Does the Hidden Curriculum hinder the implementation of Evidence Based Health Care

1. 1 Does the Hidden Curriculum hinder the implementation of Evidence Based Health Care? Studies show that upwards of 30% of patients receive care that is inconsistent with scientific evidence, and more than 20% will received care that is not needed or is potentially harmful. Around the world, between 2.9% and 11.7% of adult patients in general hospitals will experience one or more adverse events. Although it is possible that this discrepancy between ideal care and the current care represents physician incompetence, it is well accepted that communication through guidelines and best practices, has at best, had only modest effects on practice. Another possible explanation is that there are other influences, that is a �hidden curriculum�, with its own directives and forces operating. This hidden curriculum may also contribute to the actions that physicians take, or do not take, and the care their patients receive.Studies show that upwards of 30% of patients receive care that is inconsistent with scientific evidence, and more than 20% will received care that is not needed or is potentially harmful. Around the world, between 2.9% and 11.7% of adult patients in general hospitals will experience one or more adverse events. Although it is possible that this discrepancy between ideal care and the current care represents physician incompetence, it is well accepted that communication through guidelines and best practices, has at best, had only modest effects on practice. Another possible explanation is that there are other influences, that is a �hidden curriculum�, with its own directives and forces operating. This hidden curriculum may also contribute to the actions that physicians take, or do not take, and the care their patients receive.

2. 2 Educational Objectives At the completion of this session you will be able; to label and describe three different types of medical education curriculum list four hidden curriculum themes that interact with evidence based health care

3. 3 Outline Medical Education Curriculum Uncovering the Hidden Curriculum Hidden Curriculum Themes Recommendations At the completion of this session you will be able; to label and describe three different types of medical education curriculum list four hidden curriculum themes that interact with evidence based health care At the completion of this session you will be able; to label and describe three different types of medical education curriculum list four hidden curriculum themes that interact with evidence based health care

4. 4 Hypothesis the informal and hidden curriculums impact on the effectiveness of EBHC teaching and uptake substantiation of the hidden curriculum will allow us to better appreciate the EBHC hidden curriculum�s existence, form, and influence The substantiation of this hidden curriculum may be found in the evidence based health care literature, and it can better help us understand the hidden curriculum around EBPs existence, form, and influence. I hypothesize that substantiation of this hidden curriculum may be found in the evidence based health care literature, and it can better help us understand the hidden curriculum around EBHC�s existence, form, and influence. Bennett N et al. J Contin Educ Health Prof 2004; 24: 145-152. The substantiation of this hidden curriculum may be found in the evidence based health care literature, and it can better help us understand the hidden curriculum around EBPs existence, form, and influence. I hypothesize that substantiation of this hidden curriculum may be found in the evidence based health care literature, and it can better help us understand the hidden curriculum around EBHC�s existence, form, and influence. Bennett N et al. J Contin Educ Health Prof 2004; 24: 145-152.

5. 5 Medical Education Curriculum Formal Informal Hidden The medical education curriculum can be described in complex layers. Hafferty translated this concept to medical education by describing a curriculum as a multidimensional learning environment that embraces at least three interrelated spheres. Formal / Informal / Hidden As educators design formal curriculum More learning will translate into better practice planned, intended, offered, endorsed curriculum comprises course work, laboratories, clinical rotations learning objectives Informal Curriculum Received curriculum: the Student experience. Medical training is a multi dimensional learning environment and the formal curriculum of the classroom never fully replaces the informal curriculum of the clinical setting. The informal curriculum is the process by which learned knowledge and skills becomes situated in the context of daily works and must be opportunistic, individualized and specifically relevant to the particular activity The informal curriculum is vital to clinical education. Involves the intentional imparting of information from the teacher to learner Acknowledge difficulty of knowledge management and transfer. an unscripted predominantly ad hoc, interpersonal form of teaching and learning that takes place between and among faculty and students exists on an interpersonal level opportunistic and individualized to a particular clinical activity The medical education curriculum can be described in complex layers. Hafferty translated this concept to medical education by describing a curriculum as a multidimensional learning environment that embraces at least three interrelated spheres. Formal / Informal / Hidden As educators design formal curriculum More learning will translate into better practice planned, intended, offered, endorsed curriculum comprises course work, laboratories, clinical rotations learning objectives Informal Curriculum Received curriculum: the Student experience. Medical training is a multi dimensional learning environment and the formal curriculum of the classroom never fully replaces the informal curriculum of the clinical setting. The informal curriculum is the process by which learned knowledge and skills becomes situated in the context of daily works and must be opportunistic, individualized and specifically relevant to the particular activity The informal curriculum is vital to clinical education. Involves the intentional imparting of information from the teacher to learner Acknowledge difficulty of knowledge management and transfer. an unscripted predominantly ad hoc, interpersonal form of teaching and learning that takes place between and among faculty and students exists on an interpersonal level opportunistic and individualized to a particular clinical activity

