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Academic Medicine, Vol. 93, No. 4 / April 2018
648
Review
Editor’s Note: An Invited Commentary by F.W.
Hafferty and M.A. Martimianakis appears on
pages 526–531.
Since its initial description in the
1960s and its application to medical
education in 1994, the reach of the
so-called “hidden curriculum” in
medical education has continuously
expanded.1–3 Frederic Hafferty originally
defined the term with respect to medical
education as the “set of influences that
function at the level of organizational
structure and culture.”4 He described
the hidden curriculum generally as the
“‘understandings,’ customs, rituals, and
taken-for-granted aspects of what goes
on in the life-space we call medical
education” and viewed the hidden
curriculum in medical education as an
institutional-level concept best visible in
“(1) policy development, (2) evaluation,
(3) resource allocation, and (4) insti-
tutional slang.”4(p404) In the 20 years
since this original conceptualization,
researchers across the medical education
spectrum have used the term to expose
and explain a number of “hidden” facets
of learning and teaching.5–8 The effects
of what is described as the hidden
curriculum are rarely innocuous and in
fact, are, in many ways, more influential
than the formal curriculum.4,9–11
According to recent studies, the hidden
curriculum is responsible for any
number of ills, from discouraging
medical students from pursuing surgical
specialties and encouraging inappropriate
student mobile device use, to increasing
medical school admissions biases.12–14
This vast and expanding use of the term
has led some to doubt its continued
utility in medical education. For instance,
MacLeod questions the benefit of labeling
the diversity and breadth of issues now
categorized as hidden curriculum as such,
writing: “What are the consequences of
‘lumping’ together a series of related but
clearly disparate issues? What is brought
to light and what is left invisible?”15(p540)
MacLeod suggests that the medical
education community shift from
repeatedly identifying what she sees as
no longer “hidden” issues to, instead,
actively addressing these now-visible
practices. She goes so far as to question
the continued use of the term within
medical discourse, writing that while the
hidden curriculum has historically been
a powerful tool for curricular innovation,
now may be the time to retire it in favor
of more actionable concepts.15 Also,
Martimianakis and colleagues16 recently
conducted a scoping review and explored
the link between the hidden curriculum
and humanism in medicine. Their
valuable results show that the hidden
curriculum is responsible for much of
future physicians’ professional identity
formation.16 Given this finding and
MacLeod’s concerns, we believe that it is
essential for researchers to understand
how the hidden curriculum is defined
and applied within the literature to
enable more effectively categorizing or
analyzing its effects. Thus, we conducted
this scoping view to systematically
analyze the definitions and uses of the
term “hidden curriculum” in the medical
Abstract
Purpose
To analyze the plural definitions and
applications of the term “hidden
curriculum” within the medical
education literature and to propose a
conceptual framework for conducting
future research on the topic.
Method
The authors conducted a literature search
of nine online databases, seeking articles
published on the hidden, informal, or
implicit curriculum in medical education
prior to March 2017. Two reviewers
independently screened articles with set
inclusion criteria and performed kappa
coefficient tests to evaluate interreviewer
reliability. They extracted, coded, and
analyzed key data, using grounded
theory methodology.
Results
The authors uncovered 3,747 articles
relating to the hidden curriculum in
medical education. Of these, they selected
197 articles for full review. Use of the
term “hidden curriculum” has expanded
substantially since 2012. U.S. and
Canadian medical schools are the focus
of two-thirds of the empirical hidden
curriculum studies; data from African and
South American schools are nearly absent.
Few quantitative techniques to measure
the hidden curriculum exist. The “hidden
curriculum” is understood as a mostly
negative concept. Its definition varies
widely, but can be understood via four
conceptual boundaries: (1) institutional–
organizational, (2) interpersonal–social,
(3) contextual–cultural, and/or (4)
motivational–psychological.
Conclusions
Future medical education researchers
should make clear the conceptual
boundary or boundaries they are
applying to the term “hidden
curriculum,” move away from general
musings on its effects, and focus on
specific methods for improving the
powerful hidden curriculum.
The Hidden Curricula of Medical Education:
A Scoping Review
Carlton Lawrence, Tsholofelo Mhlaba, MBChB, MMed, Kearsley A. Stewart, PhD,
Relebohile Moletsane, PhD/MsC, Bernhard Gaede, MBBCh, MMed, PhD,
and Mosa Moshabela, MBChB, MMed, PhD
Please see the end of this article for information
about the authors.
