By Hanneke Mulder
Photograph of Hanneke Mulder
We are pleased to feature a guest post from Hanneke Mulder, PhD, an Associate Professor of Innovation of Medical Education at the Center for Research and Development of Education at University Medical Center Utrecht, The Netherlands. Dr. Mulder’s areas of interest include what she terms the “hidden curriculum” and faculty development.
In the piece below, she describes a sorting tool that she has created specifically for doctors to help them explore the implicit values, rules, and expectations of their professional practice, as well as the tool’s applications and wider implications.
As a medical educationalist, I have for a long time been fascinated by the so called “hidden curriculum,” especially in the clinical workplace.
The hidden curriculum, commonly described in negative terms, refers to the learning that takes place outside a formal curriculum: to the set of implicit messages about values, norms, and attitudes that learners infer from the behavior of individual role models as well as from group dynamics, processes, rituals, and structures. Examples of such messages, from the context of medical education, are:
“Knowing how to deflect patients elsewhere is an important component of good medical practice” (Webster, writing about a “hidden curriculum of efficiency”),
“Doctors never admit to not knowing something”; and
“Leaving the hospital (to eat, sleep, etc.) is a sign of weakness” (Haidet and Stein).
The hidden curriculum is considered highly influential in medical education, but structured approaches to address it are limited in number and scope.
Together with colleagues, I recently published an article in which we present a practical method to facilitate reflection and discussion on the hidden curriculum by faculty members and trainees. We called this method REVIEW: Reflecting & Evaluating Values Implicit in Education in the Workplace.
REVIEW approaches the hidden curriculum as a reflection of the professional microculture of a clinical team. Following Champy’s work on the sociology of professions, we state that this microculture results from collective problem solving and mutual negotiation when facing different, often conflicting, demands and interests, and their underlying values in daily clinical practice.
Using this non-judgmental conceptual framework, REVIEW employs a series of 50 culture statements. The statements describe behaviors of clinicians related to the interests of patients, of colleagues, of the professional him/herself, and of society as a whole, e.g. cost consciousness, transparency, accountability, and education of new clinicians.
Examples include:
“We take time for every patient”;
“We show appreciation to our colleagues”;
“We systematically take time for our own professional development”; and
“We discuss errors in order to learn from them”.
These statements must be prioritized using Q-sort methodology, reflecting how the culture in a particular clinical context (e.g. ward or department) is perceived by faculty members and trainees.
As all statements describe defensible behaviors, mirroring the necessity of prioritization and compromise with regard to values and demands in the clinical workplace, no ranking is a priori “right” or “wrong.” The Q-sorting process, which uses forced-choice rank ordering of statements, is meant to create awareness of particular professional issues and dilemmas.
The sorting procedure can be done individually or in groups, online or with a card game version of the tool. Although the sorting process as such encourages reflection on a particular culture, most important is the resulting team discussion which should occur after the exercise: a discussion about perceptions of actual team culture and the culture desired by the team.
Our early experiences suggest that REVIEW is an attractive and feasible tool for addressing the hidden curriculum, or, in other words, the transfer of a professional microculture in medical education. REVIEW, however, may also be of use in settings that are not (primarily) educational or clinical. It facilitates reflection on and evaluation of the existing culture–the values, norms, attitudes and related behaviors–within a team, department or organization.
With an adapted item set, the method can be applied in any occupational group dealing with competing demands and values.
Recently, the Dutch Professional Honor Foundation, a group encouraging “good work” in the Netherlands and beyond, adopted the REVIEW method as part of their “Good Work” approach and adapted the item set for civil servants and customs officers. Feedback from participants from these occupational groups also indicated that REVIEW is appreciated as a catalyst for reflection and discussion.
Click here to read the article and access the REVIEW tool.
Reference:
Hanneke Mulder, Edith ter Braak, H. Carrie Chen, & Olle ten Cate (2018). Addressing the hidden curriculum in the clinical workplace: A practical tool for trainees and faculty. Medical Teacher. DOI: 10.1080/0142159X.2018.1436760.