6. 6 Hidden Curriculum represented by the three �R�s Rules Regulations Routines a set of influences that function at the levels; organizational structure institutional culture learn the norms of the health care delivery culture unrealized Students learn from conversations on rounds, informal tutorial session, from observing the md interact with patients. Hidden curriculum is often unrealized transmission of implicit beliefs, attitudes, and behaviors, and the hierarchy of medicine. Comprises the commonly held understandings, customs rituals, and take for granted aspects of what goes on in the life-sake we call medical education. Training institutions are both cultural entities and moral communities intimately involved in constructing definitions about what is bad and good medicine. Hidden curriculum is a function not only of the institutional implicit held values, but more so by whom the trainees is surround by personally. The last curricular layer with its potentially powerful unrealized effect. Students learn from conversations on rounds, informal tutorial session, from observing the md interact with patients. Hidden curriculum is often unrealized transmission of implicit beliefs, attitudes, and behaviors, and the hierarchy of medicine. Comprises the commonly held understandings, customs rituals, and take for granted aspects of what goes on in the life-sake we call medical education. Training institutions are both cultural entities and moral communities intimately involved in constructing definitions about what is bad and good medicine. Hidden curriculum is a function not only of the institutional implicit held values, but more so by whom the trainees is surround by personally. The last curricular layer with its potentially powerful unrealized effect.

7. 7 Hidden Curriculum formal curriculum ? hidden curriculum impair students� professional growth and development impair the ability to foster genuine relationships within the health care team contributes to the inadvertent negative attitudes, beliefs and behaviors expressed by health care trainees We are teaching much more than we know: Every time we chose not to speak or act, Every smile, Every curse, Every sigh is a lesson in the hidden curriculum. Our act is to simply add more courses, more time, more subject areas to the formal curriculum. The hidden curriculum must be addressed to produce the necessary fundamental challenges and changes in the culture of medical education. Contradictions create internal conflicts in students that diminish the credibility of the medical teacher. The hidden curriculum supersedes the lecture. Such contraindications initiate students into an enculturation process that erodes the altruism, undermines ethics and creates cynicism. Although changes in course content, however less attention to the hidden curriculum, has emerged as the influential concept in medical education. Education is more than the simple transfer of knowledge rather it is a socialization process, quietly transforming social norms and values to the student. Training institutions are cultural identifier and moral communities. Damaging influences of informal and hidden curriculum on medical trainees. We are teaching much more than we know: Every time we chose not to speak or act, Every smile, Every curse, Every sigh is a lesson in the hidden curriculum. Our act is to simply add more courses, more time, more subject areas to the formal curriculum. The hidden curriculum must be addressed to produce the necessary fundamental challenges and changes in the culture of medical education. Contradictions create internal conflicts in students that diminish the credibility of the medical teacher. The hidden curriculum supersedes the lecture. Such contraindications initiate students into an enculturation process that erodes the altruism, undermines ethics and creates cynicism. Although changes in course content, however less attention to the hidden curriculum, has emerged as the influential concept in medical education. Education is more than the simple transfer of knowledge rather it is a socialization process, quietly transforming social norms and values to the student. Training institutions are cultural identifier and moral communities. Damaging influences of informal and hidden curriculum on medical trainees.