Correspondence should be addressed to Carlton
Lawrence, Centre for Rural Health, 4th Floor, George
Campbell Building, Howard College Campus,
University of KwaZulu-Natal, Durban, South Africa;
telephone: +27312601569; e-mail:
carlton_lawrence@hms.harvard.edu.
Acad Med. 2018;93:648–656.
First published online November 7, 2017
doi: 10.1097/ACM.0000000000002004
Copyright © 2017 by the Association of American
Medical Colleges
Supplemental digital content for this article is
available at http://links.lww.com/ACADMED/A497.
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Review
Academic Medicine, Vol. 93, No. 4 / April 2018 649
education literature. Our ultimate goal
was to provide a strategic and deliberate
framework for using the term “hidden
curriculum” in the future.
Method
We employed a rigorous scoping
review methodology17 to map medical
education’s “hidden curriculum”
literature. Scoping reviews are used
for a variety of purposes, including to
examine the extent, range, and nature of
research activity; to determine the value
of undertaking a full systematic review;
to summarize and disseminate research
findings; or to identify gaps in the existing
literature.17 This scoping review focuses
on conceptual mapping, the process of
establishing how a particular term—in
this case “hidden curriculum”—is used
in the literature. We observed that within
the medical education literature the term
seemed to lack a distinct and universal
definition; this ambiguity and its effects
on curricular understanding prompted
us to adopt this “concept mapping”
approach, which we felt would allow
for more systematic interventions based
on specific meanings, knowledge, and
learning encompassed by the hidden
curriculum.
The particular approach to and level of
rigor of a scoping review is important,
as the technique is not standardized.18,19
To ensure the reliability of our methods,
we used the five-step approach originally
described by Arksey and O’Malley17 and
later refined by Levac and colleagues20:
(1) identifying the research question; (2)
identifying relevant studies; (3) selecting
the studies; (4) charting the data; and (5)
collating, summarizing, and reporting the
results.
1. Identifying the research question
Our scoping review focused on
answering the question, How is the term
“hidden curriculum” understood within
medical education? After conducting
background research, we discovered that
the terms “informal curriculum” and
“implicit curriculum” are often used in
conjunction with, or as synonyms for,
“hidden curriculum.” Thus, we decided to
include these terms in our analysis.
2. Identifying relevant studies
After considering our project goals and
consulting our university-affiliated
librarian, we drafted the following
Boolean search query for our database
search: (“hidden curriculum” OR
“implicit curriculum” OR “informal
curriculum” OR “hidden curricula”
OR “implicit curricula” OR “informal
curricula”) AND (“medicine” OR
“medical”). Scoping reviews that aim to
map global concepts such as the hidden
curriculum must be comprehensive; thus,
we scanned seven databases: PubMed,
Scopus, Web of Science, ProQuest,
ScienceDirect, JSTOR, and EBSCOhost
(filtered to relevant results from ERIC,
WorldCat, Academic Search Complete,
OCLC ArticleFirst, and PsycINFO). We
conducted the initial search on October
20, 2015, and a follow-up search on
March 21, 2017. In addition, because of
our placement in South Africa and the
failure of some of the larger databases
to include local journals, we decided to
conduct direct searches of the African
Journals Online database and the African
Index Medicus. We did not limit the
results by publication date, language, or
study type at this stage.
3. Selecting the studies
We imported all the titles our search
uncovered into EndNote software and
deleted duplicates. Two of us (C.L. and
T.M.) independently applied a screening
tool to all retrieved article titles and
abstracts to determine their eligibility
for full article review. We used a kappa
coefficient reliability test to determine the
reliability of our screening tool. Because
the initial test of 50 articles resulted in a
kappa value of 0.78 (standard deviation
[SD] = 0.151), which was below our goal
of 0.90 (“almost perfect”),21 we refined
the screening tool and conducted a
second test on 100 new articles. That test
yielded an acceptable kappa coefficient
of 0.96 (SD = 0.0332), and given the
new high level of reliability, we (C.L.,
T.M.) each independently reviewed all
nonduplicative titles and abstracts for
inclusion. After this review, all of us
discussed any discrepancies and came to a
consensus on which articles to include for
full review.
