What Residency Programs Get Wrong About Teaching

Every residency program runs two curricula and writes down one of them.

The written one is precise. It lives in the ACGME program requirements, the block diagram, the conference calendar, the rotation goals and objectives, the milestone evaluations, the annual program evaluation. It states what a graduating resident should know and what she should be able to do. It is reviewed, revised, and defended at accreditation.

The other one is learned from what the program rewards and what it lets pass. From which attending gets requested and which gets quietly avoided. From what happens the first time an intern calls the attending at two in the morning. From whether the senior resident who took a shortcut was corrected or admired.

Medicine named the second curriculum thirty years ago. Issue 003 of this publication borrowed Frederic Hafferty's name for it in passing, to mark the hidden curriculum off from the theory-practice gap as an adjacent problem, and then set it aside. I am taking it up here. Hafferty and Ronald Franks published "The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education" in Academic Medicine in 1994. Hafferty extended the argument in the same journal in 1998, in "Beyond Curriculum Reform: Confronting Medicine's Hidden Curriculum," and drew a distinction that has held. The formal curriculum is what is stated and endorsed. The informal curriculum is the unscripted teaching that passes between individuals, attending to resident, senior to intern. The hidden curriculum is what the organization itself teaches through its structure: its schedule, its budget, its evaluation forms, its promotions.

The name is thirty years old. The method for seeing it is not there. A program that tries to assess its own hidden curriculum does it by asking the residents.

Residents are the least reliable informants available about the curriculum that is forming them. The nurses on the units where those residents work are among the most reliable. I have not encountered a program that asks them.

Four Curricula

Elliot Eisner added a fourth category that medical education has mostly ignored. In The Educational Imagination (1979), Eisner argued that a school teaches through what it leaves out. He called this the null curriculum: the content and the modes of thought that are simply absent, and whose absence instructs. A student learns from a four-year silence that the silent subject does not bear on the work.

The null curriculum is why a physician can finish medical school and residency and not know that nursing has theorists. Nobody taught that nursing has no intellectual tradition. Nobody had to. The absence did the teaching. Issue 011 of this publication argued that the ignorance between the two professions is bilateral, and it is. Eisner's category names the mechanism by which a bilateral ignorance gets manufactured on both sides without anyone intending it.

This is a different failure from the one Issue 003 described. The theory-practice gap concerns material that was taught and then not used. The hidden curriculum concerns material that was never taught and is used every day. A program can close the first gap and leave the second untouched. Most curriculum reform in graduate medical education has worked on the first, because the first is the one written down, and revising what is written is the kind of work an institution knows how to do.

The hidden curriculum is not a metaphor for institutional hypocrisy. It is a description of how organizations teach. A program that schedules its interprofessional communication seminar at seven in the morning on a post-call day has taught something about the standing of interprofessional communication, and it has taught it more durably than the seminar itself will teach anything. The schedule is the argument. The syllabus is the announcement.

Why the Resident Cannot Report It

The evidence that trainees absorb an unwritten curriculum is old and it is good.

Howard Becker and his colleagues spent two years with medical students at the University of Kansas and published Boys in White in 1961. What they found was a student culture that organized itself around a working estimate of what the faculty would actually require, which was not the same as what the faculty said it required. The students were not cynics. They were accurate. They allocated effort to the operative rule.

Charles Bosk did fieldwork in a surgical residency and published Forgive and Remember in 1979. He distinguished technical error from normative error. A resident who tied a knot badly was forgiven, because technical failure is expected of someone still learning. A resident who failed to disclose that he had tied the knot badly was not forgiven, because that failure was about the kind of person he was becoming. That distinction appeared in no syllabus. Every resident in the program learned it within months. Bosk's book remains the clearest single description of a hidden curriculum operating at full strength.

Renée Fox wrote "Training for Uncertainty" for The Student-Physician in 1957, on how medical students learn to keep working while uncertain. No course taught this. Students learned it anyway, because the wards required it.

Here is why the resident cannot report what she learned. Acquiring the hidden curriculum is the same event as becoming competent. The material goes from strange to obvious, and once it is obvious it is invisible. An intern in July is startled by something on the unit. By March she does it without noticing that she does it. She has not forgotten the strangeness. The strangeness has been converted into skill, and skill does not present itself to the person who has it as a thing that was taught.

Jean Lave and Etienne Wenger described this in Situated Learning: Legitimate Peripheral Participation (1991). Learning, on their account, is a change in a person's participation in a community of practice, and therefore a change in identity. When it works, the learner cannot narrate it, because the person who would do the narrating is the product of the change.

