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Rapid Responses: Rapid Responses published:
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With respect to teachers
- Tony Rao (1 October 2004)
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Hidden Curriculum or Experiential Learning?
- Paul B. Batalden (1 October 2004)
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The hidden curriculum: Do not talk about the microbes of mass destruction!
- Friedrich Flachsbart (1 October 2004)
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With respect to students
- Adrian S. Blaj (3 October 2004)
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Re: With respect to students
- Tony Rao (4 October 2004)
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Belief and Pseudo-science in New Zealand
- Ron Law (4 October 2004)
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Clap trap
- W Parsonage (4 October 2004)
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Partners in Teaching
- Adrian S. Blaj (4 October 2004)
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Re: The hidden curriculum: Do not talk about the microbes of mass destruction!
- michael E godfrey (5 October 2004)
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Fear factor
- Jonathan D Beavers (5 October 2004)
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Master, where are you? Re: Fear factor
- Adrian S. Blaj (5 October 2004)
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Re: Re: The hidden curriculum: Do not talk about the microbes of mass destruction!
- Friedrich Flachsbart (7 October 2004)
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Caution, sometimes the bullied bite back
- Darren M Walkley (7 October 2004)
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Is competitiveness a negative trait?
- Ian A Rowe (10 October 2004)
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Culture change is needed
- Philip J Peacock (10 October 2004)
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Valuing diversity in academic medicine.
- Hany George El-Sayeh (11 October 2004)
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Relationships and Respect: Keys to Addressing the “Hidden Curriculum”
- Alexander Wong (12 October 2004)
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Hierarchy through humiliation
- Bella Vivat (15 October 2004)
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What bullying? In defence of medical education
- Aled M jones (1 November 2004)
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The hidden curriculum in medical education
- Moira C Stewart, Susan L Morison and John G Jenkins (11 November 2004)
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Graduate Medical Students More Likely to Recognise Humiliation Tactics
- Minha Rajput (7 December 2004)
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“Weak Humiliation” in the not so hidden medical curriculum
- Mike J McNamee (3 February 2005)
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Tony Rao, Consultant/Senior Lecturer in Old Age Psychiatry Guy's Hospital, London SE1 9RT
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Senior staff (particularly consultants) in teaching hospitals are often passionate about their area of expertise. Formal teaching, be it in the classroom or on the wards, should be audited and refined on a regular basis in order to make teaching informative, interactive and fun. Didactic teaching, historically carried out by flashing slides or overheads on the screen for a few seconds, should now have been replaced by frequent summaries of what has been covered and possibly the use of MCQs or open questions to facilitate learning. Given the changing nature of teaching in an attempt to improve learning, it is therefore still disappointing when students fall asleep in classroom settings and when they do not turn up for clinical teaching sessions. As mentioned in the paper (1), it is true that most clinical teachers have other commitments. Notwithstanding such commitments, consultants frequently contribute over and above what is expected in terms of bedside teaching. Teaching should have moved away from learning by humiliation, but students fail to understand that they have an equal part to play in the learning process. Self-directed learning and curiosity are central to getting the most out of medicine. A similar qualitative study interviewing teachers may form a more rounded view of teaching and learning. Usurping a well known tenet and turning it on its head, 'those who can, learn'! (1) Lempp L, Searle C. The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. BMJ 2004;329:770-773. Competing interests: A clinical teacher at GKT Medical School |
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Paul B. Batalden, Professor, Pediatrics and Community and Family Medicine Dartmouth Medical School
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I enjoyed the further description of the "hidden curriculum" of medical students. How is this different from David Kolb's description of "Experiential Learning" ? Competing interests: None declared |
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Friedrich Flachsbart, General Medicine Praxis 37085 Göttingen
