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The Hidden Curricula of Medical Education: a Scoping Review Carlton Lawrence, Tsholofelo Mhlaba, Mbcbb, Mmed, Kearsley A

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The Hidden Curricula of Medical Education: a Scoping Review Carlton Lawrence, Tsholofelo Mhlaba, Mbcbb, Mmed, Kearsley A Review The Hidden Curricula of Medical Education: A Scoping Review Carlton Lawrence, Tsholofelo Mhlaba, MBCbB, MMed, Kearsley A. Stewart, PhD, Relebohile Moletsane, PhD/MsC, Bernhard Gaede, MBBCh, MMed, PhD, and Mosa Moshabela, MBChB, MMed, PhD Abstract Purpose reliability. They extracted, coded, and curriculum” is understood as a mostly To analyze the plural definitions and analyzed key data, using grounded negative concept. Its definition varies applications of the term “hidden theory methodology. widely, but can be understood via four curriculum” within the medical conceptual boundaries: (1) institutional– education literature and to propose a Results organizational, (2) interpersonal–social, conceptual framework for conducting The authors uncovered 3,747 articles (3) contextual–cultural, and/or (4) future research on the topic. relating to the hidden curriculum in motivational–psychological. medical education. Of these, they selected Method 197 articles for full review. Use of the Conclusions The authors conducted a literature search term “hidden curriculum” has expanded Future medical education researchers of nine online databases, seeking articles substantially since 2012. U.S. and should make clear the conceptual published on the hidden, informal, or Canadian medical schools are the focus boundary or boundaries they are implicit curriculum in medical education of two-thirds of the empirical hidden applying to the term “hidden prior to March 2017. Two reviewers curriculum studies; data from African and curriculum,” move away from general independently screened articles with set South American schools are nearly absent. musings on its effects, and focus on inclusion criteria and performed kappa Few quantitative techniques to measure specific methods for improving the coefficient tests to evaluate interreviewer the hidden curriculum exist. The “hidden powerful hidden curriculum. Editor’s Note: An Invited Commentary by F.W. taken-for-granted aspects of what goes ‘lumping’ together a series of related but Hafferty and M.A. Martimianakis appears on on in the life-space we call medical clearly disparate issues? What is brought pages XXX–XXX. education” and viewed the hidden to light and what is left invisible?”15(p540) curriculum in medical education as an MacLeod suggests that the medical institutional-level concept best visible in education community shift from Since its initial description in the “(1) policy development, (2) evaluation, repeatedly identifying what she sees as 1960s and its application to medical (3) resource allocation, and (4) no longer “hidden” issues to, instead, education in 1994, the reach of the institutional slang.”4(p404) In the 20 years actively addressing these now-visible so-called “hidden curriculum” in since this original conceptualization, practices. She goes so far as to question medical education has continuously researchers across the medical education the continued use of the term within expanded.1–3 Frederic Hafferty originally spectrum have used the term to expose medical discourse, writing that while the defined the term with respect to medical and explain a number of “hidden” facets hidden curriculum has historically been education as the “set of influences that of learning and teaching.5–8 The effects a powerful tool for curricular innovation, function at the level of organizational of what is described as the hidden now may be the time to retire it in favor structure and culture.”4 He described curriculum are rarely innocuous and in of more actionable concepts.15 Also, the hidden curriculum generally as the fact, are, in many ways, more influential Martimianakis and colleagues16 recently “‘understandings,’ customs, rituals, and than the formal curriculum.4,9–11 conducted a scoping review and explored the link between the hidden curriculum Please see the end of this article for information According to recent studies, the hidden and humanism in medicine. Their about the authors. curriculum is responsible for any valuable results show that the hidden Correspondence should be addressed to Carlton number of ills, from discouraging curriculum is responsible for much of Lawrence, Centre for Rural Health, 4th Floor, George medical students from pursuing surgical future physicians’ professional identity Campbell Building, Howard College Campus, specialties and encouraging inappropriate formation.16 Given this finding and University of KwaZulu-Natal, Durban, South Africa; student mobile device use, to increasing MacLeod’s concerns, we believe that it is telephone: +27312601569, e-mail: carlton_ 12–14 [email protected]. medical school admissions biases. essential for researchers to understand This vast and expanding use of the term how the hidden curriculum is defined Acad Med. XXXX;XX:00–00. has led some to doubt its continued and applied within the literature to First published online doi: 10.1097/ACM.0000000000002004 utility in medical education. For instance, enable more effectively categorizing or Copyright © 2017 by the Association of American MacLeod questions the benefit of labeling analyzing its effects. Thus, we conducted Medical Colleges the diversity and breadth of issues now this scoping view to systematically Supplemental digital content for this article is categorized as hidden curriculum as such, analyze the definitions and uses of the available at http://links.lww.com/ACADMED/A497. writing: “What are the consequences of term “hidden curriculum” in the medical Academic Medicine, Vol. XX, No. X / XX XXXX 1 Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. Review education literature. Our ultimate goal librarian, we drafted the following (1) focus on and explicitly name was to provide a strategic and deliberate Boolean search query for our database the hidden, implicit, or informal framework for using the term “hidden search: (“hidden curriculum” OR curriculum, curriculum” in the future. “implicit curriculum” OR “informal (2) involve medical school curricula— curriculum” OR “hidden curricula” not solely curricula from other OR “implicit curricula” OR “informal Method disciplines such as nursing, science, curricula”) AND (“medicine” OR pharmacology, or the like, and We employed a rigorous scoping “medical”). Scoping reviews that aim to review methodology17 to map medical map global concepts such as the hidden (3) focus on students obtaining education’s “hidden curriculum” curriculum must be comprehensive; thus, their medical degree, as that is literature. Scoping reviews are used we scanned seven databases: PubMed, understood in various countries (i.e., for a variety of purposes, including to Scopus, Web of Science, ProQuest, undergraduate medical education examine the extent, range, and nature of ScienceDirect, JSTOR, and EBSCOhost [UME] in the United States), and not research activity; to determine the value (filtered to relevant results from ERIC, exclusively on residents or fellows. of undertaking a full systematic review; WorldCat, Academic Search Complete, to summarize and disseminate research OCLC ArticleFirst, and PsycINFO). We We excluded books, book reviews, findings; or to identify gaps in the existing conducted the initial search on October commentaries, and letters to the editor, as 17 literature. This scoping review focuses 20, 2015, and a follow-up search on well as non-English articles. on conceptual mapping, the process of March 21, 2017. In addition, because of establishing how a particular term—in our placement in South Africa and the To confirm selection process rigor, we this case “hidden curriculum”—is used failure of some of the larger databases searched the bibliographies of 10 selected in the literature. We observed that within to include local journals, we decided to articles for the terms “hidden” and the medical education literature the term 22–31 conduct direct searches of the African “informal.” The search recovered no seemed to lack a distinct and universal new articles, providing further support of Journals Online database and the African definition; this ambiguity and its effects the rigor and comprehensiveness of our Index Medicus. We did not limit the on curricular understanding prompted search protocol. results by publication date, language, or us to adopt this “concept mapping” study type at this stage. approach, which we felt would allow 4. Charting the data for more systematic interventions based 3. Selecting the studies We employed Arksey and O’Malley’s17 on specific meanings, knowledge, and “descriptive-analysis” approach to data We imported all the titles our search learning encompassed by the hidden extraction, summarizing information from uncovered into EndNote software and curriculum. the selected articles and recording the data deleted duplicates. Two of us (C.L. and in an Excel sheet (Microsoft, Redmond, The particular approach to and level of T.M.) independently applied a screening Washington). This allowed us to analyze rigor of a scoping review is important, tool to all retrieved article titles and the selected articles through a common as the technique is not standardized.18,19 abstracts to determine their eligibility framework. We also followed Levac and To ensure the reliability of our methods, for full article review. We used a kappa colleagues’ recommendations for the data we used the five-step approach originally coefficient reliability test to determine the charting process.20 First, we collectively described by Arksey and O’Malley17 and reliability
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