8. 8 Hidden Curriculum all of us teach in a hidden curriculum the majority of teaching values occur within the hidden curriculum people are the strength of the hidden curriculum one of the challenges that medical educators in evidence based health care must face impervious to educational innovations Educators need a way to identify and directly address specific aspects of the Hidden Curriculum in order to modify its overall impact on attitudes and behaviors of students. Need to identify that there is a hidden curriculum. A function to fate impact values held by the institution as a whole buy the individual educators and allied health professionals working with trainees in the learning environmentEducators need a way to identify and directly address specific aspects of the Hidden Curriculum in order to modify its overall impact on attitudes and behaviors of students. Need to identify that there is a hidden curriculum. A function to fate impact values held by the institution as a whole buy the individual educators and allied health professionals working with trainees in the learning environment

9. 9 Curriculum Concordance formal curriculum ? hidden curriculum the most effective formal curriculum and the hidden curriculum need to be concordant We are teaching much more than we know: Every time we chose not to speak or act, Every smile, Every curse, Every sigh is a lesson in the hidden curriculum. Our act is to simply add more courses, more time, more subject areas to the formal curriculum. The hidden curriculum must be addressed to produce the necessary fundamental challenges and changes in the culture of medical education. Contradictions create internal conflicts in students that diminish the credibility of the medical teacher. The hidden curriculum supersedes the lecture. Such contraindications initiate students into an enculturation process that erodes the altruism, undermines ethics and creates cynicism. Although changes in course content, however less attention to the hidden curriculum, has emerged as the influential concept in medical education. Education is more than the simple transfer of knowledge rather it is a socialization process, quietly transforming social norms and values to the student. Training institutions are cultural identifier and moral communities. Damaging influences of informal and hidden curriculum on medical trainees.We are teaching much more than we know: Every time we chose not to speak or act, Every smile, Every curse, Every sigh is a lesson in the hidden curriculum. Our act is to simply add more courses, more time, more subject areas to the formal curriculum. The hidden curriculum must be addressed to produce the necessary fundamental challenges and changes in the culture of medical education. Contradictions create internal conflicts in students that diminish the credibility of the medical teacher. The hidden curriculum supersedes the lecture. Such contraindications initiate students into an enculturation process that erodes the altruism, undermines ethics and creates cynicism. Although changes in course content, however less attention to the hidden curriculum, has emerged as the influential concept in medical education. Education is more than the simple transfer of knowledge rather it is a socialization process, quietly transforming social norms and values to the student. Training institutions are cultural identifier and moral communities. Damaging influences of informal and hidden curriculum on medical trainees.

10. 10 Hidden Curriculum Uncovering the Hidden Curriculum Institutional Policy Development Evaluation Activity Resource Allocation Decisions Institutional Slang or Nomenclature Exploration of the Hidden Curriculum Hafferty FW. Acad Med 1998;73:403-407. To uncover the hidden curriculum Hafferty suggested examining four phenomena or domains, concerning what is valued by institutional community: Institutional policy, evaluation, resource allocation, slang. The four domains that Hafferty identified, and suggested approaching them in two fundamentally different ways asking two questions; (a.) how are educational domains reinforced or undermined by certain policies (b.) what values are being created with each of these domainsExploration of the Hidden Curriculum Hafferty FW. Acad Med 1998;73:403-407. To uncover the hidden curriculum Hafferty suggested examining four phenomena or domains, concerning what is valued by institutional community: Institutional policy, evaluation, resource allocation, slang. The four domains that Hafferty identified, and suggested approaching them in two fundamentally different ways asking two questions; (a.) how are educational domains reinforced or undermined by certain policies (b.) what values are being created with each of these domains

11. 11 Institutional Policy Development expresses values of an institution by Rules Regulations (policies) organizational guidelines strongly influences decisions that clinicians reach and kinds of health care provided Is there mention about EBHC in the vision of the centre? Is EBHC a key point of interest within the institution? Investigating the hidden curriculum also involves �doing battle� with constituencies and interest groups that reside outside the walls of institutions. Policies are legion in medical education. They are contained in faculty and student handbooks, procedure manuals, and work contracts for faculty and postgraduate trainees These are the �rules of the road� and �key points of interest�, but they also implicitly convey messages about what is and is not valued by the institutional community itself. Investigating the hidden curriculum also involves �doing battle� with constituencies and interest groups that reside outside the walls of institutions. Policies are legion in medical education. They are contained in faculty and student handbooks, procedure manuals, and work contracts for faculty and postgraduate trainees These are the �rules of the road� and �key points of interest�, but they also implicitly convey messages about what is and is not valued by the institutional community itself.