Next, each of us read a designated
number of the articles selected for full
review. We each applied strict inclusion/
exclusion criteria to determine eligibility.
To be included in the data extraction
sheet, each article needed to
1. focus on and explicitly name the
hidden, implicit, or informal
curriculum,
2. involve medical school curricula—
not solely curricula from other
disciplines such as nursing, science,
pharmacology, or the like, and
3. focus on students obtaining
their medical degree, as that is
understood in various countries (i.e.,
undergraduate medical education
[UME] in the United States), and not
exclusively on residents or fellows.
We excluded books, book reviews,
commentaries, and letters to the editor, as
well as non-English articles.
To confirm selection process rigor, we
searched the bibliographies of 10 selected
articles for the terms “hidden” and
“informal.”22–31 The search recovered no
new articles, providing further support of
the rigor and comprehensiveness of our
search protocol.
4. Charting the data
We employed Arksey and O’Malley’s17
“descriptive-analysis” approach to data
extraction, summarizing information from
the selected articles and recording the data
in an Excel sheet (Microsoft, Redmond,
Washington). This allowed us to analyze
the selected articles through a common
framework. We also followed Levac and
colleagues’ recommendations for the data
charting process.20 First, we collectively
developed the data extraction form to
include both demographic data (e.g., year
of publication, location of publication)
and thematic categories (e.g., definitions
of key terms, effects of curricular reforms,
conclusions). The review process was
iterative; that is, we added and edited
columns on our spreadsheet as necessary
throughout the process.
5. Collating, summarizing, and
reporting the results
We synthesized and collated various
themes that emerged from the data
extraction sheet. The extraction
sheet informed both quantitative and
qualitative results and became a platform
for synthesizing various definitions and
effects of the hidden curriculum. We used
qualitative thematic analysis, based in the
grounded theory process of descriptive
coding,32 to generate the four conceptual
boundaries (see Results). We extracted all
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Review
Academic Medicine, Vol. 93, No. 4 / April 2018
650
the definitions of “hidden curriculum,”
“informal curriculum,” and “implicit
curriculum,” directly from the data on
our extraction sheet. We generated open
descriptive codes (i.e., organizational,
institutional, interpersonal, interactions,
norms, experiences, behaviors, socialization,
outside formal, location, implicit,
unintentional, culture, value) directly
from the definitions in the articles.
Next, as outlined by Saldaña,32 we
synthesized these primary descriptive
codes into coherent axial codes, grouping
similar definitions (i.e., organizational/
institutional/structure, interpersonal/
interactions/socialization, location-based/
outside of formal/settings related, intention-
determined/implicit). The theoretical
codes, presented below in the Results as
the four conceptual boundaries, emerged
from each of these axial codes. Next, we
coded the selected articles a final time
to examine them for the presence of any
conceptual boundaries (nonexclusively)
and to gather final frequency statistics.
Results
Descriptive summary
Our initial search uncovered 3,747 titles, of
which 749 were duplicative. After applying
our screening tool to the remaining
2,998 titles, we identified 197 articles to
include in our final analysis (see Figure 1
and Supplemental Digital Appendix 1 at
http://links.lww.com/ACADMED/A497).
Of these 197 articles, 121 (61%) were
published after 2010, and only 14 (7%)
were published between 1980 and 1999
(Figure 2). The bulk of the articles were
either qualitative studies (n = 84; 43%) or
perspective pieces (n = 71; 36%). Literature
reviews (n = 17; 9%), mixed-method
studies (n = 13; 6%), and quantitative
studies (n = 12; 6%) each constituted less
than 10% of the total.