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Dear Sir, the Prime Minister is suffering again. And NATURE shows us the hidden cause: "The harder you look, the more you find ... and that isn't always good news. A European research network has found that infections with group A Streptococcus .., also known as 'flesh-eating bacteria', are more common than previously thought. Scientist in 11 countries .. found five times as many such infections as they anticipated in the first 18 months of their surveillance. They estimate that about 20.000 severe cases occur in the European Union each year, and this seems to be increasing." (1) The Prime Minister is suffering again. And the NEW ENGLAND JOURNAL of MEDICINE shows us the epidemic: "Emergence of New Epidemics of Cardiovascular Disease. ..In addition to heart failure, the number of hospital discharges for atrial fibrillartion more than doubled from 111.000 in 1984 to 270.000 in 1994. This is worrisome, because patients with this arrhythmia are at risk of embolic stroke and heart failure.." (2) "Westernized countries are in the midst of an asthma epidemic. Despite much effort, therapeutic advances have not kept pace with the dramatic increases in the incidence, prevalence, and serverity of allergic asthma that have occured over the past two decades in such countries." (3) And the Prime Minister is suffering again. And he and his people will suffer more and more, unless we learn again the lesson of the century: "By then the connection between streptococcal infection and rheumatic heart disease was clear.." (2) By then even the connection between streptococcal infection and asthma was clear, Professor NGM Orie taught it to me. We have to re-learn these old concepts! Sincerely Yours Friedrich Flachsbart 1. Flesh-eating bacteria get a taste of success Nature 2004;431:393 2. Braunwald E: Cardiovascular Medicine at the Turn of the Millenium: Triumphs, Concerns, and Opportunities. NEJM 1997;337:1360-1369 3. Wills-Karp M, Karp CL: Chitin Checking - Novel Insights into Asthma. NEJM 2004;351:1455-1456 Competing interests: None declared |
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Adrian S. Blaj, Psychiatrist Chase Farm Hospital, Middlesex, EN2 8JL
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If I am not mistaken, there is a general tendency in people of making dispositional attributions. In other words, usually the dead victim gets the blame. Dr Rao (Rao, 2004) appears to be no exception from this rule forgetting that medical students have their own problems by no means free of turmoil at that delicate age. How many times we read in various journals about the 'giants' of our time making reference to a special teacher who influenced them in their career during a critical period of development? As a rule of thumb, good teachers produce good disciples; the corollary would be: garbage in, garbage out! Reference: With respect to teachers - Tony Rao (1 October 2004) - Rapid response to: Lempp, H. and Seale, C. (2004) The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching, BMJ 2004; 329: 770-773 Competing interests: Distant memories of life as a medical student forced to work part-time |
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Tony Rao, Consultant/Senior Lectuer in Old Age Psychiatry Guy's Hospital
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Dr Blaj has clearly taken exception to a statement about students being in charge of their own learning. My own views are based entirely on my own experience as a teacher. The grating generalisation of 'garbage in, garbage out' is perhaps more an example of generalising dispositional attributes and little suprising. Whether or not a student is at a 'delicate' stage of their life does not exonerate them from being an active part of the learning process. Competing interests: Teacher at GKT Medical School |
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Ron Law, Risk & Policy Analyst Beyond Alternative Solutions
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Lempp, and Seale define "Hidden curriculums" as: "the set of influences that function at the level of organisational structure and culture including, for example, implicit rules to survive the institution such as customs, rituals, and taken for granted aspects..." They then say that there are six learning processes of the hidden curriculum of medical education have been identified: loss of idealism, adoption of a "ritualised" professional identity, emotional neutralisation, change of ethical integrity, acceptance of hierarchy, and the learning of less formal aspects of "good doctoring." The term 'hidden curriculum' seems to be weasel speak, and incorrect terminology. The article makes it sound even part way acceptable. What it really is is subtle brainwashing, the sort of thing we would consider cult training from the Moonies or something like that. What the authors are really talking about is those things that make up the culture, the "religion" "customs or rituals" as they put it... that unless you are prepared to change your attitudes, and are compliant to do what the system wants to do, you can't succeed. The current frenzy being created through the use of Pseudo-science and emotion to mass vaccinate 1.2 million children in New Zealand with an experimental vaccine with no proven efficacy is ample evidence that such a belief system is alive and well in the New Zealand public health system. Competing interests: Member of the New Zealand Ministry of Health Expert Group that advised the Ministry on the management of medical injury in the health system. |
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W Parsonage, Doctor Australia
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This kind of publication explains a lot about the chaotic state of medical education. How can a series of anecdotes from 36 highly selected subjects from a biased sample of a population have any scientific (or sociologic, or educationalistic...) merit? Good enough to be a leading article in a prestigeous medical journal, obviously. Is this really the best the BMJ is receiving? Sure, this is fun/entertaining/horrifying stuff to read but in the same way as sitting around the coffee bar telling the same same stories was a few years ago (ok quite a few years ago). Beyond that I hope no-one takes it too seriously. Competing interests: None declared |
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Adrian S. Blaj, Psychiatrist Chase Farm Hospital, The Ridgeway, Middlesex, EN2 8JL
