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

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 of our screening tool. Because developed the data extraction form to later refined by Levac and colleagues20: the initial test of 50 articles resulted in a include both demographic data (e.g., year (1) identifying the research question; (2) kappa value of 0.78 (standard deviation of publication, location of publication) identifying relevant studies; (3) selecting [SD] = 0.151), which was below our goal and thematic categories (e.g., definitions the studies; (4) charting the data; and (5) of 0.90 (“almost perfect”),21 we refined of key terms, effects of curricular reforms, collating, summarizing, and reporting the the screening tool and conducted a conclusions). The review process was results. second test on 100 new articles. That test iterative; that is, we added and edited yielded an acceptable kappa coefficient columns on our spreadsheet as necessary 1. Identifying the research question of 0.96 (SD = 0.0332), and given the throughout the process. Our scoping review focused on new high level of reliability, we (C.L., answering the question, How is the term T.M.) each independently reviewed all 5. Collating, summarizing, and “hidden curriculum” understood within nonduplicative titles and abstracts for reporting the results medical education? After conducting inclusion. After this review, all of us We synthesized and collated various background research, we discovered that discussed any discrepancies and came to a themes that emerged from the data the terms “informal curriculum” and consensus on which articles to include for extraction sheet. The extraction “implicit curriculum” are often used in full review. sheet informed both quantitative and conjunction with, or as synonyms for, qualitative results and became a platform “hidden curriculum.” Thus, we decided to Next, each of us read a designated for synthesizing various definitions and include these terms in our analysis. number of the articles selected for full effects of the hidden curriculum. We used review. We each applied strict inclusion/ qualitative thematic analysis, based in the 2. Identifying relevant studies exclusion criteria to determine eligibility. grounded theory process of descriptive After considering our project goals and To be included in the data extraction coding,32 to generate the four conceptual consulting our university-affiliated sheet, each article needed to boundaries (see Results). We extracted all

the definitions of “hidden curriculum,” Of these 197 articles, 121 (61%) were Identifying the hidden curriculum “informal curriculum,” and “implicit published after 2010, and only 14 (7%) Systematic techniques for identifying or curriculum,” directly from the data on were published between 1980 and 1999 categorizing the hidden curriculum were our extraction sheet. We generated open (Figure 2). The bulk of the articles were rare.52 Through this scoping review, we descriptive codes (i.e., organizational, either qualitative studies (n = 84; 43%) or compiled a list of research methods used institutional, interpersonal, interactions, perspective pieces (n = 71; 36%). Literature to study the hidden curriculum. The norms, experiences, behaviors, socialization, reviews (n = 17; 9%), mixed-method most commonly used quantitative tools outside formal, location, implicit, studies (n = 13; 6%), and quantitative were the Communication, Curriculum, unintentional, culture, value) directly studies (n = 12; 6%) each constituted less and Culture (C3) Survey and the from the definitions in the articles. than 10% of the total. Patient–Provider Orientation Scale.53–56 Next, as outlined by Saldaña,32 we Both of these tools, however, measure the synthesized these primary descriptive Of the 109 empirical studies, over two- hidden curriculum solely with respect codes into coherent axial codes, grouping thirds (n = 76; 70%) were conducted to the patient centeredness of care and similar definitions (i.e., organizational/ in the United States or Canada or in do not extend to other elements of institutional/structure, interpersonal/ Central America. Other settings included UME.55 We noted that additional study- interactions/socialization, location-based/ Europe (n = 18; 16%), Asia (n = 8; 7%), or site-specific surveys were employed outside of formal/settings related, intention- and Oceania (n = 5; 5%). Our search in the three remaining quantitative determined/implicit). The theoretical produced only two empirical studies studies,34,57,58 but we identified no other codes, presented below in the Results as from Africa (2%), despite including the standardized measurement tool for the four conceptual boundaries, emerged continent-specific databases—African assessing the hidden curriculum. This from each of these axial codes. Next, we Journals Online and the African Index lack of standardization is likely due to the coded the selected articles a final time Medicus—in our search (see Table 1). The ambiguity of the definition of “hidden to examine them for the presence of any hidden curriculum is understood as deeply curriculum” across settings and among conceptual boundaries (nonexclusively) context and culture dependent, making authors, which we discuss in depth below. and to gather final frequency statistics. this geographic gap problematic.26,33 The majority of qualitative studies Results Although much of the literature speaks employed interviews and focus groups generally of the hidden curriculum of medical students to explore their self- Descriptive summary within UME, some authors focused identified understanding of the hidden Our initial search uncovered 3,747 titles, of special attention on certain topic areas, curriculum; however, some studies which 749 were duplicative. After applying including the hidden curriculum in used non-institution-specific surveys our screening tool to the remaining relation to palliative and end-of-life such as Australia’s Critical Reflection 34–40 41–44 2,998 titles, we identified 197 articles to care, the surgical rotation, Tool to analyze the informal elements 22,45–47 include in our final analysis (see Figure 1 postmortem exercises, and attitudes of their curriculum.59 A number of and Supplemental Digital Appendix 1 at toward marginalized or underrepresented investigators plumbed student and 48–51 http://links.lww.com/ACADMED/A497). groups. faculty reflections—written on paper and online—to find information relating to the hidden curriculum11,41,60–62; however, the effectiveness of these methods for 3,747 identifying the hidden curriculum is A. Identification records identified through database search dependent on the definition of the term 749 itself, something that is up for debate. records excluded as duplicates Addressing the hidden curriculum 2,998 B. Screening records reviewed for Through our review, we extracted any screening (title and abstract) methods cited as effective in changing or 2,685 records excluded using preserving the hidden curriculum. The screeningtool most common recommendation was 313 that schools make the hidden curriculum C. Eligibility records kept for full text explicit to both faculty and students.63–68 review 116 “Painful feedback,” one author’s records excluded after full term for the process of making the review hidden curriculum visible, encourages presenting direct evidence of the harmful elements of the hidden curriculum to students and other stakeholders.69 Open D. Included 197 records included in review discussion and self-reflection were also often encouraged.24,31,70–74 Chuang and colleagues75 state that separating Figure 1 Flowchart of search process and results. The flowchart outlines the process through curricular analysis at the individual, which the authors selected the articles included in this scoping review. departmental, and institutional levels