The ACGME Resident and Fellow Survey is a good instrument and it cannot solve this. It is annual, anonymous, aggregated to the program level, and it asks about supervision, faculty teaching, evaluation, resources, and the learning environment. It reliably detects a program in trouble. It was not built to surface what residents learned that nobody set out to teach, and it asks its questions in the vocabulary of the formal curriculum, which is the vocabulary least likely to catch what the formal curriculum missed.

The closest thing the accreditation system has built is the Clinical Learning Environment Review, which visits sponsoring institutions and reports on a fixed set of focus areas. It is an institutional instrument aimed at the hospital. It does not tell a program director what her interns learned in July.

The Standing Observers

A nurse on a unit staffed by residents sees three things at once that no one inside the program sees.

She sees the whole cohort. A program director sees residents one at a time, in evaluations, in semiannual reviews, in the cases that go wrong. The nurse sees all of them, side by side, doing the same work in the same rooms.

She sees them repeatedly across years. A charge nurse on a family medicine inpatient service has watched eight or ten intern classes arrive. She knows what the first week looks like. She knows what has changed by October. She knows which behaviors show up in every intern class regardless of who is in it, and that is the operational definition of a curriculum. A behavior that recurs across cohorts made of different people is not personality. It is being taught by something.

She sees the part of formation that happens where no attending is standing. At two in the morning. In the family meeting after the attending has left the room. At the moment an intern decides whether to walk into the room or write the order from the workroom. Issue 021 of this publication argued that the nurse sees the patient the physician does not see. The same standpoint that produces knowledge about patients produces knowledge about how physicians are made.

And she is not being graded by the program. Her account is not shaped by the incentive that operates on a resident asked to evaluate the program that will write his letters.

This is not multisource feedback. Programs already collect nursing ratings of individual residents, and have for years, because competency assessment requires input from people other than physicians. That instrument converts the nurse's observation into data about a resident. It produces a number on a form in a personnel file, and a resident who reads it learns that nursing observation is a thing that can be used against him.

What I am describing points the same observation in the opposite direction. The unit of analysis is the cohort, not the person. The finding is about the program, not about anyone in it. The question is not how a particular resident performed on your unit last month. The questions are these. What did this year's interns learn on your unit that nobody set out to teach them? What do all of them do by October that none of them did in July? What did the last three intern classes have in common that you have never seen written anywhere?

Answers of that shape are curricular data. They name the operative rule. A program that hears "they all learn in the first month that calling you about a rash is a waste of your time, so they stop calling" has just been handed a finding that no resident survey will ever produce, and that its formal curriculum on interprofessional communication is actively contradicting.

The mechanism is not special to medicine, and this is where honesty requires the symmetry. Nursing has a hidden curriculum too, and nurses cannot see theirs either.

Susan Jo Roberts published "Oppressed Group Behavior: Implications for Nursing" in Advances in Nursing Science in 1983, applying Paulo Freire's analysis of colonized populations to a profession trained for a century under another profession's authority. Her argument was that such a group turns the aggression it cannot direct outward against itself. The literature on lateral hostility that followed describes something no nursing school teaches and a substantial number of new graduates learn in their first year on a unit. Kathleen Melia interviewed student nurses in Scotland for Learning and Working: The Occupational Socialization of Nurses (1987) and found their accounts organized around a rule that appeared in no curriculum: get the work done. It governed their behavior more completely than anything they had been formally taught.

A physician who has spent years on the same unit could describe nursing's hidden curriculum with more accuracy than most nurses on it. The mechanism is identical in both directions. You can see a formation you are not undergoing.

The intervention is small and it is cheap. One structured conversation a year, on each unit where residents rotate, with the nurses who work there, asked as a program-evaluation question rather than as a complaint channel, recorded, and read into the annual program evaluation next to the resident survey. An hour per unit. No new committee.

The cost is not the hour. The cost is that a residency program which asks nurses what its residents learned has conceded that the nurses were teaching. They were, all along, and the program's curriculum document does not have their names in it.

The formal curriculum is a statement of intent. The hidden curriculum is a record of what the institution actually did. Every institution has both, and the distance between them is not evidence of bad faith. What is a failure is holding a thirty-year-old name for the problem, an annual survey that cannot detect it, and a unit full of people who could describe it in ten minutes and have never once been asked.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.