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Original Article

Stunting professionalism: The potency


and durability of the hidden curriculum
within medical education
Barret Michaleca,* and Frederic W. Haffertyb
a

Department of Sociology University of Delaware, Newark, DE 19716, USA.


Mayo Clinic Rochester, MN 55905, USA.

*Corresponding author.

Abstract Despite an extensive literature within medical education touting the necessity
in developing professionalism among future physicians, there is little evidence these
calls have thus far had an appreciable effect. Although various researchers have suggested that the hidden curriculum within medical education has a prominent role in
stunting the development of professionalism among future physicians, there has been
minimal discussion of how the content of the hidden curriculum actually function to this
end. In this article, we explore: (i) how the hidden curriculum may function within
medical education as a countervailing force to medicines push for professionalism and
(ii) why the hidden curriculum continues to persist within medical training and particular
aspects so difcult to dilute. We conclude by proposing mechanisms to assuage elements
of the hidden curriculum, which may, in turn, allow the principles of professionalism to
blossom among medical students.
Social Theory & Health (2013) 11, 388406. doi:10.1057/sth.2013.6;
published online 1 May 2013
Keywords: professionalism; hidden curriculum; medical education

Introduction
Calls for a recommitment to principles of professionalism1 have been widespread
within organized medicine since the early 1990s (Hafferty and Levinson, 2008;
AAMC, 2011; Boudreau et al, 2011). Extensive research and policy statements
have highlighted the charge for and by medical professionals to renew their
social contract with the public, express compassion, empathy and connectedness with their patients, promote and practice teamwork within health care
delivery, rid themselves of their political and nancial drives, and pursue the
highest levels of clinical competence and ethical standards (Institute of Medicine,
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Professionalism and the hidden curriculum