Figure 2 Publication frequency of articles included in this scoping review by year. Note: The years on the x-axis are in nonlinear groups because of the relatively few publications in years prior to 1996.

is necessary to ensure multilevel Ambiguity in hidden curriculum to compare definitions across articles interventions. Encouraging small-group We noted ambiguity in both the and map how each concept is defined in learning, patient-centered curricula, definition and application of the term reference to the others. The most common humanities education, and better “hidden curriculum.” Hafferty and and perhaps most alarming finding from integration of marginalized groups Franks2 first described the term “hidden this process was the ambiguous and also had positive effects on the hidden curriculum” in relation to medical interchangeable use of the terms “hidden” 31,62,76–78 curriculum. education in 1994, and Hafferty4 and “informal.” Of the 197 articles we later (1998) distinguished it from the reviewed, 17% (n = 33) included both the terms “hidden curriculum” and “informal Table 1 “informal curriculum.” As mentioned, Hafferty4(p404) delineated the “hidden curriculum” without providing distinct Summary of Articles Included in definitions; that is, the authors of these 2017 Scoping Review of the Medical curriculum” as “a set of influences that Education Literature on the “Hidden function at the level of organizational articles often treated the two phenomena Curriculum” structure and culture”; he felt the “hidden as equivalent (we included these 17 articles curriculum” included “the commonly both in our count for articles citing the Characteristic Number (%) held ‘understandings,’ customs, rituals, “hidden curriculum” and in our count of Study type and taken-for-granted aspects of what articles citing the “informal curriculum). Qualitative 84/197 (43) goes on in the life-space we call medical Four articles included the term “implicit 23,26 Perspective 71/197 (36) education.” Informal curriculum for him, curriculum,” and in 2 articles, the Review 17/197 (9) on the other hand, is an “unscripted, term was also used interchangeably with “hidden curriculum.” Some authors clearly Mixed methods 13/197 (6) predominantly ad hoc, and highly see the hidden and informal curriculum as Quantitative 12/197 (6) interpersonal form of teaching and learning that takes place among and interchangeable, while others see them as Study locationa between faculty and students.”4(p404) In distinct concepts. The United States, 76/109 (70) his understanding, the two terms are Canada, and Central Conflicting connotations of hidden b overlapping and influence one another America curriculum Europe 18/109 (16) but are not synonyms. The term “hidden curriculum” is Asia 8/109 (7) Through this scoping review, we found ambiguous and generally non-neutral.16 Oceania 5/109 (5) that the literature extends well beyond By extracting the effects of the hidden Africa 2/109 (2) Hafferty’s original definitions. The curriculum from the articles we reviewed, South America 0 search tool uncovered articles variously we found the literature often portrays Term used referencing the “hidden,” “implicit,” or the hidden curriculum as negative or Hidden 184/197 (93) “informal” curriculum. Specifically, intrinsically in conflict with the formal Informal 76/197 (39) of the 197 articles we fully reviewed, curriculum. Balboni and colleagues’ 79 Implicit 4/197 (2) 156 included at least one of our key comments illustrate this sentiment: terms (see Table 1): “hidden” (n = 184; “We refer to the [hidden curriculum] as aThe denominator includes only the 109 empirical 93%), “informal” (n = 76; 39%), and the process … which instills behaviors, studies; the authors have excluded reviews and perspective pieces. “implicit” (n = 4; 2%). Using the extracted attitudes, and values among trainees bHere Central American comprises Grenada. definitions from the articles, we were able in tension with the ideals of the medical