Of the 109 empirical studies, over two-
thirds (n = 76; 70%) were conducted
in the United States or Canada or in
Central America. Other settings included
Europe (n = 18; 16%), Asia (n = 8; 7%),
and Oceania (n = 5; 5%). Our search
produced only two empirical studies
from Africa (2%), despite including the
continent-specific databases—African
Journals Online and the African Index
Medicus—in our search (see Table 1). The
hidden curriculum is understood as deeply
context and culture dependent, making
this geographic gap problematic.26,33
Although much of the literature speaks
generally of the hidden curriculum
within UME, some authors focused
special attention on certain topic areas,
including the hidden curriculum in
relation to palliative and end-of-life
care,34–40 the surgical rotation,41–44
postmortem exercises,22,45–47 and attitudes
toward marginalized or underrepresented
groups.48–51
Identifying the hidden curriculum
Systematic techniques for identifying or
categorizing the hidden curriculum were
rare.52 Through this scoping review, we
compiled a list of research methods used
to study the hidden curriculum. The
most commonly used quantitative tools
were the Communication, Curriculum,
and Culture (C3) Survey and the
Patient–Provider Orientation Scale.53–56
Both of these tools, however, measure the
hidden curriculum solely with respect
to the patient centeredness of care and
do not extend to other elements of
UME.55 We noted that additional study-
or site-specific surveys were employed
in the three remaining quantitative
studies,34,57,58 but we identified no other
standardized measurement tool for
assessing the hidden curriculum. This
lack of standardization is likely due to the
ambiguity of the definition of “hidden
curriculum” across settings and among
authors, which we discuss in depth below.
The majority of qualitative studies
employed interviews and focus groups
of medical students to explore their self-
identified understanding of the hidden
curriculum; however, some studies
used non-institution-specific surveys
such as Australia’s Critical Reflection
Tool to analyze the informal elements
of their curriculum.59 A number of
investigators plumbed student and
faculty reflections—written on paper and
online—to find information relating to
the hidden curriculum11,41,60–62; however,
the effectiveness of these methods for
identifying the hidden curriculum is
dependent on the definition of the term
itself, something that is up for debate.
Addressing the hidden curriculum
Through our review, we extracted any
methods cited as effective in changing or
preserving the hidden curriculum. The
most common recommendation was
that schools make the hidden curriculum
explicit to both faculty and students.63–68
“Painful feedback,” one author’s
term for the process of making the
hidden curriculum visible, encourages
presenting direct evidence of the harmful
elements of the hidden curriculum to
students and other stakeholders.69 Open
discussion and self-reflection were
also often encouraged.24,31,70–74 Chuang
and colleagues75 state that separating
curricular analysis at the individual,
departmental, and institutional levels
3,747
records identified through
database search
2,998
records reviewed for
screening (title and abstract)
749
records excluded as
duplicates
313
records kept for full text
review
2,685
records excluded using
screeningtool
116
records excluded after full
review
197
records included in review
A. Identification
C. Eligibility
D. Included
B. Screening
Figure 1 Flowchart of search process and results. The flowchart outlines the process through
which the authors selected the articles included in this scoping review.
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Academic Medicine, Vol. 93, No. 4 / April 2018 651
is necessary to ensure multilevel
interventions. Encouraging small-group
learning, patient-centered curricula,
humanities education, and better
integration of marginalized groups
also had positive effects on the hidden
curriculum.31,62,76–78
Ambiguity in hidden curriculum
We noted ambiguity in both the
definition and application of the term
“hidden curriculum.” Hafferty and
Franks2 first described the term “hidden
curriculum” in relation to medical
education in 1994, and Hafferty4
later (1998) distinguished it from the
“informal curriculum.” As mentioned,
Hafferty4(p404) delineated the “hidden
curriculum” as “a set of influences that
function at the level of organizational
structure and culture”; he felt the “hidden
curriculum” included “the commonly
held ‘understandings,’ customs, rituals,
and taken-for-granted aspects of what
goes on in the life-space we call medical
education.” Informal curriculum for him,
on the other hand, is an “unscripted,
predominantly ad hoc, and highly
interpersonal form of teaching and
learning that takes place among and
between faculty and students.”4(p404) In
his understanding, the two terms are
overlapping and influence one another
but are not synonyms.
Through this scoping review, we found
that the literature extends well beyond
Hafferty’s original definitions. The
search tool uncovered articles variously
referencing the “hidden,” “implicit,” or
“informal” curriculum. Specifically,
of the 197 articles we fully reviewed,
156 included at least one of our key
terms (see Table 1): “hidden” (n = 184;
93%), “informal” (n = 76; 39%), and
“implicit” (n = 4; 2%). Using the extracted
definitions from the articles, we were able
to compare definitions across articles
and map how each concept is defined in
reference to the others. The most common
and perhaps most alarming finding from
this process was the ambiguous and
interchangeable use of the terms “hidden”
and “informal.” Of the 197 articles we
reviewed, 17% (n = 33) included both the
terms “hidden curriculum” and “informal
curriculum” without providing distinct
definitions; that is, the authors of these
articles often treated the two phenomena
as equivalent (we included these 17 articles
both in our count for articles citing the
“hidden curriculum” and in our count of
articles citing the “informal curriculum).