2003; Arnold and Stern, 2006; Veloski and Hojat, 2006; Cruess and Cruess, 2008;
Wynia, 2008; Camp et al, 2010; Dyrbye et al, 2010).
Evetts (2011) notes that groups can utilize the discourse of professionalism in
composing their occupational identity and promoting its image with clients
and customers (p. 407). In this sense, the clamor for professionalism within the
medical profession can be seen, in part, as a response to shifts in the sociopolitical and economic context of health care with the rise of consumerism,
increased commercialism within the medical eld in general, the proletarianization of the health care workforce, the rise in available medical information as
ushered by the information age and increased specialization leading to fragmentation in the delivery of care (Light and Levine, 1988; Relman, 2003; Hafferty,
2006a,b; Woodruff et al, 2008).2 Organized medicine, once touted as the
prototypical profession, has seen its public image battered and bruised, and
although many of the spotlighted issues and noxious elements appear to be tied
to the arena of clinical practice, remedial calls have targeted medical education as
the battleground in bringing about a needed shift in professional behaviors,
duties and attributes.
Numerous medical education institutions have implemented various courses,
programs and standards designed to provide students with extensive learning
opportunities steeped in promoting professionalism (Baernstein et al, 2009;
Rabow et al, 2009; Branch, 2010). The Liaison Committee on Medial Education
(LCME), the body that accredits the United States and Canadian medical schools,
has an accreditation standard (MS-31-A) that requires schools to account for the
professional attributes of their students. The Accreditation Council of Graduate
Medical Education (ACGME) has identied professionalism as one of its six Core
Competencies (along with patient care, medical knowledge, practice-based learning
and improvement, interpersonal communication skills and systems-based practice)
(Swing, 2007). There are similar efforts in other countries. Parallel reports in both
Canada (CanMEDs, The Canadian Federation of Medical Students and so on) and
the United Kingdom (the General Medical Council, the Royal College of Physicians
and so on) also stand as socio-political testimonies to a broad and sustained effort by
organized medicine to re-establish its principles of professionalism (Frank et al,
1996; GME, 2009; Bridgewater et al, 2011; Mondoux, 2011).
At the practice level, various medical specialty bodies have developed
professionalism codes and charters. For example, the American Board of Internal
Medicine Foundation, the American College of Physicians, the American Society
of Internal Medicine Foundation and the European Federation of Internal
Medicine have created a physician professionalism charter, now endorsed by
over 125 medical organizations worldwide (ABIM Foundation, ACP-ASIM
Foundation, and European Federation of Internal Medicine, 2002). Furthermore,
the American Board of Medical Specialties, the organization that sets standards
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for the 24 of the 27 approved medical practice specialty boards, has just (as of
2011) established a standing committee on professionalism.
Nevertheless, and in the face of all this progress, critics have argued that
medical school administrators and faculty have been overly eager to advance
professionalism as an educational enterprise and have therefore rushed to
conceptualize and operationalize an overly nostalgic version of professionalism
(Wear and Kuczewski, 2004; Hafferty, 2006c; Prasad, 2011). Moreover, they
argue that this call to arms fails to address the issues related to professionalism
present at the systemic and organizational levels both in training and in medical
care settings, and suggest that if medical education truly is committed to reform
then education and practice leaders will need to address not only factors at the
individual level, but also the overarching culture and organizational climate of
medicine that seeps into the teachings of future doctors (Hafferty, 2006d; West
and Shanafelt, 2007; Lesser et al, 2010; Cunningham et al, 2011).
Further complicating this picture, medical students have expressed considerable dismay with and resistance to the ways in which faculty have produced
addendums and supplements to an already saturated curriculum in the name of
inculcating professionalism characterizing such curricular appendages as
pedantic, harassing and even insulting, and thus turning them off to the whole
call for professionalism (Reddy et al, 2007; Baernstein et al, 2009; Finn et al,
2010). Moreover, students consistently have pointed out that they are not seeing
the values, behaviors and attributes touted in the classroom being actualized by
clinical faculty and supposed role models (Brainard and Brislen, 2007; Leo and
Eagen, 2008). In short, medical students do not see these explicit teachings of
professionalism as a useful addition to their training, nor do they see medical
school faculty and shadowed physicians as fully practicing what they appear to
be preaching.
In these respects, critics argue that there is a hidden curriculum nested within
medical training (for example, cultural mores transmitted through formal and
informal training processes that reect the norms and values upheld by the
institution of medicine (Haer et al, 2011)) and that this more invisible and
tacitly transmitted curriculum functions as a perpetual culprit in burdening and/
or dampening the cultivation of professionalism among medical students3
(Chuang et al, 2010). As Hilton (2004, p. 71) argues, the hidden curriculum
is probably the most important factor inuencing development of professionalism. Nonetheless, research has yet to dissect how and why this usual suspect
impedes the blossoming of professionalism. Therefore, it is important to better
understand the ways in which the hidden curriculum affects the teachings of
professionalism within medical education, as well as why this dimension of
medical training continues to persevere despite its hiding in plain sight (Gair
and Mullins, 2001; Wear and Skillicorn, 2009).
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This present article offers a discussion of how the hidden curriculum may
function within medical education to stunt the growth of professionalism among
medical students. More specically, this article examines how the teachings of
the authority and autonomy (particularly via the privileged nature of medical
knowledge) nested within the hidden curriculum actually serve to contradict and
counteract explicit formal instruction in the principles of professionalism. Conversely, although the hidden curriculum can be viewed as detrimental to
students professionalism (or at least how professionalism has been discussed
in the medical education literature), we suggest that the hidden curriculum also
serves as a vehicle for protecting the embattled medical profession by providing
subterrestrial lessons in authority and autonomy which have been viewed,
both within medicine and by sociology, as markers of any true profession. Put
simply, we argue that although elements of the hidden curriculum, such as the
teachings of authority and autonomy, may have detrimental impact on students
development of professionalism, these same elements of the hidden curriculum
are actually essential to the perpetuation of medicines status as a profession and
therefore protected and promoted by both cultural practices within medical and
by other-than-formal pedagogical strategies within medical education.