profession” [emphasis added]. Further, another 20% of the articles (n = 40) used curricula have become increasingly the literature cites the hidden curriculum a definition that included more than one blurred, as shown in the 17% of articles as a major factor in the erosion of conceptual boundary. The most common that use the terms synonymously. Thus, idealism63 and the increase in cynicism80 overlap, used in 35 articles (18%), was we believe that it is essential for scholars and bias81 that occur during medical between the institutional–organizational to effectively describe what they mean by school. and interpersonal–social conceptions. the hidden curriculum and where they Gaufberg et al71 exemplify this cross- see its influence within UME. We found far fewer insights depicting concept application when they write, the hidden curriculum as a positive Recommendations for scholars element within UME, although they do we use the term “hidden curriculum” to investigating the hidden curriculum in refer to learning that occurs by means of UME exist. For example, some elements of the informal interactions among students, hidden curriculum, such as rural health faculty, and others [interpersonal–social] Recommendation 1: Specify the placements or medical clerkships, seem to and/or learning that occurs through conceptual boundary and the context. have an overall positive effect on students’ organizational, structural, and cultural The conceptual boundaries outlined here experiences and their developing influences intrinsic to training institutions may provide clarity to a term that has 30,82,83 [institutional–organizational]. (italicized professionalism. 15 words in brackets added for illustration) garnered criticism from some because of its ambiguous and seemingly ubiquitous Conceptual classification of hidden use. The widespread application of curriculum Researcher positionality in hidden “hidden curriculum” as a term may make As noted, we observed that the approach curriculum studies researching and evaluating the efficacy to and application of the “hidden Importantly, the conceptual boundary of various hidden curriculum reforms curriculum” varies widely across the used in hidden curriculum studies is not difficult. In addition, UME operates in literature. To better understand the arbitrary but, instead, is likely informed many contexts—whether these are formal ambiguity, we attempted to map the use by the researcher’s (or researchers’) classroom teaching, medical clerkships, of the term. Using definitions extracted reflexivity, expertise, and/or fields of electives, or other spaces. Although from all included articles and grounded study—and, in turn, the boundaries many norms and values span learning theory methodology, four different but chosen by individual researchers directly environments, hidden curricula and their overlapping conceptions emerged (see affect their study methods, outcomes, impact are context dependent and should Table 2). We propose that the term is and recommendations. Table 2 highlights not be viewed as a monolith spanning understood, depending on the article, the discipline most associated with all settings. Therefore, education policy as (1) an institutional–organizational the various conceptions. For instance, would benefit greatly if authors explicitly concept, (2) an interpersonal–social researchers who view the hidden addressed the following in publications concept, (3) a contextual–cultural curriculum as an interpersonal–social regarding the hidden curriculum: (1) concept, and (4) a motivational– concept are likely to use sociological the conceptual boundary or boundaries psychological concept. As shown in methods to explain or uncover its they are applying to the term, and (2) Table 2, each conceptual boundary effects. The methods of these studies the specific learning environments in lends itself to a distinct disciplinary often involve eliciting self-reflection which they see the hidden curriculum lens—retrospectively, policy, sociology, from individual students, and the results acting (i.e., is the hidden curriculum anthropology, and psychology. focus on individual- or departmental- bounded or unbounded by certain level interventions. On the other hand, spaces?). Recommendations to address Once we delineated the four research that examines the hidden the hidden curriculum will vary according classifications, we worked to understand curriculum as solely an institutional– to the conception used, so the efficacy their frequency of use and overlap. organizational concept must extend and efficiency of curricular reforms may We noted that the various uses or beyond the individual learner to the depend on employing the proposed conceptions of the term are not culture of the medical school as an conceptual framework outlined in Table 2. exclusionary or necessarily distinct; organization; thus, the unit of analysis for instead, authors have used them in these studies is almost always the medical Recommendation 2: Clarify research tandem. Among the 197 articles we institution. Proposed interventions from methodologies and results. We reviewed, the hidden curriculum as an these studies often entail changes to argue that UME is filled with hidden institutional–organizational concept, policy, programs, or curricula, and they curricula—not blanketed by a singular applied in 82 articles (42%), was the usually differ in scope from those using hidden curriculum. We believe that, most common. The interpersonal–social other conceptual boundaries. moving forward, authors should make conception, applied in 57 articles explicit the what, where, and how of (29%), was the second most common, their hidden curriculum as they see and followed by contextual–cultural (applied Discussion are investigating it—within both the in 40 articles [20%]), and, finally, Use of the term “hidden curriculum” Methods and Results sections of their motivational–psychological (applied in in the literature is clearly on the rise: research reports. Explicitly specifying 20 articles [10%]). Notably, a full fifth Nearly half of the articles we included will allow policy makers and curriculum of the articles (n = 41 [21%]) did not have been published since 2012. Further, developers to better identify literature include a direct definition for the term although originally understood as distinct related to their own particular needs “hidden curriculum.” Additionally, phenomena,2 “hidden” and “informal” and initiatives. Using a more systematic