Four articles included the term “implicit
curriculum,” and in 2 articles,23,26 the
term was also used interchangeably with
“hidden curriculum.” Some authors clearly
see the hidden and informal curriculum as
interchangeable, while others see them as
distinct concepts.
Conflicting connotations of hidden
curriculum
The term “hidden curriculum” is
ambiguous and generally non-neutral.16
By extracting the effects of the hidden
curriculum from the articles we reviewed,
we found the literature often portrays
the hidden curriculum as negative or
intrinsically in conflict with the formal
curriculum. Balboni and colleagues’
comments79 illustrate this sentiment:
“We refer to the [hidden curriculum] as
the process … which instills behaviors,
attitudes, and values among trainees
in tension with the ideals of the medical
Figure 2 Publication frequency of articles included in this scoping review by year. Note: The years on the x-axis are in nonlinear groups because of the
relatively few publications in years prior to 1996.
Table 1
Summary of Articles Included in
2017 Scoping Review of the Medical
Education Literature on the “Hidden
Curriculum”
Characteristic No. (%)
Study type
Qualitative 84/197 (43)
Perspective 71/197 (36)
Review 17/197 (9)
Mixed methods 13/197 (6)
Quantitative 12/197 (6)
Study locationa
The United States,
Canada, and Central
Americab
76/109 (70)
Europe 18/109 (16)
Asia 8/109 (7)
Oceania 5/109 (5)
Africa 2/109 (2)
South America 0
Term used
Hidden 184/197 (93)
Informal 76/197 (39)
Implicit 4/197 (2)
aThe denominator includes only the 109 empirical
studies; the authors have excluded reviews and
perspective pieces.
bHere Central American comprises Grenada.
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Academic Medicine, Vol. 93, No. 4 / April 2018
652
profession” [emphasis added]. Further,
the literature cites the hidden curriculum
as a major factor in the erosion of
idealism63 and the increase in cynicism80
and bias81 that occur during medical
school.
We found far fewer insights depicting
the hidden curriculum as a positive
element within UME, although they do
exist. For example, some elements of the
hidden curriculum, such as rural health
placements or medical clerkships, seem to
have an overall positive effect on students’
experiences and their developing
professionalism.30,82,83
Conceptual classification of hidden
curriculum
As noted, we observed that the approach
to and application of the “hidden
curriculum” varies widely across the
literature. To better understand the
ambiguity, we attempted to map the use
of the term. Using definitions extracted
from all included articles and grounded
theory methodology, four different but
overlapping conceptions emerged (see
Table 2). We propose that the term is
understood, depending on the article,
as (1) an institutional–organizational
concept, (2) an interpersonal–social
concept, (3) a contextual–cultural
concept, and (4) a motivational–
psychological concept. As shown in
Table 2, each conceptual boundary
lends itself to a distinct disciplinary
lens—retrospectively, policy, sociology,
anthropology, and psychology.
Once we delineated the four
classifications, we worked to understand
their frequency of use and overlap.
We noted that the various uses or
conceptions of the term are not
exclusionary or necessarily distinct;
instead, authors have used them in
tandem. Among the 197 articles we
reviewed, the hidden curriculum as an
institutional–organizational concept,
applied in 82 articles (42%), was the
most common. The interpersonal–social
conception, applied in 57 articles
(29%), was the second most common,
followed by contextual–cultural (applied
in 40 articles [20%]), and, finally,
motivational–psychological (applied in
20 articles [10%]). Notably, a full fifth
of the articles (n = 41 [21%]) did not
include a direct definition for the term
“hidden curriculum.” Additionally,
another 20% of the articles (n = 40) used
a definition that included more than one
conceptual boundary. The most common
overlap, used in 35 articles (18%), was
between the institutional–organizational
and interpersonal–social conceptions.