The Hidden Curriculum and Tenets of Professionalism: An


Apparent Contradiction
Although the term often is attributed to the education scholar Philip Jackson
(1968), the notion that there is a hidden dimension to curricula practices rst
appeared in the writings of sociologist, Fred Strodtbeck (1964), a student of
Talcott Parsons. Frequently referenced in reviews of primary and secondary
education, the hidden curriculum represents an undercurrent of norms, values
and regulations embedded within the training process that students are to
assume and embrace in order to function effectively in a social role (Wren,
1999). Apple (1979) suggests that the internalization of these rules, codes and
values actively creates and reinforces the boundaries of institutional legitimacy
that students will come to represent in their occupational pursuits. Previous
research on the hidden curriculum has addressed how the structure and
processes of education perpetuate inequalities, foster ideologies and practices
of particular social groups and facilitate individual disempowerment (Giroux,
1985). In turn, professional education has been shown to reproduce hierarchies,
degrees of marginalization, ways of thinking and other values of that particular
occupational sector (Margolis et al, 2001). These properties and practices of
differential legitimization have been noted to exist in medical training and are
argued to be found in customs, rituals and everyday experiences that replicate
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ideologies regarding inequality and stratied relationships (Hafferty and Franks,


1994; DEon et al, 2007; Chuang et al, 2010; Manhood, 2011).
In medical education, the hidden curriculum reects the ethos of medical work
and has the potential to reverberate degrees of separateness and distinction
within health-care delivery, thereby fostering distance between doctors-to-be
and laypersons (Michalec, 2011a), and further strengthening a status hierarchy
among health professionals. This promotion of stratication, however, is in clear
opposition with the tenets of professionalism cited earlier (for example, team
orientation, patient-centeredness, empathy and so on). Yet, despite this apparent
contradiction, elements of the hidden curriculum continue to subsist within
medical training. We argue this is in part because lessons embedded within the
hidden curriculum also function to support two fundamental/traditional characteristics that are essential to the preservation of medicines professional status:
authority and autonomy.

Authority and Autonomy: Essential Elements of the Profession of


Medicine
Autonomy and authority are extensively intertwined within the medical profession, and it has been argued that autonomy, or a professions degree of control
over its area of work and clientele, stems from its degree of cultural authority,
which sprouts from the attainment and promulgation of an esoteric body of
(medical) knowledge. Moreover, and as argued by Freidson (1970a, 2001) and
Abbott (1988), medicine maintains professional autonomy not only through its
development and transference of that body of clinical knowledge, but also
through its control over its own work, the division of labor (boundaries of
specializations) and new member entry. Similarly, medicine asserts its autonomy
and professional control by staving off interference and regulation from outside
forces such as other health workers and the government. In addition, and as icing
on the cultural authority cake, medicine also controls the work of other healthcare occupations (Freidson, 1970b). In sum, the degree of control and autonomy
enjoyed by medicine stems from its ability to control a body of esoteric knowledge, maintain a sense of legitimacy in the public eye, and sustain a certain
degree of power granted by governmental entities.
According to Latham (2002, p. 367), the physician profession is grounded in
the expert authority that accompanies their clinical/medical knowledge. It is this
authority that asserts and relates the necessity of their profession. Put simply,
They know something that neither their patients nor society at large can know.
Medical knowledge is perhaps the integral element to the role of the physician.
Doctors claim the knowledge and mastery of the intricacies of the human body,
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of particular medical technologies and procedures, as well as the diagnosis and


treatment of disease (Fainzang, 2002), with this knowledge being gathered
through years of training. Wear and Castellani (2000) argue that the current
culture of medicine reected in the medical school curricula touts science,
scientic methods and the knowledge gleaned from medical education as the
true knowledge, and therefore something much more valuable than the
patients knowledge. the existing medical curriculum, aligned as it is almost
exclusively with science and its methods, results in doctors, not patients, who are
the real knowers (p. 606).
According to Parsons (1951), physicians serve as agents of social control,
empowered to regulate what behavior is deemed normal (healthy) or deviant
(sick) because of their knowledge and expertise. It should be made clear,
however, that the authority that physicians maintain is not just over laypersons
(that is, patients) but involves other health-care workers as well, such as nurses,
physical and occupation therapists, psychologists and those involved in holistic
care. Studies have shown that a status hierarchy exists in medicine that is
consistently reinforced through daily interactions in the health-care setting, and
is transferred through education (Waring and Currie, 2009). This hierarchy is
based, in part, on differences in medical knowledge and the asymmetrical power
granted to those higher up on the medical hierarchy because of this knowledge
what Friedson (1970b) referred to as professional dominance.
In the following sections, we address how authority and autonomy are taught
through the hidden curriculum, and suggest why these elements of the hidden
curriculum (authority and autonomy) may continue to circulate through the
learning environment of medical education. We will rst address the how by
exploring key vehicles and arenas within which the hidden curriculum functions.