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I apologise if I inadvertently offended anybody. My intention was to emphasise that in the new era of internet revolution and information transparency, when patients - for instance - no longer feel that their care should be left to the benevolence of doctors and demand to be partners in their own care, the medical students should be viewed as partners in teaching as opposed to 'partners' in the old charade of teaching by humiliation. If the lecture(r) does not have the power to be interesting, who can blame the poor audience? Competing interests: Devil's Advocate |
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michael E godfrey, Private practice physician 157 fraser st. tauranga 3001 NZ
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Dear Sir, Look at the host instead of the bug, to quote: “Le terrain c’est tout – le microbe n’est rien.” There is a common but usually missed factor underlying cardio-vascular disease and especially tachy-arrhythmias, senile dementia of the Alzheimer’s type, as well as asthma and autistic spectrum disorders. It is called mercury. Notably, the current middle-aged cohort, including presumably the British Prime Minister, were the first to have been subjected as children to an inordinate amount of dental amalgam fillings in the post-WW2 years, something that had never been previously done to such an extent. The legacy of that uncontrolled albeit well-intentioned experiment in socialized dentistry is now coming to fruition as shown in our paper (1). Mercury as thimerosal was also present in most of the childhood vaccines and with the increased vaccine combinations in the 1980s, infants were being given bolus doses totaling >180mcg compared to <50mcg in earlier years. Notably, a doubling of asthma has been reported following vaccination in controlled studies including 13,900 children in the USA(2) and although there is still considerable debate concerning the mercury-autism association, the latest Californian autism statistics have shown the first decrease in 30 years after the figures for the ’99-’00 birth cohort (who were not given 180mcg of thimerosal), were computed in. Mercury also greatly depletes selenium and thus glutathione peroxidase. Selenium is cardio-protective, cancer-protective and essential for a healthy functioning anti-oxidant system. Logically, those that are chronically selenium depleted will be at greater risk of pathology depending on their genetic weaknesses and mercury will exacerbate this. Isn’t it time that those teaching future doctors included instructions concerning what is in patients’ teeth as they are also an integral part of the body? M.E.Godfrey MBBS (London 1963)
References 1. Godfrey ME, Wojcik DP and Krone CA. Apolipoprotein E genotyping as a potential biomarker for mercury neurotoxicity. J. Alzheimer’s Dis. 2003;5:189-195 2. Third U.S. National Health and Nutrition Examination Survey. Hurvitz et al. J. Manip. Physiol.Ther. 2000;23:81-90 Competing interests: None declared |
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Jonathan D Beavers, Medical Student University of Edinburgh Medical School, EH8 9AG
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Fear, bullying, intimidation, disrespect from other professionals. No matter what profession you work in, any atmosphere where you are afraid to speak your mind or scared to ask a question does nothing for the advancement of your training. Despite this being a small sample, the majority of medical students will be able to relate to the issues touched on in this article. Many medical academics are fine role models for students and often go beyond the call of duty in providing support, help and advice to medical students. The British Medical Association Medical Students Committee would welcome and actively participate in the setting up of schemes that reward good teaching practice, particularly to those who excel in their field. However, we cannot ignore the fact that many students report bully tactics and intimidation, particularly in the clinical setting. Whilst students should work hard to gain the knowledge required of them (and believe me, we do work hard!), we are just that; Students. We don't know everything yet and we are there to learn. We cannot do that in an environment where we are scared to have a go when we aren't sure, or ask a question if we don't understand. Any student in such a situation should immediately report the incident through the University/Medical schools whistle-blowing procedures. However, many students are afraid to do this for fear of not passing their course or don't know how to do so. Medical schools have an obligation to inform students of how these procedures work and make sure they are completely confidential. It is simply unacceptable that students are taught in fear. It is upto those of us who believe in good medical practice and a positive learning environment to ensure that bullying of any sort is stamped out of the healthcare profession. Jonathan Beavers Deputy Chair for Welfare, British Medical Association Medical Students Committee Competing interests: None declared |
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Adrian S. Blaj, Psychiatrist Chase Farm Hospital, The Ridgeway, Middlesex, EN2 8JL
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Thank God there is a medical student who speaks loud and clear at last. I sincerely believed that in the aftermath of the publication of the original article, there would have been a flood of letters pouring from the direction of the medical students! It is interesting to know whether they have knowledge of this dynamic and interactive site which offers amongst others the opportunity to be famous for a few seconds :) The amazing technology advances offer nowadays a unique chance of learning medicine directly from the source in a live fashion, bypassing those textbooks which are anyway well out of date by the time they are printed. But how many of us teach the students to go directly to the source to search for the best articles published in their chosen field? The time of traditional teaching may have gone forever; an astute medical student can again choose his 'Master', just as well as in those golden times of a Freud, Schneider, Bleuler, etc. The problem, I guess, is finding them! Competing interests: None declared |
