More than an education: the hidden curriculum, professional attitudes and career choice

Objectives: In this qualitative study we examine how teachers' egalitarian or discriminatory behaviours and values at odds with those of the individual learner or the institution are perceived and absorbed by students, and how this hidden curriculum shapes the doctors students become.

Methods: During 2011, a total of 120 randomly selected medical students from each class at three Canadian medical schools were electronically asked for examples of teachers' words, attitudes or behaviours that discriminated against or promoted equality towards a group or groups of doctors or patients. We examined the content of participants' examples of unexpected messages and their reactions to these. Responses were aggregated, sorted and coded for conceptual themes. An independent qualitative researcher repeated the analytic process and then engaged in discussion with us to reach consensus on themes and meanings.

Results: The 76 (63%) respondents noted that attitudes in keeping with universally held, institutional values of equality towards, for example, homosexuals or marginalised populations were expressed, but also described role-modelling at odds with this. Patient characteristics such as obesity, drug abuse, mental illness and poverty were presented as signs of individual weakness or moral failing. Some teachers assumed immigrant status based on a student's or patient's skin colour or last name. Respondents described how women in medicine were maligned as potential surgeons and were expected to put family before career. Teachers denigrated doctors from specialties other than their own. Students reacted to discordant role-modelling by challenging, dissociating themselves, with silence or with confusion followed by attempts at individual transformation to realign careers and behaviours with those of teachers.

Conclusions: When teaching contradicts institutional or learners' values, or is particularly inspiring, students notice and may be influenced to the extent that they rethink personal beliefs and plans to fit their future doctor selves to these models.