The Teachings of Authority and Autonomy within the Hidden


Curriculum
Explicit technical, medical knowledge is clearly imparted to medical students
through a formal curriculum of courses, labs and clinical training. The hidden
curriculum, however, provides an excellent context to inculcate the norms and
values of separateness, control and power because medical school faculty are
constrained from explicitly stating to students in an open classroom or lab setting
You are better than PT students., or You dont need to listen to nurses. A
recent statement from the Committee on Ethics of the American College of
Obstetricians and Gynecologists (2011, p. 401) states, Inherent in the education
of health-care professionals is the problem of disparity in power and authority
. Michalec (2011a) found that rst- and second-year medical students report
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being taught that medical knowledge carries particular esteemed qualities.


During his interviews, students spoke not merely of having trouble communicating with laypersons because of distinctiveness of what they were learning
(medical knowledge), but that according to their instructors, what they were
learning was also powerful and accompanied by a high level of authority.
Furthermore, these preclinical students sensed teachings (during ceremonies
such as orientation and the White Coat Ceremony (WCC), as well as with regard
to consistent praise and complementation key arenas of the hidden curriculum)
of authority nested within their medical training, and that faculty and administration often suggested in both direct and oblique ways that they (students) were
superior, smarter and of more social worth than those outside of medicine. What
Michalecs study highlights is that medical students are being told, (repeatedly
and tacitly) that they are special, a veritable best and brightest.
Moreover, a variety of structural elements within medical education continuously reinforce these teachings of authority and autonomy. Several reports have
indicated that less curriculum hours are actually allocated to the teaching and
learning of the social and ethical issues as compared with bioscience and clinical
aspects of medicine and health care (Hafferty, 1998, 2000; Michalec, 2011b).
Such disparities in the formal curriculum may lend to less exposure to learning
and practice opportunities for medical students in these specic elds, thereby
showcasing, and perhaps even enhancing, the presence and value of the
authority of clinical knowledge over other forms of knowledge. Moreover, in
spite of decades of touting the importance of teamwork and team-based practice,
medical students experience the overwhelming majority of their training in sole
company of other medical students (Michalec, 2011b), with interprofessional
training remaining more of a pedagogical mirage than an active practice
(Baldwin, 2007). Similarly, Whitehead (2007) explains that because doctors are
expected to bear the onus of medical decision making (compared with other
health care professionals), the assumption of this responsibility must be
incorporated in their training, and it is through this training (explicit and
implicit) that medical students conrm the legitimacy of their autonomous
decision-making ability.
Much like ceremonies, persistent adulation and curriculum design, role
modeling represents yet another medium for conveying the hidden curriculum
(of authority and autonomy) as students learn various aspects of physicians
professional identity and responsibilities (Reuler and Nardone, 1994; Batlle,
2004; Lempp and Seale, 2004). Role modeling remains one crucial area where
repeated negative learning experiences may adversely impact the development
of professionalism in medical students and residents (Kenny et al, 2003,
p. 1203). Although the role modeling of behaviors, values and ethical standards
can lend to positive professionalization of future physicians (Wessel, 2004;
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Janssen et al, 2008; Baernstein et al, 2009; Helmich et al, 2011), previous
research featuring students accounts of their training have shown that students
do witness physicians openly mock and put down patients, disrespect other
health care workers, put patients at risk and blatantly ignore hospital procedures
and ethical standards and face no signicant sanction or punishment from
within, or outside, their institution (Ginsburg et al, 2002; Brainard and Brislen,
2007; Michalec, 2012).
Feudtner et al (1994) presented medical trainees observations of physicians
overtly exercising their authority over patients, such as sedating a patient with
Haldol in order to give them medications intravenously (simply because the
patient did not desire to take her medications), and performing unnecessary
forceps deliveries for practice. Hinze (2004) provides narratives that highlight
how the teachings of authority and a rigid status hierarchy are alive and well
within medical training especially concerning gender differences in professional
medicine, offering rst-person accounts of how male practicing physicians
explicitly and implicitly demean and vitiate female medical students and
practicing female physicians in front of medical trainees without recourse or
sanction. In their exploration of the effects of the teachings of hidden curriculum
in medical education, Lempp and Seale (2004) found that 21 out of 36 students in
their study reported numerous instances of humiliation (from practicing physicians) either through observation or through personal experience. The authors
suggest that One of the principle ways in which students learnt about the
importance of hierarchy in medicine is through teaching that involved humiliation. (p. 771). These studies, and others, provide direct evidence of how
modeled behavior, as a veritable lecture hall for the teachings of the hidden
curriculum, can project lessons in the authority (of medical knowledge and
specic status characteristics) and autonomy of the medical profession in
general. Consequentially, these teachings can have detrimental impact on the
development of students professionalism.
Therefore, why would organized medical education turn a blind eye to a
mechanism that has been shown to not only be disadvantageous to the
cultivation of acclaimed characteristics among future physicians, but also has
been spotlighted by extant research? Why do the teachings of authority and
autonomy (through the hidden curriculum) persist?