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Friedrich Flachsbart, General Medicine Praxis 37085 Göttingen
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Dear Sir, the interactions between tooth and post-streptococcal-reactive disease are in the focus of Thomas Mann's work. "Es ist gelernte Wurzelbehandlung", sagte er zu mir. "Für Streptokokken-Überschwemmung komm' ich nicht auf." "That is sophisticated treatment of the root of a tooth", he said to me. "I do not accept responsibility for streptococcal- inundation." (1) The interactions between tooth and post-streptococcal-reactive disease are in the center of Wolfgang H. Veil's work. He even treated paranoid depression connected with infection of the root of the tooth by clearing the infection. (2) 1. T. Mann: Doktor Faustus: Das Leben des deutschen Tonsetzers Adrian Leverkühn, erzählt von einem Freunde. S. Fischer Verlag, Berlin, 1963. Page 163. 2. W. H. Veil: Der Rheumatismus und die streptomykotische Symbiose. Pathologie und Therapie. Ferdinand Enke, Stuttgart, 1939. Page 675. Sincerely Yours Friedrich Flachsbart Competing interests: None declared |
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Darren M Walkley, Locum Consultant Salford Royal Hospital, M6 8HD
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While still a PRHO, a colleague of mine arrived on his first day to be given the unenviable task of presenting at the following day’s Grand Round. Not only had patient X died the previous week, none of his team were going to be able to make the presentation either. He soon learned that the round was a well known battle ground for senior prima-donnas to humiliate their opposition with their light sabre sharp ‘retrospectoscopes’. The following day arrived, and never having really read his ‘Hidden Curriculum’(1), my colleague gave all the attending juniors a relevant page number in the ubiquitous Oxford Handbook. Soon as his case presentation had finished the onslaught started. The all too familiar, and thinly disguised, questions on management appeared as a personal attack. He took it well and had soon moved onto the slide presentation regarding the condition. He started to ask questions to the floor, and soon found the same style of attack. He quickly started to ask his attackers simple factual questions on the topic, and not being satisfied with their responses, turned to the juniors, armed with their aid memoirs, to be given model answers. He was never humiliated again. This story highlights some of the problems associated with bullying and humiliation as teaching techniques. Not only does it reduce the students’ self-esteem, it undermines the authority of the teacher. All too often, teachers with vast depths of knowledge and experience are secretly ridiculed or avoided because of their over bearing approaches. In other situations of bullying and abuse, the abused often go on to become the abuser. The medical profession needs to be immune to this. Much has been done to reduce bullying, but with reduced hours and stretching of manpower, efficient and encouraging mechanisms of education need to be taught at all levels to prevent reversion to the old ways of harassment. Requiring a standardised teaching module prior to achieving CCST is a first step towards this goal. 1. Heidi Lempp and Clive Seale. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. BMJ 2004; 329: 770-773 Competing interests: None declared |
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Ian A Rowe, Senior House Officer in General Medicine University Hospital Nottingham, Nottingham, NG7 1UH
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Dear Sir – Lempp and Seale suggest competitiveness is a negative aspect of the “hidden curriculum”(1). To enter medical school one needs to pass exams, have the requisite experience and perform well at interview, in direct competition with other students. The majority of medical students are caring, compassionate but also likely ambitious individuals. Is it really surprising that this competitiveness is continued into medical education? It is clearly a concern when half of students questioned in this study feel that competition is the defining characteristic of medicine. This is a worrying finding given the importance of team working in clinical practice, especially as it was the clinical students who identified competition more readily. Team working in education may be as important as it is in clinical medicine, especially with the advent of the “problem based learning” curriculum. Competitiveness is in itself not a bar to good team working. I would suggest that this study was carried out in a Medical School with a “traditional” curriculum with more “traditional” values. It would be interesting to know if these data were comparable with data obtained from students enrolled in a “problem based learning” curriculum, given the negative article published recently with regard to the problem based learning curriculum(2). The real question is whether this competitiveness is counterproductive. The answer is that it is not… In moderation. Competition is healthy and natural. And after all it seems unlikely that competitive spirits will, or should, be eliminated from students since they will be forced to compete with each other intermittently throughout their careers. 1. Lempp L, Searle C. The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. BMJ 2004;329:770-773. 2. Williams G, Lau A. Reform of undergraduate medical teaching in the United Kingdom: a triumph of evangelism over common sense. BMJ 2004;329:92 -4. Competing interests: IAR is a recent graduate from a problem based learning curriculum. |