12. 12 Evaluation Activity Regulations evaluation tools are not simply an instrument of assessment a vehicle to convey what is and what is not important what does and does not get placed on the examination Where is EBHC placed in the curriculum? How is EBHC evaluated and assessed? Examples of evaluation range from the exam strewn battlefield to tradition laden rituals as deans letters. They include issues of faculty promotion and tenure as well as accreditation reviews at the organizational level. In recent years, the profile of evaluation has been enhanced by the methodology of evidence base practice, the importance of outcome analysis. Tools of evaluation are not simply instruments of assessment. They are also vehicles for conveying what is and is not important within the organization. The message the students receive about the newer values such as EBP may conflict with the more traditional messages they are exposed to. Students encounter these newer directives first within the hidden curriculum, long before they surface in the formal curriculum.Examples of evaluation range from the exam strewn battlefield to tradition laden rituals as deans letters. They include issues of faculty promotion and tenure as well as accreditation reviews at the organizational level. In recent years, the profile of evaluation has been enhanced by the methodology of evidence base practice, the importance of outcome analysis. Tools of evaluation are not simply instruments of assessment. They are also vehicles for conveying what is and is not important within the organization. The message the students receive about the newer values such as EBP may conflict with the more traditional messages they are exposed to. Students encounter these newer directives first within the hidden curriculum, long before they surface in the formal curriculum.

13. 13 Resource Allocation Decisions Routines reflect values we place on certain activities $ $ or the functional equivalent Who is present at the EBHC course? both junior and senior people faculty development Where is EBHC housed in the infrastructure? Whether the issue of money or some functional equivalent (appointment or promotion) , need to know how the availability and distribution of institutional resources shapes what faulty and students learn about the institutional mission and organizational values. In an environment where needs always outstrip resources, what and who percolate to the top? Not about hidden agenda, but rather the concept posits and correctly so that in many instances there is much more going on than can be revealed by official explanations.Whether the issue of money or some functional equivalent (appointment or promotion) , need to know how the availability and distribution of institutional resources shapes what faulty and students learn about the institutional mission and organizational values. In an environment where needs always outstrip resources, what and who percolate to the top? Not about hidden agenda, but rather the concept posits and correctly so that in many instances there is much more going on than can be revealed by official explanations.

14. 14 Institutional Slang & Nomenclature Routines the ways in which a community refers to its work provides a shorthand way to reflect What does the institution say about EBHC? The hidden curriculum can be unearthed in the language used within organizations. The terms end up re-socializing ever so subtly Paradigm shift, The above are hidden because there is seldom an open discussion about the lesion being taughtThe hidden curriculum can be unearthed in the language used within organizations. The terms end up re-socializing ever so subtly Paradigm shift, The above are hidden because there is seldom an open discussion about the lesion being taught

15. 15 Outcomes loss of Idealism ritual attainment of professional identity emotional socialization and mental health loss of idealism adoption of ritualized identity emotional neutralization change of ethical integrity acceptance of hierarchy learning of less formal aspects of �good doctoring� Cribb A, Bignold S. Stud Higher Educ 1999;24:195-209. King�s College London In the process of uncovering the hidden curriculum Alan Cribb identified several outcomes from the hidden curriculum that he believes in the end leads to the enculturation of the medical students. 1.) The loss of idealism amongst medical students as they move from articulating humanistic ideals upon entry to an increased pragmatism and sometimes cynicism. A transformation of �idealism: as increasingly �real world� values are adopted. Alienation and separation from lay society 2.) The picture of professionalism as a partly a symbolic process of social separation and of professional identify as based not just on knowledge and skill, but also on ritual transformation. 3.) the management of emotion and the process of emotional socialization. Transforming the patient or the procedure into ant o an analytic object or event six learning outcomes of the hidden curriculum; Lempp H. BMJ 2004;329:770-773. Univeristy of London Together these six outcomes achieve the enculturation of trainees as they develop into both practioners and members of the medical profession. Qualitative study using these 6 outcomes, lead to the development of four themes Cribb A, Bignold S. Stud Higher Educ 1999;24:195-209. King�s College London In the process of uncovering the hidden curriculum Alan Cribb identified several outcomes from the hidden curriculum that he believes in the end leads to the enculturation of the medical students. 1.) The loss of idealism amongst medical students as they move from articulating humanistic ideals upon entry to an increased pragmatism and sometimes cynicism. A transformation of �idealism: as increasingly �real world� values are adopted. Alienation and separation from lay society 2.) The picture of professionalism as a partly a symbolic process of social separation and of professional identify as based not just on knowledge and skill, but also on ritual transformation. 3.) the management of emotion and the process of emotional socialization. Transforming the patient or the procedure into ant o an analytic object or event six learning outcomes of the hidden curriculum; Lempp H. BMJ 2004;329:770-773. Univeristy of London Together these six outcomes achieve the enculturation of trainees as they develop into both practioners and members of the medical profession. Qualitative study using these 6 outcomes, lead to the development of four themes