Gaufberg et al71 exemplify this cross-
concept application when they write,
we use the term “hidden curriculum” to
refer to learning that occurs by means of
informal interactions among students,
faculty, and others [interpersonal–social]
and/or learning that occurs through
organizational, structural, and cultural
influences intrinsic to training institutions
[institutional–organizational]. (italicized
words in brackets added for illustration)
Researcher positionality in hidden
curriculum studies
Importantly, the conceptual boundary
used in hidden curriculum studies is not
arbitrary but, instead, is likely informed
by the researcher’s (or researchers’)
reflexivity, expertise, and/or fields of
study—and, in turn, the boundaries
chosen by individual researchers directly
affect their study methods, outcomes,
and recommendations. Table 2 highlights
the discipline most associated with
the various conceptions. For instance,
researchers who view the hidden
curriculum as an interpersonal–social
concept are likely to use sociological
methods to explain or uncover its
effects. The methods of these studies
often involve eliciting self-reflection
from individual students, and the results
focus on individual- or departmental-
level interventions. On the other hand,
research that examines the hidden
curriculum as solely an institutional–
organizational concept must extend
beyond the individual learner to the
culture of the medical school as an
organization; thus, the unit of analysis for
these studies is almost always the medical
institution. Proposed interventions from
these studies often entail changes to
policy, programs, or curricula, and they
usually differ in scope from those using
other conceptual boundaries.
Discussion
Use of the term “hidden curriculum”
in the literature is clearly on the rise:
Nearly half of the articles we included
have been published since 2012. Further,
although originally understood as distinct
phenomena,2 “hidden” and “informal”
curricula have become increasingly
blurred, as shown in the 17% of articles
that use the terms synonymously. Thus,
we believe that it is essential for scholars
to effectively describe what they mean by
the hidden curriculum and where they
see its influence within UME.
Recommendations for scholars
investigating the hidden curriculum in
UME
Recommendation 1: Specify the
conceptual boundary and the context.
The conceptual boundaries outlined here
may provide clarity to a term that has
garnered criticism from some15 because of
its ambiguous and seemingly ubiquitous
use. The widespread application of
“hidden curriculum” as a term may make
researching and evaluating the efficacy
of various hidden curriculum reforms
difficult. In addition, UME operates in
many contexts—whether these are formal
classroom teaching, medical clerkships,
electives, or other spaces. Although
many norms and values span learning
environments, hidden curricula and their
impact are context dependent and should
not be viewed as a monolith spanning
all settings. Therefore, education policy
would benefit greatly if authors explicitly
addressed the following in publications
regarding the hidden curriculum: (1)
the conceptual boundary or boundaries
they are applying to the term, and (2)
the specific learning environments in
which they see the hidden curriculum
acting (i.e., is the hidden curriculum
bounded or unbounded by certain
spaces?). Recommendations to address
the hidden curriculum will vary according
to the conception used, so the efficacy
and efficiency of curricular reforms may
depend on employing the proposed
conceptual framework outlined in Table 2.
Recommendation 2: Clarify research
methodologies and results. We
argue that UME is filled with hidden
curricula—not blanketed by a singular
hidden curriculum. We believe that,
moving forward, authors should make
explicit the what, where, and how of
their hidden curriculum as they see and
are investigating it—within both the
Methods and Results sections of their
research reports. Explicitly specifying
will allow policy makers and curriculum
developers to better identify literature
related to their own particular needs
and initiatives. Using a more systematic
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Academic Medicine, Vol. 93, No. 4 / April 2018 653
framework for discussing the hidden
curriculum will also better inform the
teaching practices of medical educators
themselves. Asking students to reflect
generally on the “hidden curriculum”
they experienced during their years
in medical school is akin to asking
them to reflect on the complete formal
curriculum: Both tasks are daunting and
likely to yield unspecific or incomplete
and possibly unhelpful results.
Recommendation 3: Remember the
positive. To better understand and
therefore harness the power of the hidden
curriculum, however defined, researchers
may also need to focus on its positive
effects. By better studying and publicizing
these positive examples, the medical
education community may find ways to
blunt the broader harmful effects.
