The hidden curriculum
Every veterinarian knows there’s much more to the job than being able to diagnose, treat, prescribe, and perform surgery. But how do veterinary students learn to be, well, veterinarians? A veterinary college’s culture shapes the way students perceive the profession, their colleagues, and themselves as well as how they interact with clients and patients. And sometimes, the informal messages students pick up on don’t match the institution’s stated goals and teachings. Enter the hidden curriculum, an anomaly that was discussed during multiple presentations at the Association of American Veterinary Medical Colleges’ Annual Conference and Iverson Bell Symposium, March 10-12 in Washington, D.C.
What it is and why it matters
There’s the formal curriculum, with its lecture halls, syllabuses, and grading and evaluation methods. Then, there’s the informal curriculum, which takes place outside the classroom among those who are teaching and trainees. In between them lies the hidden curriculum. It is, more or less, the collective messages that students unknowingly pick up from the faculty and administration. Put another way, it is the ideological and subliminal messages of both the formal and informal curricula that influence the culture of an institution (Acad Med 1998;73:403-407). It can take the form of policy development, resource allocation, activities, organizational or power structures, rituals and routines, or institutional slang and nomenclature.
Dr. Liz Mossop, associate professor of veterinary education at the University of Nottingham, has researched the hidden curriculum in veterinary programs, including her own (Med Educ 2013;47:134–143). She has found these programs tend to have a culture that normalizes disease and death, such as by euthanasia, as well as emphasizes competitiveness and hierarchy. Sometimes, a school’s hidden curriculum even involves faculty teaching by humiliation.
Dr. Rosanne Taylor, dean of the University of Sydney Faculty of Veterinary Science, says the hidden curriculum is a major contributor to the formation of professional attitudes among veterinary students, particularly during clinical training as they learn the rules of the community of practice they are joining. Often, the hidden curriculum conflicts with what is learned during formal professionalism studies, creating a dilemma for students when the behaviors they see and believe they should emulate are at odds with their understanding of best practices. For example, students may be taught to communicate clearly and empathetically with clients but may see different behavior from clinicians in the teaching hospital.
Dr. Taylor says the hidden curriculum often persists because of a reluctance by faculty, students, or administrators to give explicit, constructive, or timely feedback as well as fear of confrontation, a fear of challenges, or subjectivity.
Dr. Stephen May is deputy principal at the University of London Royal Veterinary College and co-author of a paper on the hidden curriculum, to be published this summer in the Journal of Veterinary Medical Education. At the AAVMC meeting, he asked the question: “Are we forgiving professional shortcomings in our role models because they are technically competent and bring in lots of money—even if they’re awful to interact with, and that’s not great for our students to be exposed to? What are we willing to do to develop a culture we want to be proud of?”
Self-assessment
During the AAVMC meeting, Dr. May detailed efforts at the RVC to study its own hidden curriculum. He and fellow faculty member Dr. Carrie A. Roder interviewed, observed, and surveyed students to get a better understanding of its effects on students’ concept of professionalism as they completed their final year in clinical rotations.
When it comes to the way students are assessed, the investigators found that the faculty approach to grading of rotations threatened learning, as it made students afraid of the consequences of asking questions. Plus, the instructors’ lack of meaningful assessment and feedback gave students an excuse to dismiss any poor grades they received in professionalism.
The hidden curriculum is not uniform across schools. We have areas that seem to work well for students and other areas that, sadly, don’t. (The Royal Veterinary College has) experienced painful lessons looking inward, but you have to ask yourself the question, ‘How does this apply to us? Is everything mutually reinforcing, or are there conflicting messages?’
Dr. Stephen May, deputy principal, University of London Royal Veterinary College
Drs. May and Roder also found that when they looked at clinical service organization, the emphasis on specialists left students thinking they must specialize to be a “good” veterinarian. However, with the exception of primary care weeks, students viewed clinical rotations as unrepresentative of their career destinations. In addition, constant exposure to the treatment of patients in university teaching hospitals left students unsure of how to handle a case in “first opinion practice” as a patient’s primary veterinarian.
As for role modeling and their rotation group, students recognized that they picked up ideas about appropriate professional conduct from clinicians through “silent teaching,” and students who wanted to do general practice often couldn’t find role models among faculty.
Finally, the investigators had students rank the importance of certain aspects of professionalism. Some attributes valued highly in the first year, such as social justice and altruism, were ranked low by the fourth year and replaced by professional autonomy and professional dominance, which both ranked highest.