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Philip J Peacock, Medical Student University of Bristol, UK
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I read with great interest Lempp and Seale's paper on medical students' perceptions of teaching.[1] The students' stories in the paper are all too familiar and match many experiences of myself and my friends. I fully agree with Jonathan Beavers[2] that bullying and humiliation are unacceptable and should be stamped out, but a complete culture change is needed before this can be achieved. As a medical student, it is generally accepted that you will sometimes (or often, depending on your consultant) be made to look stupid in front of friends, doctors and patients, and the 'hidden curriculum' teaches you to accept this early on. Students will only begin to report unacceptable behaviour by senior doctors if they are taught themselves that it is unacceptable - otherwise it will continue to be seen as an inevitable part of training to be a doctor. Huge culture change is needed before such practices will be stopped, and the responsibility for this is with the medical schools and hospitals, not with the students. Refs: [1] Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. BMJ 2004;329:770-773 [2] Beavers JD. Fear factor. BMJ Rapid response to [1] Competing interests: None declared |
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Hany George El-Sayeh, Honorary Lecturer in Psychiatry Academic Unit of Psychiatry and Behavioural Sciences, 15 Hyde Terrace, Leeds, LS2 9LT
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Dear Editor, I was very interested to read the recent article by Lempp and Seale (1) - which in light of a medical student survey, proposed changes to the ‘hidden’ undergraduate medical curriculum. Although, I believe that many of their views are perceptive and added to the debate on medical education, others are less so. In particular, I would like to draw their attention to the observation that women and ethnic minority doctors involved in education were poorly-represented in terms of being viewed as role models by medical students. Only 2/46 of the named role models were ‘non-white’, in spite of 14/36 surveyed students being ‘non-white’. Likewise 27/46 of the role models were males, and 19/46 were females. One may infer from the article that white, male teachers are more likely to be perceived as role models by medical undergraduates- regardless of their own ethnic backgrounds. Are women and ‘non-white’ teachers inherently less inspirational than their white, male counterparts? Personally, I have my doubts. What the article explicitly failed to do, was to provide information on the gender and ethnic make-up of the medical teachers that the student cohort may have come into contact with during their training. My guess is that women and ethnic minority teachers formed a disproportionately small number of the medical educationalists, and thus this finding is hardly surprising. The fact that women and ethnic minorities are under-represented in academic medicine (of which teaching forms a major part) is not new, and is well borne out by other notable articles(2,3). As a ‘non-white’ medical teacher, I found this observation potentially misleading. I would like to ask the authors to provide further information and a more rigorous analysis of their findings- prior to inferring value judgements on the perceived worth of different groups of teachers. Funding: None
References: 1 Lempp H, Seale C. The hidden curriculum in undergraduate medical education. BMJ 2004; 329:770-3. 2 Reichenbach L, Brown H. Gender and academic medicine: impacts on the health workforce. BMJ 2004; 329: 792-5. 3 Fang D, Moy E, Colburn L, Hurley J. Racial and Ethnic Disparities in Faculty Promotion in Academic Medicine. JAMA 2000; 284:1085-1092. Competing interests: None declared |
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Alexander Wong, Medical Student Schulich School of Medicine, University of Western Ontario, London, ON, Canada. N6A 5C1
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Dear Editor,
There certainly is no shortage of literature which reviews and recognizes the negative influence of the “hidden curriculum” in shaping the morals and beliefs of aspiring physician-healers (1, 2). Despite a renewed emphasis on defining and developing professionalism, recent studies indicate that attributes typically associated with professional virtue often decline during undergraduate medical education, a most worrisome reality (3, 4). Irregardless of one’s institution, there are universal incongruences between what medical students are told to do (the formal curriculum) and what medical students see as being acceptable behaviour (the informal curriculum). While the presence of this “gap” is widely accepted, what remains far less clear is what can be done to reduce or eliminate this “gap” altogether. A promising concept for combating the deleterious effects of the “hidden curriculum” is the relationship-centered learning environment. While numerous attempts at changing various aspects of a medical curriculum have met with limited success, perhaps a golden key lies not in the curriculum itself, but rather the context in which that curriculum is delivered. Imagine an environment where students and faculty treat each other with respect and dignity, where education and growth are viewed as a shared collaboration that benefit the student and teacher equally. Does this sound like an impossible fantasy? It is closer than you might think (5). Medical students, no different than any other group, absorb and propagate the behaviours and attitudes we observe around us. If we are cared for and treated with respect, it will reflect in how we care for our patients, our colleagues, and each other. This