16. 16 Themes personal encouragement haphazard teaching importance of hierarchy getting ahead by being competitive Given the high values trainees place on the clinical experience as a core source of education, a negative experience can undermine EBP education. Hattab AS. Develop World Bioethic 2004;4:160-172. Medical educators must develop learning objectives for educational programs that would clearly reflect the values that work towards the integral formation of physicians who are devoted to the ethical and moral caules of the profession. four main themes identified by medical students and postgraduate trainees perception of clinical teaching; personal encouragement students report positive and effective role models, but with valued characteristics perceived according to traditional gendered stereotypes among teachers. haphazard teaching importance of hierarchy getting ahead by being competitive students report a hierarchal and competitive atmosphere in which haphazard teaching by humiliation continues to occur Given the high values trainees place on the clinical experience as a core source of education, a negative experience can undermine EBP education. Hattab AS. Develop World Bioethic 2004;4:160-172. Medical educators must develop learning objectives for educational programs that would clearly reflect the values that work towards the integral formation of physicians who are devoted to the ethical and moral caules of the profession. four main themes identified by medical students and postgraduate trainees perception of clinical teaching; personal encouragement students report positive and effective role models, but with valued characteristics perceived according to traditional gendered stereotypes among teachers. haphazard teaching importance of hierarchy getting ahead by being competitive students report a hierarchal and competitive atmosphere in which haphazard teaching by humiliation continues to occur

17. 17 Theme Personal Encouragement positive role models who encourage and motivate commitment to teaching to communication Many students report positive and effective role models, but with valued characteristics perceived according to traditional gendered stereotypes among teachers. Emotions play an important roles in students and is associated with (i.) retention of knowledge (ii.) conceptualization of phenomena (iii.) future behaviorsMany students report positive and effective role models, but with valued characteristics perceived according to traditional gendered stereotypes among teachers. Emotions play an important roles in students and is associated with (i.) retention of knowledge (ii.) conceptualization of phenomena (iii.) future behaviors

18. 18 Theme Haphazard Teaching problems with disregard over timetable and unscheduled changes to teaching sessions lack of commitment and poor teaching skills demotivates the students leads to non-attendance There is a worrying lack of accountability of medical teachers in the over stretched clinical settingThere is a worrying lack of accountability of medical teachers in the over stretched clinical setting

19. 19 Theme Importance of Hierarchy the principal way trainees learn about the hierarchy in medicine is through teaching that involves intimidation and humiliation trainees often blame themselves for these events or reported excuses for senior staff Students often report a hierarchal and competitive atmosphere in which haphazard teaching by humiliation continues to occurStudents often report a hierarchal and competitive atmosphere in which haphazard teaching by humiliation continues to occur

20. 20 Theme Getting Ahead by Being Competitive competition rather than cooperation is the defining characteristic of medicine this view more common in clinical medicine need to impress senior medical staff to prepare the way for prestigious career in the future