Authority and Autonomy as Elements to Conserve and Protect


Authority and autonomy not only are outcomes/by-products of becoming a
profession, but are also viewed within traditionally framed organized medicine
as pillars of the profession itself (Parsons, 1951; Friedson 1970b, 2001). In these
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ways, authority and autonomy are key to preserving medicines perception of


itself as a profession. Therefore, these elements that contribute to both the self
image and even its actuality not only must be protected and closely guarded, but
their value and importance also must be fostered and passed along to the next
generation of those in the profession (medical students). The hidden curriculum
serves both of these purposes.
In the case of medicine, the same events, movements and challenges that have
spawned the call for professionalism (that is, consumerism, proletarianization,
complementary and alternative medicine and so on) have threatened medicine
and led the embattled profession to question the stability and durability of its
authority and autonomy (Hess, 2004; Cohen, 2006; Lowrey and Anderson,
2006). In addition, whereas medical school faculty and administration have touted
a range of attributes such as compassion, teamwork and patient-centeredness in
their push for professionalism (Boudreau et al, 2011), the actuality is that in order
to sustain medicines professional status (and all that comes with it) medicine
also must seek to safeguard its domain-based authority and autonomy. As
discussed earlier, this is accomplished through the hidden curriculum by
mechanisms such as the consistent reinforcement of hierarchical boundaries
between doctors and patients and other health professionals, differentiated
praise for particular behaviors and even a general talking-up of the value and
signicance of medical knowledge (over other forms and loci of knowing). As
Latham (2002, p. 367) states, The physicians authority over the patient is thus
also authority over the patients community. He [sic] must therefore retain the
trust of both, or else render his authority suspect and his expertise useless.
Similarly, when authority is questioned, autonomy and control are threatened
and weakened (Abbott, 1988). Hence, despite hiding in plain sight, the hidden
curriculum has yet to be dissolved, and particular teachings, such as those
involving authority and autonomy, have yet to be stymied or hindered. Rather, in
highly strategic ways, the hidden curriculum is being nurtured and harbored
because it assists in the defense of the traditional medical powers and privileges.
Timmermans and Oh (2010) outline how the medical profession has been
extremely resilient and unyielding throughout the past decades, consistently
confronting its challenges. The authors suggest that the medical profession has
survived numerous threats to their status and power through strategic takeovers
(that is, the absorption of the least radical features of complementary and
alternative medicines (CAM)), tightening their grip on clinical knowledge (that
is, their engagement with evidence-based medicine (EBM)) and establishing
tactical partnerships (that is, their symbiotic relationship with the pharmaceutical industry). We suggest that the hidden curriculum has also served a
prominent role in this set of strategic defenses and realignments by protecting
and conserving the professions core resources (authority and autonomy) and by
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imparting these resources in a range of tacit and often times implicit ways to the
next generation of physicians during medical training. Furthermore, perhaps this
is why the recent calls for professionalism, as well as the programs and courses
that have been established to increase professionalism among trainees, have
been referred to as mere window dressing and/or lackluster, and why medical
students continue to see behavior among their preceptors and shadowed
physicians that is not in-line with tenets of professionalism behavior that is
unprofessional (Reddy et al, 2007; Baernstein et al, 2009).