is not a new phenomenon within the context of the world in which we live – all of us have heard the common saying, “Treat others with the respect that you think you deserve.” Why should the context in which medical education is delivered be any different? Amazingly, for many decades, it has been. The time is ripe for change. Finally, a plea to my fellow medical students – it is important for us all to recognize the existence of the “gap” that exists between the formal and informal curricula and how it may affect our professional development. However, it is just as important once we recognize this gap to aid in closing it. Each faculty has its kindred spirits, many often tucked away in places where we would least expect to find them. Seek these individuals out – share your experiences, build meaningful relationships, and discuss what kind of difference you can make. After all, if we are not part of the solution, we are part of the problem. References 1. Lempp L, Searle C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. BMJ 2004; 329: 770-773. 2. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003. 3. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Acad Med 1994; 69: 670-679. 4. Marcus ER. Empathy, humanism, and the professionalization process of medical education. Acad Med 1999; 74: 1211-1215. 5. Suchman AL, Williamson PR, Litzelman DK, Frankel RM, Mossbarger DL, Inui TS. Toward an informal curriculum that teaches professionalism. Transforming the social environment of a medical school. J Gen Intern Med 2004; 19: 501-504. Competing interests: None declared |
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Bella Vivat, Research Fellow King's College London, Denmark Hill, London SE5 9RS
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Having worked as a research fellow in and/or with several academic medical departments, I would like to highlight that the process of maintaining hierarchies through humiliation which this paper discusses are not unique to medical student training but also at times present in medical academia. Not only is this atmosphere abusive, even shading at times into bullying, but also counter-productive, since, if members of a department are treated as subordinates rather than colleagues, any real debate is stifled. One of the implicit, taken-for-granted rules in such situations is often that medical doctors are superior to all other professional groups. This is reinforced through the pay system, whereby "non-clinical" researchers are paid significantly less than "clinical" researchers, even when doing equivalent work. Medical students do at least have the opportunity of eventually reaching the pinnacle of the hierarchy, but this route is closed to all other professions. An additional problem is the system of short-term contracts, which is unfortunately still endemic in academia, despite government guidelines. The consequent need for researchers to "toe the line" in order to obtain a good reference for the next post, echoes the dependence of medical students and junior doctors on the good will of their consultants, and similarly inhibits open discussion of these issues. The irony for me is that I was previously a medical student, who left medicine in part because of my profound distaste with the "hidden curriculum" (although at the time I was not aware of this concept). Competing interests: None declared |
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Aled M jones, medical student Oxford University Medical School, John Radcliffe Hospital, Oxford
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I regret to read of the experience of several medical students being subjected to humiliation teaching methods in pursuit of the hidden curriculum (1). Such report of bully tactics in educating tomorrow’s doctors does nothing to inspire confidence in the medical profession of the future. I was surprised to read that this was not the only UK medical school. It seems that experience of a fear factor being used to motivate medical students is commonplace in at least two other UK medical schools (2,3). I agree with the view expressed by two medical students (2,3) that bullying and humiliation are unacceptable in the education of any professional, especially doctors. However, I must disagree with Philip Peacock's (3) and Jonathan D Beavers’ (2) observations that such events are familiar to the majority of medical students. Based on my experience of medical school, this is not the case. As a final year student, I have never felt humiliated by a clinical teacher, and not once felt pressured to learn in order to avoid embarrassment. I assure you, this is not due to particularly sound knowledge or clinical acumen. On the contrary, I have experienced tremendously patient and dedicated teachers, despite my lack of knowledge, throughout my years at medical school. I felt the need to defend current medical education standards. My medical education has been characterised by inspirational role models who strive to teach positively. It seems to me that bullying methods are thankfully a thing of the past. In fact, my medical school has gone to such lengths to prevent such behaviour that the main gripe of students nowadays is the endless completion of feedback forms on medical teaching. In my opinion this culture change has achieved a climate where it is impossible to get away with negative teaching. References: (1) Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. BMJ 2004;329:770-773 (2) Beavers JD. Fear factor. BMJ Rapid response to (1) (3) Peacock PJ. Culture change is needed. BMJ Rapid response to (2) Competing interests: None declared |
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Moira C Stewart, Consultant Paediatrician/Senior Lecturer in Child Health Department of Child Health, Queen's University, Belfast, BT12 6BJ, Susan L Morison and John G Jenkins
