Harnessing the Hidden Curriculum in Clinical Clerkship; A Four-Step Reflective Competency Approach

Educating the next generation of physicians to enact professionalism at a new level is seen as the answer to some of the intractable problems of our profession. We design curricula for them to address failures in such areas as professionalism, collaboration, communication, evidence based practices, patient safety and quality improvement. But students experience a tension between the realities of clinical practice and previously held idealized perspectives, including those expressed and taught in our formal curricula. Often a hidden curriculum of role modeling and practice that reinforces the status quo gets in the way of our best efforts for change. How do we educate medical students to resist adopting unprofessional practices they see in the clinical environment? This integrative review of the literature explores these issues. Informed by this literature, we propose for education of medical students, the development and reinforcement of a specific set of reflective competencies as they transition from classroom curricula to clinical practice, in a four-step approach: 1. Priming the students that there is a hidden curriculum in their clinical environment and that we all function with a set of sub-conscious motivations to conform or comply with external pressures, 2. Noticing; students are educated to be aware of their motivations in situations in which they experience these pressures, 3. Processing; guidance is provided for students to analyze their experiences in collaborative reflective exercises and finally, 4. Choosing; students are supported in selecting behaviors that validate and reinforce their aspirations as they develop their best professional identity.