Recommendation 4: Consider other
settings. Research into hidden curricula
Table 2
Conceptual Boundaries of the Hidden Curriculum, Developed Through Grounded
Theory Qualitative Analysis of 197 Articles on the “Hidden Curriculum” Discovered
Through a 2017 Scoping Review
Concept (and
frequency of usea) Example “definitions” from the literature Description
Disciplinary
lens
Institutional–
organizational
(n = 82 [42%])
• “[The hidden curriculum is] a set of influences that
function at the level of organizational structure and
culture.”4
• “We defined the hidden curriculum as the physical
and workforce organizational infrastructure that
influences the learning process.”84
• “The hidden curriculum is defined as the
organizational structure and culture that influences
learning.”85
• Based on Hafferty’s original definition, the hidden
curriculum operates at the institutional level4
• Powerful tool for analyzing organizational or
macroculture of medical education86
• Focuses on medical school structure, norms, and
culture33,81,87–89
• Visible within institutional policy, evaluation
activities, resource allocation, and institutional
slang4
Policy and
business
Interpersonal–social
(n = 57 [29%])
• “The premise of this hidden or informal curriculum
is that students learn such things as professional
behavior not only in classes but also in their day-to-
day interactions with faculty, residents, staff, and
patients in the context of clinical care.”90
• “[T]he implicit messages being conveyed continually
to students through a lecturer’s or a role model’s
example, rather than the person’s spoken words.”91
• “The hidden curriculum runs parallel to the formal
curriculum and is a process of socialization to the
complexities of physician–patient, physician–
interprofessional team, and physician–community
relationships.”92
• Denotes interpersonal learning, either structured or
unstructured10,93,94
• Socialization process of medical student learned via
interaction95
• Often uncovers various subcultures within medical
education (e.g., physician, student, patient,
medical specialty)86
• Deeply dependent on learning environment96
• Synonymous with Hafferty’s definition of “informal
curriculum”4
Sociology
Contextual–
cultural
(n = 40 [20%])
• “The “hidden” or “informal” curriculum [is] the
broader cultural milieu of medical education that
occurs outside of formal instruction.”97
• “Implicit curriculum includes learning activities (also
referred to as the hidden or informal curriculum)
that occur in the shadow of the explicit curriculum
but are beyond direct control of curriculum
leadership, such as the modeling of behaviors of
residents.”23
• Broad categorization that encompasses any
knowledge transmission occurring outside the
“formal curriculum”73
• The broadest conceptualization of the term,
applicable to anything learned without being
explicitly stated in the curriculum
• Often is transmitted beyond traditional and/or
explicit learning environments11,76,98
Anthropology
Motivational–
psychological
(n = 20 [10%])
• “Unintended lessons in education through informal
dialogue, messages, and interactions at school”99
• “In addition to the intentional teaching of
knowledge and skills by surgeons to their trainees
and protégés is the unintended, often unrealized
transmission of implicit beliefs, attitudes, and
behaviors through a process called the hidden
curriculum”44
• “The hidden curriculum refers to attitudes and
values unwittingly transmitted to students both by
what is (and is not) taught and how such teaching
features in the curriculum.”46
• Determined by the motivation behind the
knowledge exchange
• Hidden curriculum, under this definition, is largely
unintentional
• Authors use terms such as “unintended,”100
“unrealized,”41 and “tacit”101 to describe this
categorization of hidden curriculum
Psychology
Undefined
(n = 41 [21%])
• No direct in-text definition of the terms “hidden,”
“informal,” or “implicit” curriculum found within
the article
• Definition of term is assumed to be understood by
author without directly explaining in the article
a The denominator for the frequency of use is 197, the total number of articles subjected to a full review. Notably,
20% of the articles (n = 40) contained elements of two or more conceptual boundaries, which highlights the
nonexclusivity of these definitions. The most common overlap, occurring in 35 articles (18%), was between the
institutional–organizational and interpersonal–social conceptions.
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Review
Academic Medicine, Vol. 93, No. 4 / April 2018
654
in UME has so far been limited mostly
to the United States and Canada. Two-
thirds of the empirical studies in this
review involved U.S. and/or Canadian
medical schools. The medical education
community’s understanding of hidden
curricula is based on a very specific
medical education system. For instance,
U.S. and Canadian medical schools award
medical degrees solely to physicians
in training who have completed their
undergraduate (baccalaureate) education,
whereas many medical schools in Africa
and Europe employ a UME system
through which trainees earn both their
baccalaureate and medical credentials.