Re-examining the Stalled Promulgation of Professionalism


Principles
In a 1988 issue of the Journal of Health and Social Behavior, Samuel Bloom
(1988) presented a powerful argument that medical educations manifest
humanistic mission is little more than a screen for the research mission which is
the major concern of the institutions social structure (p. 294). Interestingly, 24
years later, we are faced with similar set of stealth-related activities within
medical education a covert push for authority and control while explicitly
sounding the call for professionalism. However, whereas Bloom was exploring
a history of reform without change, we are arguing that medicine actually is
ghting for its professional livelihood, and that the hidden curriculum has been
activated as a vital weapon for medicine in this battle.
These front- and backstage maneuverings present medicine with a substantial
conundrum: In order to maintain its professional status, medicine must sustain
some degree of authority and autonomy. Yet, the promulgation of such
necessities (through the hidden curriculum) is somewhat antithetical to this
push for professionalism. The notions of authority and autonomy within
medicine are not necessarily negative side-effects of medicine achieving or
maintaining professional status. Rather, it is their reection and translation
through the hidden curriculum that appears to lend to the detriment. Hence,
whereas a great deal of attention and effort to cultivate principles in professionalism among medical students has been directed toward developing, offering and
assessing professionalism-laden programs, we suggest that focus should shift
toward the mechanism(s) nested within medical education that appear to be
antithetical to these principles and could very well be stunting their development
among medical students toward the tempering of the hidden curriculum and
the teachings of authority and autonomy.
As noted earlier, the hidden curriculum within medical training reects and
reinforces hierarchies, status inequalities and overarching differences in health
and health care. Therefore, a key to enfeebling aspects of the hidden curriculum
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and their effects is by muting the notion that medicine is the profession within
health care. Although interprofessional training within medical education circles
has been somewhat of a straw dog over the past several decades (Baldwin, 2007),
there is evidence that medical education institutions are taking signicant strides
toward emphasizing a more interprofessional, team-oriented approach to
health care. A number of medical schools have recently constructed and
implemented elaborate, multi-year Interprofessional Education (IPE), programs
aimed at bringing together students from multiple health care disciplines during
their years of training to breakdown the hierarchy within health care delivery,
increase patient-centeredness from a team approach, and foster communication
and respect among the various health professions (Clark, 2004; Thistlethwaite
and Moran, 2010). These programs are integrated into preclinical and clinical
training agendas for these institutions, but given the novelty of these programs,
research is currently underway to assess to what messages and values are being
translated to the students of the various disciplines through these programs.
These programs are not slated as programs in professionalism per-say, rather
they are geared toward bringing together each of the health disciplines under the
umbrella of improving health care delivery, the experiences of health care
professionals, and patient outcomes in general. Another important element of
IPE programs is that they often include members of the local patient population/
general public to serve as a guide to the pre-professionals through the illness
experience. IPE, with its focus on team-based care, patient-centeredness, and
inclusion of the public in the education process, has the potential to have
signicant impact on the hidden curriculum and lay the groundwork for aspects
of professionalism to take root.
Another manner in which the medical education community can assuage the
potentially injurious profession dominating teachings of the hidden curriculum is
to transform the WCC. Often held during the rst year of medical training, the
WCC is a ritual in which students are draped with the quintessential regalia of a
physician. The white coat has been described as a magical cloak that protects
the medical student and doctor from the suffering of their patients (Druss, 1998),
and as a symbol of science and technology, and a reection of life and purity
(Blumhagen, 1979). Although it may seem to occupy a relatively negligible
footprint with the overall process of medical education, and while ofcials within
medicine have argued for its benets and appropriateness (as outlined in Branch,
1998; Huber, 2003), others such as Wear (1998) and Russell (2002), have
suggested that the white coat actually functions as a source of the hidden
curriculum and thus transmits messages of power, authority, elitism and the
dominance of science that it symbolizes.
Whatever the issue, it is important that medical educators be willing and
