Fictional depictions of the hidden curriculum vs reality
Fictional depictions of the hidden curriculum identified in television programs reflect real-life examples of the hidden curriculum. While we did not rate exemplars based on our interpretation of how realistic they were, our findings suggest that enactments of the hidden curriculum in medical dramas may reflect some healthcare realities. All themes established in this study overlap with those in previous literature examining real-life examples of the hidden curriculum among medical trainees. The themes of hierarchy, personal versus professional life balance, ‘faking it’, staging, the competitive nature of medicine, and role modeling were readily identified in many studies [12, 13, 25].
Interestingly, there were certain themes described in other studies of the hidden curriculum that overlapped with those in our study; we labeled these themes differently than the other studies, but the themes reflected similar content. For instance, our theme of consequences of the hidden curriculum, (Table 2) includes the suppression of normal emotional responses and emerging accountability that are considered by Gaufberg and colleagues as independent themes [13]. Furthermore, the theme of personal encouragement, as identified by Lempp and Seale’s work, was defined as the presence of positive role models and their ability to motivate students [25]. We categorized such instances in the television programs as a reflection of role modeling,; however, we found few positive examples of role modeling with staff and surgical interns in various stages of training. This may reflect the heightened reality of television or an effort to garner viewer interest by emphasizing negative behavior by role models. Variable respect for patients, a theme identified by Lamiani, described certain physicians who lacked respect for their patients and others who were kind and engaging [12]. For the purpose of our study, we categorized such instances as either examples of unprofessionalism or role modeling. Disease-centered medicine was another theme by Lamiani that overlapped with our study’s theme of patient dehumanization. We noted many scenes which depicted patient-physician relations, with a primary focus on a patient’s disease and not on the patient as a whole and classified such vignettes as reflections of patient dehumanization. Differing semantics, which may reflect the subjective process of identifying themes of the hidden curriculum, may account for such discrepancies. Despite these differences, there is substantial overlap of content of the hidden curriculum among television programs and actual medical trainee experiences.
Protecting patients was used to denote the approach of optimism for patient conditions and the need to calm patients by Lamiani [12]. We collected examples of similar examples in which physicians limited information or did not disclose the truth completely to patients, but labeled these instances as examples of unprofessionalism. Lamiani discusses that the paternalistic nature of the Italian health care system may explain why a theme may have a positive or negative connotation, depending on the cultural milieu [12].
Differing depictions of the hidden curriculum in medicine
There are several themes of the hidden curriculum discussed in the literature, which were not identified among television programs in this study. These themes included: positive experiences of human connection; haphazard teaching; the power differential and a delegation of patient’s emotional needs to nurses [12, 13, 25]. Human connection is a general term for situations that encourage the formation of longitudinal relationships among medical personnel, through learning names, celebrating together, and transitions [13]. This theme was not identified among the three television programs. Another theme we did not identify was haphazard teaching, which was described by Lempp and Seale as the tendency for clinical staff to disregard timetables for teaching classes [25]. This particular study examined concepts of the hidden curriculum among real–life student experiences in the classroom. In contrast, all three television programs we viewed were set in an institutional clinical setting among medical staff and students, who were beyond this level of training. As such, we believe that this difference in learning environments plays a major role in this discrepancy [12]. Power differential – defined as the gap in approachability between physicians and patients – was also not noted in this study [12]. This theme encompassed instances in which physicians used jargon with patients or in which patients showed submissiveness with senior physicians and not medical students.
Finally, delegating emotional patient needs to nurses was also not identified in our study. As the television programs we viewed centered on physicians and residents, with limited screen time with other health care professionals, we believe that this accounts for this difference.
Unique depictions of the hidden curriculum in medical television programs
We identified several unique themes of the hidden curriculum particular to television programs, which have not been well documented in studies on real life examples of the hidden curriculum. For example, unprofessionalism included depictions of physicians demonstrating a lack of respect for their patients; however we also identified instances of junior trainees not only experiencing unprofessionalism, but also tolerating the phenomenon itself. In addition, while the literature attests to the phenomenon of hierarchy in medicine, we specifically identified the issue of hierarchy in terms of a patient’s perspective, specifically how patients prefer to be treated by staff physicians as opposed to physicians-in-training. This may have been noted in our study because as the viewer, we are able to observe different viewpoints during the full patient and physician encounter. Most studies on the hidden curriculum in medicine only focus on interviewing medical professionals and therefore do not examine the perspective of patients.
Comparing and contrasting educational values of various programs
Depictions of the hidden curriculum were common to medical dramas, most notably representations of hierarchy, unprofessionalism, and patient dehumanization. Grey’s Anatomy and ER had the highest number of excellent and moderate examples of the hidden curriculum, which may speak to the dramatic nature of these programs. Both television shows demonstrate clear examples of the hidden curriculum, without overwhelming associated plot or character development. We suggest that between these two programs, ER may be most suitable as an educational tool. One of the reasons is that Grey’s Anatomy tended focus on long-term plot and character development; at times storylines were resolved over a number of episodes, rendering their use for teaching more challenging. As an example, Season 5 focused on one particular character’s personal evolving disease, diagnosis and management, which had little relevance to the hidden curriculum.