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Medical education provides the means by which students begin to develop their professional identity, defines how they must behave and the knowledge and skills they must acquire in order to be perceived as professionally acceptable to their teachers and fellow professionals.1 However, a current dilemma for the medical profession is to agree what constitutes professional competence. Doctors are required to be caring, effective communicators and team workers and at the same time to be at the forefront of cutting-edge scientific research and able to understand and utilise rapidly advancing technology. For all the criticism it has received, the traditional approach to medical education provided medical practitioners with clearly defined roles, a strong sense of identity and has produced a highly trained and motivated workforce capable of driving technological advancements. However, its hierarchical and professionally insular structure has been held responsible for failing to promote team working and communication skills and to have contributed to the highly publicised problems faced by the medical profession in recent years.2,3 Lempp and Seale4 highlighted a problem with medical education’s hidden curriculum. We suggest that a clear answer to this problem and intrinsically linked to the issue of professional identity, is the involvement of students from different professions in interprofessional education (IPE). Rather than taking a hierarchical and competitive approach to medical education, IPE enables teachers and learners to experience and appreciate the skills and competencies of other healthcare professionals. Contrary to arguments that IPE blurrs professional boundaries, ward-based IPE delivered by an interprofessional team can help teachers and learners define and understand their own unique but complementary roles.5 Effective communication and reflective practice are integral components of this approach and the skills learned have the additional advantage of being inherently transferable to a variety of clinical settings and to different groups of healthcare professionals. Ward-based IPE has been introduced in to the undergraduate medical and nursing curricula at Queen’s University, Belfast. Teachers and students reported that this programme had improved their ability to communicate with patients and other healthcare professionals and had enhanced their understanding of the need for a collaborative approach to patient care.5 Just as the medical profession must embrace change so medical education needs to prepare students appropriately for C21st professional practice, and through evaluation of these changes, improve patient care. References 1. Slotnick, HB. How Doctors learn: Education and Learning across the Medical-school-to-practice Trajectory. Academic Medicine 2001; 76:1013- 1026. 2. Department of Health. Learning from Bristol: The Report of the Public Inquiry into Children’s heart Surgery at the Bristol Royal Infirmary 1984-95 2001; London: TSO. 3. Department of Health. Royal Liverpool Children's Inquiry 2001; London: Stationery Office. 4. Llempp H. and Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. BMJ 2004; 329: 770-773. 5. Stewart M, and Morison S. Assessing interprofessional education. Archives of Disease in Childhood 2004; 89: (1) A27. Competing interests: None declared |
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Minha Rajput, Medical student University of Dundee
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Now almost at the end of my undergraduate medical training, I have been reflecting on my experiences at medical school. One that comes to mind in particular is that of our first simulated patient consultation. My group consisted of the younger (straight from school) and slightly older graduate students. As a group we all had varying levels of anxieties at having our communication styles recorded on video tape and critically reviewed. We all responded differently to comments from our tutors – some thought that the tutor had been too strict, others believed that the assessment was fair. What I do recall is that overall the older students having a more questioning approach to their feedback. It has been reported that graduate students feel significantly less anxious and more prepared than their undergraduate colleagues at the transitional stage of getting into fulltime clinical attachments.(1) Graduate students by virtue of their age are far more likely to have dealt with challenging life situations and thus maybe are better prepared to cope with and question the validity of remarks made by teachers. Thus, I wonder if this observation maybe of use in interpreting a recent study that reported of a hierarchical and competitive atmosphere where teaching is frequently haphazard and often involved humiliation by professors.(2) One of the reasons why medical students feel that they are being humiliated maybe because of a change in perception. Of course this goes without saying that some medical educators have not quite understood the breed known as a graduate entrant to medicine. Often these students have excelled in other areas of professional and personal development, have experienced what life has to offer and thus expect more respect as individuals for their commitment to medicine. This acknowledgment need not be more than a few well placed words of encouragement. Speaking to this type of student in a condescending tone (as is often done in medical teaching rounds) may be easily perceived as a humiliation tactic. I note the difference in my younger colleagues now and how some of them have really ‘grown up’ and started to question the appropriateness of certain teaching styles. With the increasing numbers of graduate entrants to medicine, what might have been accepted as the norm in terms of how medical educators interact with students is fast changing towards empowering the medical student in taking responsibility for one’s learning. 1. Hayes K, Feather A, Hall A, Sedgwick P, Wannan G, Wessier-Smith A, et al. Anxiety in medical students: is preparation for full-time clinical attachments more dependent upon differences in maturity or on educational programmes for undergraduate and graduate entry students? Med Educ 2004;38(11):1154-63. 2. Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching. Bmj 2004;329(7469):770-3. Competing interests: Graduate entrant to Medicine |