Table 2 Conceptual Boundaries of the Hidden Curriculum, Developed Through Grounded Theory Qualitative Analysis of 197 Articles on the “Hidden Curriculum” Discovered Through a 2017 Scoping Review

Concept (and Disciplinary frequency of usea) Example “definitions” from the literature Description lens Institutional– • “[The hidden curriculum is] a set of influences that • Based on Hafferty’s original definition, the hidden Policy and organizational function at the level of organizational structure and curriculum operates at the institutional level4 business 4 (n = 82 [42%]) culture.” • Powerful tool for analyzing organizational or 86 • “We defined the hidden curriculum as the physical macroculture of medical education and workforce organizational infrastructure that • Focuses on medical school structure, norms, and 84 influences the learning process.” 33,81,87–89 culture • “The hidden curriculum is defined as the • Visible within institutional policy, evaluation organizational structure and culture that influences activities, resource allocation, and institutional 85 learning.” slang4 Interpersonal– • “The premise of this hidden or informal curriculum • Denotes interpersonal learning, either structured or Sociology 10,93,94 social concept is that students learn such things as professional unstructured (n = 57 [29%]) behavior not only in classes but also in their day-to- • Socialization process of medical student learned via day interactions with faculty, residents, staff, and interaction95 patients in the context of clinical care.”90 • Often uncovers various subcultures within medical • “[T]he implicit messages being conveyed continually education (e.g., physician, student, patient, to students through a lecturer’s or a role model’s medical specialty)86 example, rather than the person’s spoken words.”91 • Deeply dependent on learning environment96 • “The hidden curriculum runs parallel to the formal curriculum and is a process of socialization to the • Synonymous with Hafferty’s definition of “informal 4 complexities of physician–patient, physician– curriculum” interprofessional team, and physician–community relationships.”92 Contextual– • “The “hidden” or “informal” curriculum [is] the • Broad categorization that encompasses any Anthropology cultural concept broader cultural milieu of medical education that knowledge transmission occurring outside the (n = 40 [20%]) occurs outside of formal instruction.”97 “formal curriculum”73

• “Implicit curriculum includes learning activities (also • The broadest conceptualization of the term, referred to as the hidden or informal curriculum) applicable to anything learned without being that occur in the shadow of the explicit curriculum explicitly stated in the curriculum but are beyond direct control of curriculum • Often is transmitted beyond traditional and/or leadership, such as the modeling of behaviors of explicit learning environments11,76,98 residents.”23 Motivational– • “Unintended lessons in education through informal • Determined by the motivation behind the Psychology 99 psychological concept dialogue, messages, and interactions at school” knowledge exchange (n = 20 [10%]) • “In addition to the intentional teaching of • Hidden curriculum, under this definition, is largely knowledge and skills by surgeons to their trainees unintentional and protégés is the unintended, often unrealized • Authors use terms such as “unintended,”100 transmission of implicit beliefs, attitudes, and “unrealized,”41 and “tacit”101 to describe this behaviors through a process called the hidden categorization of hidden curriculum curriculum”44 • “The hidden curriculum refers to attitudes and values unwittingly transmitted to students both by what is (and is not) taught and how such teaching features in the curriculum.”46 Undefined • No direct in-text definition of the terms “hidden,” • Definition of term is assumed to be understood by (n = 41 [21%]) “informal,” or “implicit” curriculum found within author without directly explaining in the article the article