Scrubs had the lowest number of examples of the hidden curriculum, possibly due to its comedic nature. In previous research, Scrubs was deemed a suitable source of examples to inform medical education in the following spheres: “teaching and learning, mentorship, professionalism, communication skills, and interprofessional relationships” (p. 238, [19]). Our findings, however, challenge the quality of such examples in the context of the hidden curriculum, due to the show’s highly comedic nature. For instance, in episode 10 of Scrubs, the protagonist comments on his view of working females in his profession, and while the message delivered is positive, the comedic scene associated with it diverts the viewer’s attention from the underlying message. As such, in the context of the hidden curriculum we found that this television program was least representative of our focus.
Previous literature has supported the use of television programs to enrich medical education. Hirt and colleagues, systematically analyzed 177 episodes from eight popular medical programs, three of which included Grey’s Anatomy, Scrubs, and ER for their potential use in medical education in academic settings [19]. Grey’s Anatomy was shown to have numerous applications in areas related to “hospital environments, communication skills, teaching and learning, ethics, professionalism, and interpersonal conflict” (p. 238, [19]). Interestingly, the authors stated that this television show in particular includes numerous interactions among health professionals of various levels, with a “learn-by-humiliation approach” (p. 240, [19]). Our findings regarding hierarchy, unprofessionalism, and issues of life balance support this previous work, and reveal its applicability for teaching purposes specific to the hidden curriculum as well.
If we consider ER, Hirt and colleagues stated that issues related to work-life balance were heavily represented in this medical television drama [19]. Additionally, there was a focus on inter-professional relationships and informed consent. Our findings indicate several such instances which, as per our identified themes, either fell under hierarchy or unprofessionalism. Furthermore, the themes we identified specific to the hidden curriculum relate to Hirt’s findings of ER being useful in describing “professionalism, communication skills, ethical issues, inter-professional relationships, procedures, and hospital environments” (p. 238, [19]).
Our findings expand upon another study which examined the frequency of professionalism issues portrayed in the television dramas Grey’s Anatomy and House M.D. [1]. Czarny and colleagues found a deficiency in the number of commendable portrayals of professionalism, in contrast to a much higher incidence of professionalism breaches, among the two studied medical dramas [1]. Our research uncovered several examples of unprofessionalism regarding truth disclosure, ethical concerns in practice and quality of life issues. In contrast, it was rare for us to find positive examples of professionalism and professional conduct. This may be due in part to the nature of the television shows themselves and dramatic techniques employed to enhance viewer interest.
Limitations
There are several limitations that merit consideration. One cannot rule out the possibility that the depictions collected in these three television shows may not be a true representation of North American healthcare, and thus not reflect a true hidden curriculum that parallels one in actual medical institutions. We argue that such an inherent limitation merits consideration, despite overlap of similar themes identified in other studies examining the hidden curriculum among medical students [12, 13].
This study considered three television programs out of a multitude of medical dramas. As such, we cannot dismiss the possibility that we would have found other themes if other programs were examined. In addition, only one season was considered for each television program. While we could have viewed more programs, we reached a saturation of themes with the 70 viewed episodes. The selection of season to view may also predispose to an inherent bias. For instance, season five of Grey’s Anatomy included a major character plot arc, in which one resident was diagnosed with a life-threatening illness. This resulted in many dramatic scenes centered on personal relationships, rather than professional clinical interactions. Furthermore, as described earlier, Scrubs had a surprisingly lower number of depictions of the hidden curriculum. While this may be due to its comedic nature, it may also have been due to the fact that each episode averaged at a running time of 20 min, while Grey’s Anatomy was 40 min, and ER was 50 min.
Relevance to education
The examples of the hidden and informal curriculum uncovered in our study have direct relevance to medical education -- the clinical teacher is encouraged to use these examples (see Additional file 1) to address specific themes of the hidden and informal curriculum that they wish students to reflect on during undergraduate and postgraduate teaching.
Ornelas and Parikh [26] have argued that because of negative portrayals of physicians in medical dramas – specifically unethical and unprofessional behaviors – television shows should not be used for educational purposes. We would argue, however, that the fact that the programs depict fictional characters engaging in these behaviors makes them a perfect tool for education. The fact that they are fictional representations allows for trainees to reflect and have open discussions on the behaviors related to the hidden curriculum that are observed, without the worry that they are “passing judgment” on actual individuals.
The behaviors identified during the television shows can also provide the stimulus for students to contrast this behavior with the behavior they witness in clinical practice. Essentially, they can reflect on the question “in the era of Grey’s anatomy (E.R, Scrubs, etc.), are ‘real doctors’ really better than the ones depicted on television?” Are their own behaviors being affected/modeled by what they are watching on television? For example is it possible that their conceptualization of behavior in the clinical domain may in fact be being learned, during the pre-clerkship years, from their television watching?
Although our study did not examine the average viewers’ impressions of the hidden curriculum in medicine, we feel this would be an important area of future study. For example, does the average viewer recognize the conflicts that trainees feel when the formal and informal/hidden curriculum collide? Do they feel these are true depictions of medicine or are simply dramatizations. Studies of viewer perceptions of the hidden curriculum could enhance our knowledge of exactly how patients view the doctors responsible for their care.