Embracing What I Learned from the “Hidden” Curriculum in Medicine

Stephen Foley is a third-year medical student at the UVM Larner College of Medicine.

In the following blog post, Foley writes about what he learned from what he termed the “hidden” curriculum in medical education.

Stephen Foley is a third-year medical student at the UVM Larner College of Medicine.
Stephen Foley

“Being in your first clerkship, you’ll realize early on that you know nothing, you can’t do anything, and you’re inevitably going to be a brick in everybody’s backpack.”

In brutally honest fashion, that opening piece of advice I received on my first day with a new surgery preceptor made this element of the hidden curriculum in medicine explicitly clear. During the pre-clinical years, medical students are often reminded of the importance of teamwork in healthcare, yet what is rarely mentioned is how to overcome the awkward detachment that often exists between the assembly line of students and medical teams. From our initial interaction, this doctor’s statement seemed to immediately separate me, a clerkship-level student, from the tight pack of interns, residents, and attendings, leaving a wide social gap for me to wrestle with while also managing my learning and patient care.

Imposter Syndrome

Throughout the first week of the rotation, a dark cloud enveloped me as I walked through the long corridors pre-rounding on my patients. The words echoed in my head, followed by ceaseless inner conversations: “Am I worth anything to the team? “How can I not get in the way today?” “What do I need to do to make myself valuable to the team?” That one initial statement flooded my brain with a mix of imposter syndrome and futility – and a feeling that any additional efforts to speak up and stand out would only slow or weigh down the team more. I wondered how many other medical students received this type of advice from a resident or attending during their training, and how many student-preceptor interactions like this reinforce the social divide as part of medical culture?

Scrub In!

By Friday, the end of the first week of the rotation, I was completely burnt out. That day included three surgeries, with the last starting at 4:30 p.m. While, thankfully, I had a lecture scheduled from 3-4 p.m. to break up the day, I was somewhat unsure of my obligations to return to the OR for the last (really interesting) case. I knew the case would end late, but for fear of missing out, I decided to stay. Upon seeing me in the OR, the very same preceptor was positively shocked: “In all my years at this hospital, rarely have I witnessed a student come back after a lecture. Soon-to-be-Dr. Foley, you’ve made my list of top students who make it clear they want to be here and learn. Scrub in!”

Chlorhexidine sponge in hand, could anyone see me beaming behind the surgical mask? 

I made the first cut. I sawed through the patient’s femur. I handed the amputated limb to the surgical tech. I bonded with my preceptor over the same taste in music and Tarantino movies. I sutured the surgical incision, a fitting reflection of how I had successfully closed the gap.

Preceptor’s Reverse Psychology

With time over the weekend to reflect on the past week, I began to understand and appreciate the reverse psychology of this preceptor’s opening line (intentional or not). I lost sleep to spend extra time late at night preparing for cases and rounds. I discovered untapped motivation to arrive early, stay late, work harder than ever to fit in, integrate with the team, and contribute in any way I could. With that single act of staying for a late surgery, I earned my preceptor’s respect and was greatly rewarded. Maybe I’m different from many of my peers, or perhaps I learn best in different conditions, but I would never interpret this preceptor’s advice as unprofessional. I maintain a strong respect and gratitude that he pushed me out of my comfort zone and challenged me to demonstrate my passion for medicine. 

Of course, staying late is not the secret to success and certainly not the cure for all difficult scenarios as a medical trainee. Rather, I’d offer that every individual should learn to control how they respond to challenging circumstances, both mentally and emotionally. This is essential preparation to adapt and thrive in a notoriously demanding career. 

Clarity Entering Clerkship

I now have clarity about the message I received about the hidden curriculum while entering clerkships – it means medical students have everything to prove and nothing to lose. They should be hungry for opportunities to get a foot in the door and stand out. Eventually, when I’m an attending and working with students, I will give the same advice. Like my surgery preceptor, I will be open and honest about expectations, because I want to encourage my students to feed their intrinsic motivation and desire to prove themselves. 

 Moreso, knowing what I know now, I intend to bridge the divide between medical students and the clinical team by reassuring students that, even though they may often feel like “a brick in everyone’s backpacks,” the metaphor is a two-way street. Because of this transformative clerkship experience, I feel enlightened, prepared, and called as a future intern, resident, and attending to embrace my responsibility for carrying students as valued, essential members of the team.