Outing the hidden curriculum

Hastings Center Report, The, July-August, 2006 by Anna B. Reisman

The hidden curriculum: Even if medical students haven't heard the term, no doubt they're keenly aware of what it is--the pressure to conform, the focus on pleasing superiors (at the expense of the patient, if necessary)--in short, the unofficial rules for survival and advancement. It's a powerful undercurrent that can turn even the most self-assured and altruistic student into an obedient drone.

Fifteen years ago, I awaited Todd (not his real name), my OB resident, outside the operating room. I was a third-year medical student. Though I was nervous, having never performed an abortion before, I was glad I had been assigned to assist Todd. He was the kind of doctor I aspired to be. Once, I found him sitting with a patient dying of ovarian cancer, holding her hand as she wept. During quiet times on call nights he would prop his well-worn Birkenstocks on a desk littered with charts and empty potato chip bags and talk at length with us about our patients. Most residents had neither the time nor the inclination for this. Nor did he take advantage of students in ways other residents might--having one of us check a laboring woman's cervix because he was too busy playing a computer game, or sending us to a supermarket two blocks away for snacks.

The patient's feet were in stirrups, her legs spread wide. Her eyes were closed. She looked relaxed. I wasn't sure if she was awake or anesthetized. Whatever the case, it seemed inappropriate to ask. At Todd's instruction, I placed my hand on top of his. Together, we pushed a series of metal dilators into the tight cervical opening which gradually yielded, allowing Todd to ease in the suction tube. Globs of red-pink pulp swooshed into a container under the table. A wave of nausea washed through me. Most of the fetus was out, Todd explained, but we had to ensure that the uterus was empty. With a metal curette, my hand again over his, we scraped the gritty lining.

Just one last thing, I remember Todd saying. He poked through the bloody remains with a metal spatula and found what he was looking for: a chunk of placenta with tiny villi, an arm with minuscule finger fronds, the skinny little skeleton with its remaining three limbs, just a few inches in size, the head lost among the gory mush. The little fetus wasn't just dead; it was torn apart. I clenched my teeth. My stomach lurched.

And then it happened something I have never forgotten, even all these years later. Todd was whistling something familiar. It took a moment, and then I recognized the song: "Another One Bites the Dust."

I froze. Was I supposed to laugh? To snicker conspiratorially? Would he be annoyed if I looked affronted? Would he think I wasn't tough enough, or humorless? I hoped the surgical mask hid the color rushing to my face. I prayed the patient hadn't heard the whistling-or, if she had, that she couldn't identify the tune.

I didn't tell anyone what had happened. I could imagine my medical student friends blithely dismissing his behavior. He was only blowing off steam, one might say. Or she probably was too sedated to hear anything--it's no big deal. But it was a big deal. I wasn't just shaken by Todd's behavior; I was ashamed of my own. In the end, my silence had nothing to do with the patient; it was all about protecting my own reputation. Worse, if I were in the same situation again, I wasn't sure I would take Todd-or any other superior--to task. What did that say about the kind of doctor I would make?

Years later, I shared this story with some fellow doctors. One thought the whistling was distasteful but also understandable--a defense mechanism. Another recalled feeling similar shock and confusion as a medical student when an attending physician made a rude remark in front of a patient.

I can see both sides now. As a practicing physician, I appreciate that doctors need ways to cope with disturbing situations. But we also have to be able to make the sometimes fine distinction between a humorous remark and an insensitive one. Medical students are sponges, after all, thirsty to absorb not only knowledge but attitudes. If they observe repellent behavior being deemed acceptable, what's to stop them from obliviously replicating it?

And here is why it behooves us, as physicians, to be aware of our students' natural instinct against the hidden curriculum: it is a gift. Their struggle, if we can recognize it, can return us to a time in our own fledgling careers when everything seemed new and strange and our sense of the patient's perspective was more acute and accurate. We are in a position to show students that confronting their feelings in these situations is critical to their professional development. We can urge them to share these experiences, whether with mentors or peers, to remind them that what they observed might not be the appropriate way to behave and that their impulses to protect and respect their patients are valid. Otherwise, the next generation of doctors may well be whistling.