine increasingly has become a job, rather than a career. • The Concept of “The Difficult Patient” • Caregivers tend to avoid such difficult patients, when these patients really need more time, attention and compassion.

  8. System – Hidden curriculum • The Influence of the Computer and the Electronic Health Record (EHR) • Ex. One patient (i.e., the “iPatient”) is in the computer and another patient is in the bed - the problem is that the doctors are trying to fix the iPatient. • The Influence of “Legal Phobia” • Collective negative effect of medico legal concerns. • Physician and Nursing Overload • Quality compassionate care has been displaced by a plethora of “busy work.” • The Negative Side of “Evidence-Based Medicine” • Improper use of evidence instead of patient centered care using knowledge, patient value system, and clinical experience.

  9. Non-Validated Survey • We designed a non-validated 32-question survey tool to assess residents' attitudes towards the Hidden Curriculum. • Statements were pooled into groups of consensus and disagreement.

  10. Examples of Survey Questions • When it is hectic, I begin to think of patients as numbers or illnesses • Completing discharge paperwork on time is NOT more important than answering questions from patients • I will delay important paperwork to spend more time with the patient and their family  • I want a job where I do not have patients when I leave the hospital • I will stay an hour or two over the 80-hour work week limit if it means I can help a patient or their family

  11. Examples of Survey Questions • Medicine is increasingly a job, NOT a career • I would much rather be working inpatient shifts than outpatient continuity care • If a chronic pain patient complains of pain, I will NOT doubt they are in true pain, regardless of how they may look • It is safer to NOT treat some patients’ pain than fall into a trap • Patients who don’t take their medications as indicated are difficult; counseling them would be a waste of my time

  12. Method • Introductory seminar to present the concept of “Hidden Curriculum” in the fall of 2012 • 105 of 171 (61.4%) residents from six specialties (Internal Medicine, Surgery, Pediatrics, Emergency Medicine, Obstetrics/Gynecology, and Psychiatry) participated in the seminar • Before the seminar residents completed the 32 question survey • We reported specialty specific differences

  13. Data Analysis • We considered a question to be in consensus if a question had a standard deviation less than or equal to one.  Conversely, we considered a question to be in disagreement if the standard deviation was greater than or equal to two. • A two-sided t-test was used to compare the mean responses of specific specialties compared to all remaining residents. To account for the possibility that the responses were non-normally distributed. • We also did Mann-Whitney U tests which were in agreement with all results from the t-tests.   • We reported significant differences at the 95% level.  

  14. Results • Surgery residents more likely to break the duty hours regulation for patient care (3.2 vs. 4.1, p<0.05). • Internal Medicine residents significantly differ from their colleagues in that that believes they practice less defensive medicine compared to their peers (3.6 vs. 4.5, p<0.05).

  15. Results • Pediatrics residents were more likely to trust attending opinion when conflicted with EBM compared to other specialty residents in similar situation in patient care decisions (4.9 vs. 3.9, p<0.05). • Psychiatry residents significantly preferred outpatient continuity care compare to other specialty residents (2.6 vs. 4.5 p<0.05)

  16. Results • Obstetrics/Gynecology residents believes that they practice patient advocacy more than peers (4.25 vs. 3.0, p<0.05). • Emergency Medicine residents enjoy their work-life balance by limiting hours of work and continuity of care (6.2 vs. 3.5, p<0.05).

  17. Conclusions • The effects of “Hidden Curriculum” were identified among residents, many of which were specialty-specific. Residents appear not to have chosen their specialty based on work-life balance. • Residents view themselves as accountable to patients despite the transition to new duty hours regulations.

  18. Reflection in Six Programs • What – explain and debrief • Where – which patient care or learning activities • How – time and who will lead • Who– residents and faculty

  19. Practical suggestions to aide reflection in daily teaching to decrease hidden curriculum • Maintain a Reflective Journal for each program • Confidential parts • Ownership • Peer support (Learning partner/critical friend) • Use a trusted colleague to reflect with • Use a group to share reflections • Important to reflect on positive experiences and outcomes • They provide a valuable ‘armoury’ of experience • Facilitated reflection sessions Paul K irk , NHS, UK on Reflective Practice

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