21. 21 Summary a primary idea behind the hidden curriculum definition moral socialization indoctrination enculturation Result: marginalization of EBHC? Hafferty FW. Acad Med 1994; 69:861-871. Medical training at the root is a process of moral enculturation, and that in transmitting normative rules regarding behaviors and emotions to its trainees, the medical schools functions as a moral community. To recognize medical training as a process of moral socialization is to acknowledge medicine cultural distinction between attitudes and behaviors for what it is. Medical training above all else involves the transmission of a distinctive medical morality. A central ingredient in the marginal status of EBP in the culture of medicine is that it is difficult to establish a connection between teaching EBP and improved patient outcomes When curriculum goals are specified, the emphasis is on teaching the skills thought to enable the students to identify, analyze, and resolves EBP problems in practice based learning competency. So which ever way you look at the process of the health care curriculum. All of us teach a hidden curriculum of evidence based practice Tacit ways in what knowledge and behaviors get constructed outside the usual course material and formally scheduled lessons Hafferty FW. Acad Med 1994; 69:861-871. Medical training at the root is a process of moral enculturation, and that in transmitting normative rules regarding behaviors and emotions to its trainees, the medical schools functions as a moral community. To recognize medical training as a process of moral socialization is to acknowledge medicine cultural distinction between attitudes and behaviors for what it is. Medical training above all else involves the transmission of a distinctive medical morality. A central ingredient in the marginal status of EBP in the culture of medicine is that it is difficult to establish a connection between teaching EBP and improved patient outcomes When curriculum goals are specified, the emphasis is on teaching the skills thought to enable the students to identify, analyze, and resolves EBP problems in practice based learning competency. So which ever way you look at the process of the health care curriculum. All of us teach a hidden curriculum of evidence based practice Tacit ways in what knowledge and behaviors get constructed outside the usual course material and formally scheduled lessons

22. 22 Curriculum Concordance the challenge of examining and modifying the full range of influences arising from all three curriculum forms is an attempt to re-design the learning environment need to identify the values transmitted by the hidden curriculum in our individual institution if these values do not parallel the formal curriculum, we must ask why and implement change Movement towards a competency based assessment (outcome) as extremely positive step to avoid problems Stating competency based assess ment at the level of the program has the potential to emphasize organizational structure and interpersonal interaction aver the curriculum. Medical training is more than acquiring a technical knowledge base it is a socialization process whereby trainees acquire skills and humanistic qualities society expect of physician. The hidden curriculum plays a more important role that the formal curriculum in transmitting values, ideals, conditions of the profession and specialty. To attract the highest quality candidates to our specialty and produce truly professional trainees we must ensure the hidden curriculum actually transmits these ideal and parallels the formal curriculum. Need to develop curricular alignment. Goal of ac concordant curriculum. A broader and subtler hidden curriculum is always at play in educational settings, consisting of knowledge, a attitudes, behaviors ad skills, that may be learned but not overtly intended.Movement towards a competency based assessment (outcome) as extremely positive step to avoid problems Stating competency based assess ment at the level of the program has the potential to emphasize organizational structure and interpersonal interaction aver the curriculum. Medical training is more than acquiring a technical knowledge base it is a socialization process whereby trainees acquire skills and humanistic qualities society expect of physician. The hidden curriculum plays a more important role that the formal curriculum in transmitting values, ideals, conditions of the profession and specialty. To attract the highest quality candidates to our specialty and produce truly professional trainees we must ensure the hidden curriculum actually transmits these ideal and parallels the formal curriculum. Need to develop curricular alignment. Goal of ac concordant curriculum. A broader and subtler hidden curriculum is always at play in educational settings, consisting of knowledge, a attitudes, behaviors ad skills, that may be learned but not overtly intended.

23. 23 Recommendations that those that teach EBHC need to aware of the trainees perceptions of EBHC the content and possible impact of the hidden curriculum must be identified and addressed all teachers in contact with learners must be both willing and able to identify EBHC issues students need to be given �real life� opportunities to appreciate the relevance of EBHC to medicine at the organizational level Hafferty FW, Franks R. Acad Med 1994;69:861-871.Hafferty FW, Franks R. Acad Med 1994;69:861-871.

24. 24 Bottom Line if the hidden curriculum values do not parallel the formal curriculum, we must ask why and implement change recognition and reform of the hidden curriculum is required to achieve the necessary fundamental changes to bring EBHC to the forefront of medicine

25. 25