Dr. May summarized implications of the research in the following ways:
- Professionalism needs to be made more explicit to promote recognition and understanding of the value of diversity and various interpretations.
- Assessment and feedback must be meaningful and two-way to be taken seriously and benefit student development.
- Faculty and students must come to terms with their own interpretations of professionalism and the implications for their professional identity.
- All need to recognize the complexity of professionalism in the context of modern veterinary practice so that graduates are well-equipped to avoid identity dissonance, which can impact early veterinary careers.
“The hidden curriculum is not uniform across schools. We have areas that seem to work well for students and other areas that, sadly, don’t,” Dr. May said. “We’ve experienced painful lessons looking inward, but all of us must ask the question, ‘How do these messages and principles apply to us? Is everything mutually reinforcing, or are there conflicting messages?’”
Diversity and wellness
The hidden curriculum’s impact on subconscious learning goes well beyond professionalism. Dr. Taylor says the literature shows that the hidden curriculum causes a decrease in empathy (Med Educ 2004;38:934-941) and animal welfare commitment among veterinary students. Research has also shown the hidden curriculum can cause an increase in acceptance of unethical behaviors (Acad Med 1998;73:1195-1200) as well as tolerance of harassment, bullying, and discrimination (Acad Med 2006;81:648-654).
That’s backed up by a 2011 study that assessed campus climate with respect to diversity at each U.S. veterinary college (J Vet Med Educ 2014;41:111-121 [PDF]). It suggested that the overall climate in relation to diversity is positive and supportive. But digging deeper, the survey also revealed that veterinary students within minority groups express feelings of discrimination and lower acceptance. These groups include minorities underrepresented in veterinary medicine and LGBT populations.
The survey found nearly one-third of racially or ethnically URVM students reported hearing comments they perceived as racist from their student colleagues occasionally to very frequently. Over 20 percent of LGBT students reported hearing comments they considered homophobic from students occasionally to very frequently.
The survey also revealed that veterinary students were more likely to experience negative diversity-related experiences at the hands of their student peers than from any other group on campus. The second-highest incidences of comments considered sexist came from faculty. Just over 21 percent of female students and 23 percent of transgender students said that they heard faculty making sexist comments occasionally to very frequently.
Mike Dibler, a fourth-year student at the University of Florida College of Veterinary Medicine, said he felt the influence of the institution’s hidden curriculum even before he was a student. During a panel discussion on diversity, he had asked admissions staff whether he should include mention in his personal essay that he is a transgender man. He was told not to because it wouldn’t be received well.
“I said, ‘The climate sounds like, to me, that I shouldn’t be out,’” Dibler said, so he stayed closeted until this past year. By then, he said, the veterinary college’s climate had changed enough, thanks in part to Dr. Jim Lloyd, who came on as dean the same year Dibler began his studies. Florida has since established a diversity committee as well as diversity training for administration and staff. The veterinary college is also working with the Broad Spectrum Veterinary Student Association and the Lesbian and Gay VMA to establish best practices in creating a more inclusive climate.
The impact of the hidden curriculum on students’ well-being is evident. The Student AVMA Mental Health & Wellness Task Force (now a standing committee) sent a survey in 2015 to SAVMA’s nearly 14,000 members to gauge their mental health. Of the 3,888 who responded, 67 percent had experienced a period of depression, and of those, 37 percent said the period lasted longer than two weeks, which meets the definition of clinical depression. Further, the rates of depression, self-harm, and suicidal ideation went up during students’ clinical year. In addition, the survey found a strong correlation between students feeling that professors care about them and how comfortable students felt seeking help.
All but six veterinary schools do not have in-house counseling services specifically for veterinary students. Even if institutions were to hire a counselor or create extracurricular programs to encourage wellness, that wouldn’t change the veterinary college’s culture. Teresa A. Johnson, PhD, coordinator for assessment and curriculum design at The Ohio State University, pointed out during the 2014 AAVMC Health and Wellness Summit: “These counselors feel like they keep putting goldfish back in dirty water. You can’t just take out a teaspoon, you have to change most of the water, and I think it’s pretty clear we have some polluted water in our curricular situations.”