These two approaches likely differ in many
aspects, including goals and expected
competencies. Additionally, as Fins et al26,33
point out, the hidden curriculum varies
among cultures or locations, even if they
employ a similar curricular format. We
believe, therefore, that any new research
must examine medical schools in these
understudied regions (Africa, South
America) to avoid creating a sense of
homogeneity among what may be very
different hidden curricula.
Recommendation 5: Develop more
quantitative tools for studying hidden
curricula. We noted a paucity of
quantitative studies examining the hidden
curriculum. This deficit is likely due, at
least in part, to the inherent difficulty
in measuring much of what is bounded
by this term. The hidden curriculum
is deeply contextually and culturally
dependent and thus does not lend itself
well to quantifiable measurement26,33;
however, some quantitative measurement
tools do exist. The most commonly used
quantitative tools cited in the articles
we reviewed are the C3 Survey and
Patient–Provider Orientation Scale.53–56
These tools are limited in that they
measure the hidden curriculum only
with respect to the patient centeredness
of care. Developing new quantitative
measurement tools to evaluate the hidden
curriculum in relation to other topics
(e.g., standardized exam performance,
student mental health, specialty choice)
would be of benefit.
Study limitations
Although we sought to be as thorough
as possible, the study is limited to
the articles uncovered by the nine
literature bases we searched. We believe
our inclusion/exclusion criteria were
clear and effective—and multiple
independent reviews and the results
of our kappa coefficient tests support
the reliability of the article selection
process—yet we may have inadvertently
excluded some relevant studies. Also,
per the scoping review approach, we did
not consider the quality of the studies
we included; this lack of discrimination
should also be considered when
extrapolating results.
Conclusions
As of now, the term “hidden curriculum”
in medical education remains shrouded
in a fog of vague definitions and
widespread application. This scoping
review illuminates the various ways
the term is used, and we encourage
future authors to move away from
general musings on its ill effects toward,
instead, studies that consider context
and conceptual boundaries, clarify
investigators’ positions, consider the
positive, evaluate diverse settings, and
lead to new tools for measuring hidden
curricula. These efforts might help
improve the powerful hidden curriculum
of medical education.
Acknowledgments: The authors wish to
acknowledge the College of Health Sciences and
Medical Education Partnership Initiative at the
University of KwaZulu-Natal (UKZN), the Duke
Global Health Institute, and the U.S. Fulbright
Fellowship program. This publication is part
of a broader UKZN research initiative entitled
“Transformation in Medical Education (TiME)
study.”
Funding/Support: This study was supported by
the South Africa National Research Foundation
(grant number 90394) and the United States
National Institutes of Health (grant number
5R24TW008863).
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
Previous presentation: “Deconstructing the
Hidden Curriculum in Medical Education: A
Scoping Review.” Oral Presentation (delivered
by Mosa Moshabela), Medical Education
Partnership Initiative Symposium; August 2–4,
2016; Nairobi, Kenya.
C. Lawrence is researcher, Centre for Rural Health,
School of Nursing and Public Health, University
of KwaZulu-Natal, Durban, South Africa, and
medical student, Harvard Medical School, Boston,
Massachusetts; ORCID: http://orcid.org/0000-0001-
7507-5582.
T. Mhlaba is public health medicine specialist,
School of Nursing and Public Health, University of
KwaZulu-Natal, Durban, South Africa; ORCID: http://
orcid.org/0000-0002-0178-2652.
K.A. Stewart is associate professor, The Practice
in Global Health and Cultural Anthropology, Duke
Global Health Institute, Duke University, Durham,
North Carolina.
R. Moletsane is professor and J.L. Dube Chair of
Rural Education, Department of Rural Education,
University of KwaZulu-Natal, Durban, South Africa;
ORCID: http://orcid.org/0000-0002-8493-7479.
B. Gaede is chair, Discipline of Family Medicine,
School of Nursing and Public Health, University of
KwaZulu-Natal, Durban, South Africa.
M. Moshabela is chair, Centre for Rural Health,
and Discipline of Rural Health, School of Nursing
and Public Health, University of KwaZulu-Natal,
Durban, South Africa, and Wellcome Trust fellow,
Africa Centre for Population Health, Mtubatuba,
South Africa; ORCID: http://orcid.org/0000-0002-
9438-7095.
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