able to step back and assess just what messages are being created by and within
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the very structures they have developed and are responsible for (Hafferty, 1998,
p. 404). This means thoroughly evaluating the meanings translated in these
ceremonies and the differentiations made between medical students and those
not within the medical profession, especially given the timing of most WCCs.
Even something as celebratory as a WCC may send conating and contradictory
messages. In this sense, medical school administrators interested in mitigating
impressions of elitism and power, and fostering positive perceptions of interprofessionalism, mutual cooperation and interdependence (among the health
professions key elements of professionalism), should look to include professional representatives from the other health care-related disciplines (that is,
Nursing, Pharmacology, Physical Therapy, Occupational Therapy, Social Work
and so on) in the WCC in some fashion other than just guests and/or spectators.
Professionals in these other disciplines could serve as speakers, ofciates or
could even adorn medical students with their white coats, thereby welcoming
them to the health care industry. Another manner in which the same directives
could be achieved would be to host a generic WCC for students of all health
care disciplines. Each discipline teaches and trains students to heal, why can they
not all join together to celebrate their collective initiation into the healing
professions? Such recongurations of the WCC could help to dismantle barriers
and fences between the health professions and counteract conceptions of a rigid
hierarchy within health care delivery, thereby potentially neutralizing certain
deleterious effects of the hidden curriculum.4
Given that the lessons of authority and autonomy through the hidden
curriculum have been shown to also be present within the professional domain
(along with the educational domain) of medicine, the efforts of dismantling the
hierarchies within health care delivery should also be done from within the
medical industry and therefore reected in the attitudes and actions of practicing
physicians. If medicine is truly invested in the promotional of professionalism
principles among its future workforce then the medical profession would do well
to adopt the motto: It takes a village and acknowledge and embrace the notion
that effective health care is delivered through a team of professionals (that is,
nurses, medical social workers, doctors, pharmacists, physical and/or occupational therapists and so on), which includes the patient (Lichtenstein et al, 2004).
In stepping down from its crumbling silo, medicine still will maintain a distinct,
esoteric body of clinical knowledge, but, in turn, the profession must profess that
its knowledge functions best when working in tandem with the knowledge of
other parties/professionals within the health care delivery team which again,
must include the patient. By doing so, medicine will relinquish some degree of
cultural authority and control, yet this will assist in ushering in a new contract
with the public as well as with other health care professionals what some are
calling a new patient-centered professionalism (Irvine and Hafferty, 2011).
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Weakening the potency of the hidden curriculum not only entails the practice
of dissolving hierarchies within health care, but also courageously and publically
purging the bad apples within the profession. If professionalism is to ourish,
the attention cannot simply be on pedagogical practices, those practicing within
the profession must be held accountable as well (Leach et al, 2006; Hafferty,
2006b). In order to save itself from its current siege, medicine must become more
transparent in terms of how it handles ethical violations, poor and out-of-date
practices and the adverse pursuits of political and nancial endeavors among its
own members (Hickson et al, 2007).
Until this point, we have steered clear of any medically oriented analogies or
metaphors, yet perhaps one must be used to better capture the manner in which
the medical profession must attack or confront certain aspects of the hidden
curriculum. Radiation therapies are a popular method of treating cancer. While
deconstructing the tumor, radiation simultaneously damages healthy cells and
tissue the desired effect being a greater sum of damage to the tumor than
healthy tissue. If we consider the hidden curriculum as having a potentially
tumorous effect within the soma of medical education, then implementing vetted
and evaluated IPE programs within the curriculum, reconguring WCCs and
fostering transparency within the profession in general may in fact impact
medical trainings healthy tissue (re-organizing curriculum to include IPE,
possibly forfeiting the positive side-effects of the WCC and even sacricing some
degree of authority and autonomy). Although some tumors may be eradicated
and others merely controlled, the overall effect is a more sustained and
nourishing environment for the seeds of a more modern-day or new professionalism to be established and ourish (Irvine, 1999, 2006; Working Party of the
Royal College of Physicians, 2005; Coverdill et al, 2010).