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Mike J McNamee, Senior Lecturer in Philosophy School of Health Science, University of Wales Swansea
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That there is a hidden curriculum in all aspects of professional socialisation should surprise no-one. It is scarcely a new or novel phenomenon in medicine or other social practices. In their recent article Lemp and Seale article, and in the many responses it spawned, one feature was frequently referred to though not properly analysed. The issue I refer to is the humiliation of medical students which is part of their initiation into the profession. The “findings” of Lempp and Seale build upon those of others who have pointed to this noxious feature of the processes of doctors-in-becoming. The philosophical question begged in all of this debate, or better one of them-there are clearly important ethical issues that I will not address here- is the conceptual question: “is humiliation the most felicitous concept to capture the ranges of experience described or implied in the circumstances that are put forward?”. I shall argue, very briefly, that without qualification it is not. I shall set out a distinction between weak and strong humiliation to defend that view. As with most morally significant notions, to fully understand this highly undesirable experience would require a careful delineation of humiliation in relation to its close conceptual cousins (a task that time and space does not permit here). A fuller analysis would need to place the experiences in a landscape that included the concepts of shame, embarrassment, dignity, hubris and humility. The paradigm case, one might reasonably assert, for humiliation would be torture. Clearly the ranges of experience in medical socialisation do not come close to the gravity of torture. Why then do people frequently describe the experiences in this way? Typically, we think of the torturer as an evil person. Ought we to think of medical professors doing their round fully equipped with vast resources of technical knowledge and concomitant sarcasm and derision to fit that description? It seems overblown-a piece of gross conceptual inflation to include these in the same categories. Disrespectful; certainly. Arrogant; quite possibly. Evil; surely not. The limit case of humiliation, torture, entails the basic denial of the means of self-respect . One’s basic dignity as a person is assaulted. In such cases we do well to describe the experience as one of “strong humiliation”. Here the humiliated are passive at the hands of the tormentor. In weaker cases such as ours, however, the power balance is not as dramatic. The question then remains, can we think of what is reported as “humiliation” as reasonable, or justifiable? There are two responses available here. The first is that humiliation entails a denial of self-respect whereas embarrassment (however intense) requires only a lowering of self- esteem. So, it could be argued, the arrogant Professor (whomever she or he maybe) is merely embarrassing, or at worst ridiculing, the student by lowering their self-esteem; showing how foolish their judgment is, how awry their diagnosis, and so on. S/he may feel ashamed at her incompetence, “beside herself” even, but it is merely rooted in a deflation of their overblown self-conceptions of their competence, it could be argued. I do not subscribe to this view. It is too weak on context in general, and specifically in its failure to accord the significance of the event in the life of the young professional. To understand the experience that the student feels it is necessary to think on the perceived significance of the context, and to consider in a narrative fashion, the place of the experience in their lives. It seems better to think of the experience as somewhere between these two cases: it is not mere embarrassment but neither is it strong humiliation. Rather, we are better to think of these as instances of “weak humiliation” . I shall say why I think this is right, after I have noted two strengths of such a conceptual move. First, to describe as embarrassing the experience of the “humiliated” student is to deflate in ethical terms the motives of the professor (who may think, mistakenly, that the comedy is of a light nature). Secondly, it fails to capture the ethically significant features of the context. Here the student whose identity is so deeply vested into the practices of medicine, and whose competence has been so publicly derided: her or his life project is momentarily shattered. So to label the experience embarrassment in virtue of the loss of self-respect felt by the student fails to capture the significance of the event in their life and render less culpable the disrespectful professor. Lemmp, H. and Seale, C The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching BMJ, Oct 2004; 329: 770 – 773 Sinclair S. Making doctors. An institutional apprenticeship. Oxford: Berg, 1997; Cribb A, Bignold S. Towards the reflexive medical school: the hidden curriculum and medical education research. Stud Higher Educ 1999;24: 195-209. Margalit, A. The decent society (goldblum, n., trans.). London: Harvard University Press, 1996. Miller, W .I. Humiliation: and other essays on honor, social discomfort and violence. London: Cornell University Press, 1993. m.j.mcnamee@swansea.ac.uk Competing interests: None declared |
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