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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

Rapid Response:

Relationships and Respect: Keys to Addressing the “Hidden Curriculum”

Dear Editor,

There certainly is no shortage of literature which reviews and recognizes the negative influence of the “hidden curriculum” in shaping the morals and beliefs of aspiring physician-healers (1, 2). Despite a renewed emphasis on defining and developing professionalism, recent studies indicate that attributes typically associated with professional virtue often decline during undergraduate medical education, a most worrisome reality (3, 4). Irregardless of one’s institution, there are universal incongruences between what medical students are told to do (the formal curriculum) and what medical students see as being acceptable behaviour (the informal curriculum). While the presence of this “gap” is widely accepted, what remains far less clear is what can be done to reduce or eliminate this “gap” altogether.

A promising concept for combating the deleterious effects of the “hidden curriculum” is the relationship-centered learning environment. While numerous attempts at changing various aspects of a medical curriculum have met with limited success, perhaps a golden key lies not in the curriculum itself, but rather the context in which that curriculum is delivered. Imagine an environment where students and faculty treat each other with respect and dignity, where education and growth are viewed as a shared collaboration that benefit the student and teacher equally. Does this sound like an impossible fantasy? It is closer than you might think (5). Medical students, no different than any other group, absorb and propagate the behaviours and attitudes we observe around us. If we are cared for and treated with respect, it will reflect in how we care for our patients, our colleagues, and each other. This is not a new phenomenon within the context of the world in which we live – all of us have heard the common saying, “Treat others with the respect that you think you deserve.” Why should the context in which medical education is delivered be any different? Amazingly, for many decades, it has been. The time is ripe for change.

Finally, a plea to my fellow medical students – it is important for us all to recognize the existence of the “gap” that exists between the formal and informal curricula and how it may affect our professional development. However, it is just as important once we recognize this gap to aid in closing it. Each faculty has its kindred spirits, many often tucked away in places where we would least expect to find them. Seek these individuals out – share your experiences, build meaningful relationships, and discuss what kind of difference you can make. After all, if we are not part of the solution, we are part of the problem.


1. Lempp L, Searle C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. BMJ 2004; 329: 770-773.

2. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003.

3. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Acad Med 1994; 69: 670-679.

4. Marcus ER. Empathy, humanism, and the professionalization process of medical education. Acad Med 1999; 74: 1211-1215.

5. Suchman AL, Williamson PR, Litzelman DK, Frankel RM, Mossbarger DL, Inui TS. Toward an informal curriculum that teaches professionalism. Transforming the social environment of a medical school. J Gen Intern Med 2004; 19: 501-504.

Competing interests:
None declared

Competing interests: No competing interests

12 October 2004
Alexander Wong
Medical Student
Schulich School of Medicine, University of Western Ontario, London, ON, Canada. N6A 5C1