Conclusion
We have posited how and why the principles of professionalism (and the
development of these principles among medical students) have struggled to
blossom within the current climate of medical education, and, in turn, how the
hidden curriculum has been able to radiate within this climate. In return for
protecting aspects of authority (including medical knowledge) and autonomy/
control over the other health professions and translating them to future
physicians, the medical profession has nurtured and sustained the hidden
curriculum, specically the teachings of power differentials, hierarchical
boundaries and overarching inequalities in health care delivery. Although
appreciable research has identied the presence of a hidden curriculum within
medical education, argued for its deconstruction and ngered it for the sluggish
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growth of professionalism within medical students, this specic work highlights


how a function of the hidden curriculum is to conserve the medical professions
critical resources of autonomy and authority, which purportedly lends to its
remarkable perseverance.
We agree with other researchers in that professionalism will not thrive until
the culture and climate of medicine (which is currently fostered in part by the
hidden curriculum) is fully explored and dissected. In order to do this, we
suggest implementing anti-hierachical rhetoric and structures within medical
training such as IPE programs and the signicant modication of WCCs. We also
argue that altering the education setting alone will not curtail the hidden
curriculum. Therefore, practicing physicians and the profession itself must not
only sacrice degrees of authority, but also levels of their autonomy by making
their judiciary practices and political and nancial endeavors more transparent
(Bridgwater et al, 2011). These mechanisms will usher in a new contract not
only between the medical profession and the general public, but also between all
health professions.

Notes
1 Throughout this work, the authors use the term Professionalism to refer to the individual-level traits,
behaviors and attitudes similar to those described in the encompassing normative definition offered by
Swick (2000). The term Profession, within this work, refers specifically to organized medicine as an
occupational entity and in relation to specific qualities of any true profession (that is, authority and
autonomy). Finally, within this work, the term Professionalization refers to the processes and
mechanisms by which medical students learn to become professional health care practitioners. In
turn, this work attempts to bridge the importunate cultural divide between the more sociologically
oriented discourse on the Profession of medicine and the more medically oriented discourse on medical
Professionalism (Hafferty and Castellani, 2010).
2 Although there remains some considerable opposition to the claim that physicians are becoming
deprofessionalized and/or subordinated to the bureaucratic controls (Pescosolido, 2006; Spalter-Roth,
2007), medical insiders remain quite convinced that physicians have suffered serious erosions of their
clinical autonomy and discretionary decision making (Shanafelt et al, 2002; Zuger, 2004).
3 Although writings on the hidden curriculum come largely from within the United States, United
Kingdom and Canadian medical education literature there are the beginnings of an expanding
international literature on the hidden curriculum. Similarly, although the concept is universal, particular
context may differ enough so that what holds for one country in terms of specific findings about content
of the hidden curriculum or the content of the space between the formal curriculum and the hidden
curriculum is particular to place (specific medical education institution). Therefore, although discussions
of the hidden curriculum (in the general sense) offered within this work could be applied to more than
one national context, given that the authors are relating the role of the hidden curriculum to the current
state of the medical profession in the United States the discussion of the hidden curriculum within in this
particular work is primarily directed toward US medical education.
4 Although the inclusion of other health professions within the WCC may have a positive impact on the
internal status hierarchy among the health professions, it may do little to address (and may even
exacerbate) the status and power divide between health care providers and patients (laypersons).
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