aThe denominator for the frequency of use is 197, the total number of articles subjected to a full review. Notably, 20% of the articles (n = 40) contained elements of two or more conceptual boundaries, which highlights the nonexclusivity of these definitions. The most common overlap, occurring in 35 articles (18%), was between the institutional–organizational and interpersonal–social conceptions.

framework for discussing the hidden curriculum: Both tasks are daunting and may also need to focus on its positive curriculum will also better inform the likely to yield unspecific or incomplete effects. By better studying and publicizing teaching practices of medical educators and possibly unhelpful results. these positive examples, the medical themselves. Asking students to reflect education community may find ways to generally on the “hidden curriculum” Recommendation 3: Remember the blunt the broader harmful effects. they experienced during their years positive. To better understand and in medical school is akin to asking therefore harness the power of the hidden Recommendation 4: Consider other them to reflect on the complete formal curriculum, however defined, researchers settings. Research into hidden curricula

in UME has so far been limited mostly clear and effective—and multiple K.A. Stewart is associate professor, The Practice to the United States and Canada. Two- independent reviews and the results in Global Health and Cultural Anthropology, Duke thirds of the empirical studies in this of our kappa coefficient tests support Global Health Institute, Duke University, Durham, North Carolina. review involved U.S. and/or Canadian the reliability of the article selection medical schools. The medical education process—yet we may have inadvertently R. Moletsane is professor and J.L. Dube Chair of Rural Education, Department of Rural Education, community’s understanding of hidden excluded some relevant studies. Also, University of KwaZulu-Natal, Durban, South Africa; curricula is based on a very specific per the scoping review approach, we did ORCID: http://orcid.org/0000-0002-8493-7479. not consider the quality of the studies medical education system. For instance, B. Gaede is chair, Discipline of Family Medicine, U.S. and Canadian medical schools award we included; this lack of discrimination School of Nursing and Public Health, University of medical degrees solely to physicians should also be considered when KwaZulu-Natal, Durban, South Africa. in training who have completed their extrapolating results. M. Moshabela is chair, Centre for Rural Health, undergraduate (baccalaureate) education, and Discipline of Rural Health, School of Nursing whereas many medical schools in Africa and Public Health, University of KwaZulu-Natal, Conclusions Durban, South Africa, and Wellcome Trust fellow, and Europe employ a UME system Africa Centre for Population Health, Mtubatuba, through which trainees earn both their As of now, the term “hidden curriculum” South Africa; ORCID: http://orcid.org/0000-0002- baccalaureate and medical credentials. in medical education remains shrouded 9438-7095. 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Arts Humanit High Educ. however, some quantitative measurement (grant number 90394) and the United States tools do exist. The most commonly used 2013;2:281–292. National Institutes of Health (grant number 9 Murakami M, Kawabata H, Maezawa M. quantitative tools cited in the articles 5R24TW008863). The perception of the hidden curriculum we reviewed are the C3 Survey and on medical education: An exploratory study. Other disclosures: None reported. Patient–Provider Orientation Scale.53–56 Asia Pac Fam Med. 2009;8:9. 10 Mahood SC. Medical education: Beware These tools are limited in that they Ethical approval: Reported as not applicable. the hidden curriculum. Can Fam Physician. measure the hidden curriculum only Previous presentation: “Deconstructing the 2011;57:983–985. with respect to the patient centeredness 11 White CB, Kumagai AK, Ross PT, Fantone JC. Hidden Curriculum in Medical Education: A A qualitative exploration of how the conflict of care. 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Med Teach. 2014;36:89–91. 7507-5582. as possible, the study is limited to 14 White J, Brownell K, Lemay JF, Lockyer JM. the articles uncovered by the nine T. Mhlaba is public health medicine specialist, “What do they want me to say?” The hidden School of Nursing and Public Health, University of curriculum at work in the medical school literature bases we searched. We believe KwaZulu-Natal, Durban, South Africa; ORCID: http:// selection process: A qualitative study. BMC our inclusion/exclusion criteria were orcid.org/0000-0002-0178-2652. Med Educ. 2012;12:17.

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