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The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching

BMJ 2004; 329 doi: (Published 30 September 2004) Cite this as: BMJ 2004;329:770

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“Weak Humiliation” in the not so hidden medical curriculum

That there is a hidden curriculum in all aspects of professional
socialisation should surprise no-one. It is scarcely a new or novel
phenomenon in medicine or other social practices. In their recent article
Lemp and Seale article, and in the many responses it spawned, one feature
was frequently referred to though not properly analysed. The issue I refer
to is the humiliation of medical students which is part of their
initiation into the profession. The “findings” of Lempp and Seale build
upon those of others who have pointed to this noxious feature of the
processes of doctors-in-becoming. The philosophical question begged in all
of this debate, or better one of them-there are clearly important ethical
issues that I will not address here- is the conceptual question: “is
humiliation the most felicitous concept to capture the ranges of
experience described or implied in the circumstances that are put
forward?”. I shall argue, very briefly, that without qualification it is
not. I shall set out a distinction between weak and strong humiliation to
defend that view.

As with most morally significant notions, to fully understand this
highly undesirable experience would require a careful delineation of
humiliation in relation to its close conceptual cousins (a task that time
and space does not permit here). A fuller analysis would need to place the
experiences in a landscape that included the concepts of shame,
embarrassment, dignity, hubris and humility. The paradigm case, one might
reasonably assert, for humiliation would be torture. Clearly the ranges
of experience in medical socialisation do not come close to the gravity of
torture. Why then do people frequently describe the experiences in this
way? Typically, we think of the torturer as an evil person. Ought we to
think of medical professors doing their round fully equipped with vast
resources of technical knowledge and concomitant sarcasm and derision to
fit that description? It seems overblown-a piece of gross conceptual
inflation to include these in the same categories. Disrespectful;
certainly. Arrogant; quite possibly. Evil; surely not.

The limit case of humiliation, torture, entails the basic denial of
the means of self-respect . One’s basic dignity as a person is assaulted.
In such cases we do well to describe the experience as one of “strong
humiliation”. Here the humiliated are passive at the hands of the
tormentor. In weaker cases such as ours, however, the power balance is
not as dramatic. The question then remains, can we think of what is
reported as “humiliation” as reasonable, or justifiable? There are two
responses available here.

The first is that humiliation entails a denial of self-respect
whereas embarrassment (however intense) requires only a lowering of self-
esteem. So, it could be argued, the arrogant Professor (whomever she or he
maybe) is merely embarrassing, or at worst ridiculing, the student by
lowering their self-esteem; showing how foolish their judgment is, how
awry their diagnosis, and so on. S/he may feel ashamed at her
incompetence, “beside herself” even, but it is merely rooted in a
deflation of their overblown self-conceptions of their competence, it
could be argued. I do not subscribe to this view. It is too weak on
context in general, and specifically in its failure to accord the
significance of the event in the life of the young professional. To
understand the experience that the student feels it is necessary to think
on the perceived significance of the context, and to consider in a
narrative fashion, the place of the experience in their lives.

It seems better to think of the experience as somewhere between these
two cases: it is not mere embarrassment but neither is it strong
humiliation. Rather, we are better to think of these as instances of
“weak humiliation” . I shall say why I think this is right, after I have
noted two strengths of such a conceptual move. First, to describe as
embarrassing the experience of the “humiliated” student is to deflate in
ethical terms the motives of the professor (who may think, mistakenly,
that the comedy is of a light nature). Secondly, it fails to capture the
ethically significant features of the context. Here the student whose
identity is so deeply vested into the practices of medicine, and whose
competence has been so publicly derided: her or his life project is
momentarily shattered. So to label the experience embarrassment in virtue
of the loss of self-respect felt by the student fails to capture the
significance of the event in their life and render less culpable the
disrespectful professor.

Lemmp, H. and Seale, C The hidden curriculum in undergraduate medical
education: qualitative study of medical students' perceptions of teaching
BMJ, Oct 2004; 329: 770 – 773

Sinclair S. Making doctors. An institutional apprenticeship. Oxford:
Berg, 1997; Cribb A, Bignold S. Towards the reflexive medical school: the
hidden curriculum and medical education research. Stud Higher Educ
1999;24: 195-209.

Margalit, A. The decent society (goldblum, n., trans.). London:
Harvard University Press, 1996.

Miller, W .I. Humiliation: and other essays on honor, social
discomfort and violence. London: Cornell University Press, 1993.

Competing interests:
None declared

Competing interests: No competing interests

03 February 2005
Mike J McNamee
Senior Lecturer in Philosophy
School of Health Science, University of Wales Swansea