She said veterinary colleges should focus on creating a supportive learning environment that is interactive, lowers competition, and fosters mutual respect. This can be achieved by normalizing help-seeking from students, providing greater social support, partnering with other campus mental health resources, and creating professional development for faculty (see JAVMA, Dec. 15, 2014).
What veterinary colleges can do
Influencing the hidden curriculum, the presenters said, requires the leadership and administration to set clear expectations, emphasize faculty development and training, acknowledge and explore the hidden curriculum, measure the culture, encourage student reflection and debriefing, mentor, and demonstrate culture by example through altruism, diversity, and service.
Dr. Kenita Rogers, executive associate dean at the Texas A&M University College of Veterinary Medicine & Biomedical Sciences, pointed out that, above all, veterinary colleges have to be deliberate in the messages they send to students and be able to back them up with their actions.
“In the case of diversity, that can mean anything from material support given to student groups, such as VOICE or Broad Spectrum, to holistic admissions practices, to mentorship provided by faculty, to inclusive language in the institution’s publications,” Dr. Rogers said. “Websites and publications can represent the values and the cultural climate of a program, and veterinary colleges should pay close attention to using inclusive language that truly represents their mission and goals. It helps tremendously if college deans have a deep-seated belief in doing the right thing and provide overt leadership in this area.”
In addition, equipping faculty and staff with the important fundamental skill sets needed to promote and support a positive workplace climate has become part of the strategic diversity plan for the college. To help achieve that, TAMU offers a 40-hour conflict-management mediation course to faculty and staff, particularly those in positions of leadership. To date, 93 individuals have participated, and by May, 113 will be certified.
“To quote my colleague Dr. Nancy Watson, ‘Conflict just is’. There will be conflict every day. Forty to 60 percent of interactions in higher administration revolve around dealing with conflict,” Dr. Rogers said. “Conflict is not good or bad, but how we deal with it can be positive or negative. If I think and respond positively, then I will probably be successful because I can diffuse the situation and make a better environment for open, engaged dialogue. The consequences for not managing conflict are huge. Yes, conflict takes time and energy, but far less so if managed well.”
Some veterinary faculty have also taken to heart the modeling of how veterinary students should take care of themselves.
Dr. Arleigh J. Reynolds, associate dean of the Department of Veterinary Medicine at the University of Alaska-Fairbanks, noticed how worn out students in the inaugural class had become since they had started in August 2015. All of them said they didn’t have enough time to sleep. In fact, some students were averaging only 2 1/2 hours of sleep each night. The following spring, he started a well-being course that involved nine discussion-based sessions and three activities. He taught the students how to prepare meals and eat healthy, cross-country ski and run a dog team, value sleep and balance school and relationships, and manage conflict. Everyone got activity trackers to track heart rate, sleep, and activity.
The classes on eating and sleeping well particularly resonated with students as did the activity classes. Students went from averaging just under six hours of sleep to more than eight hours. Plus, all the student participants were taking more than 10,000 steps a day compared with hardly any before.
“My argument is you’ll do everything better if you take time out to exercise 30 minutes a day. You can’t say you don’t have time,” Dr. Reynolds said. “The habits you set up in school are the habits you default to the rest of your life. Look at the profession, how we’re struggling with burnout and substance abuse. We have to treat the cause of those, not the symptoms. The cause comes down to treating yourself, and there needs to be a paradigm shift. We need to lead by example.”
After listening to students’ feedback, Dr. Reynolds also had the school’s schedule rearranged so that students now get 20 minutes between classes instead of 10.
“That has helped their attitude tremendously. At the end of day, they have more energy and aren’t as tired, and it’s just a little shift,” he said.
Dr. Taylor says the hidden curriculum is transmitted as much by example as anything else, and sometimes it’s at odds with what veterinary colleges are espousing. But she emphasizes the old maxim: Culture eats strategy for breakfast.
The three curricula
Formal: The actual course of study (teaching, evaluation methods, and syllabuses) and educational setting (lecture halls and laboratories).
Informal: Occurs in clinical settings and is opportunistic, idiosyncratic, and often unplanned. Instruction takes place among those who are teaching and trainees.
Hidden: Ideological and subliminal messages of both the formal and informal curricula. Examples are policy development, evaluation, resource allocation, and institutional slang or nomenclature.
Source: Acad Med 1998;73:403-407
Related JAVMA content:
Studies confirm poor well-being in veterinary professionals, students (May 1, 2016)
AAVMC continues to move the needle on diversity (May 1, 2015)