From the (Assistant) Dean

This week’s “From the Dean” column is brought to you by Patrick Carr, Ph.D., the School’s assistant dean for medical curriculum, who will discuss facilitating leadership in medical students and unmasking the “hidden curriculum.”

As another academic year begins, our thoughts are focused on helping our incoming students on their road to mastering the skills, knowledge, and behaviors required of their chosen professions. In the past, formalized and intentional educational approaches have consisted of information that is deliberately taught (knowledge), expectations communicated by “rules,” policies or guidelines (values and behaviors), and abilities acquired through instruction, practice, and repetition (skills).

This process, however, did not encompass all of what was required of graduates. Most educational programs also had a covert list of expectations that were unspoken, untaught, and not directly assessed. It was anticipated that these expectations (often referred to as the “hidden curriculum”) were acquired by observation, experience, and trial and error.

It would be difficult, though, to argue that “hidden” was a synonym for “unimportant.” Some of these desired skills and behaviors, such as leadership and professionalism, were and are highly valued. The characteristic that made them “hidden” was the lack of intentional training, coupled with no direct method of assessment. There was no valid and reliable tool used to gauge the learner’s developmental arc and to determine whether those skills and behaviors had been acquired and could be demonstrated at a suitably proficient level. Educational programs now realize that if there is value in the knowledge and behavior acquired through a “hidden curriculum,” then the curriculum needs to identify them, emphasize them, and test to be sure that learners acquire them. A prime example in medical training, as in much of higher education, has been the movement of leadership skills from the “hidden” to the goal-based curriculum. These skills, once acquired through observation, trial and error, and years of experience, are now goals that must be taught, assessed, and mastered. The appearance of these goals in curricula seems obvious in hindsight. We expect our physicians to be leaders: at work, in their profession and in the community. Leadership is not an innate skill, nor is it one-size-fits-all. It develops through a mix of awareness of expectations, time to practice, incorporation of feedback, and the embrace of a leadership style that resonates with that particular individual. However, one cannot lead in a vacuum. Leadership must be considered in the context of groups of individuals, whether they are teams, committees, departments, or divisions. It is equally important to teach and practice how and when not to lead. Learning to be an effective team-member simultaneously forces reflection on leadership as these skills sets and behaviors exist along the same continuum of effective interpersonal partnership. At its core, leadership is not a personal characteristic, but an approach that requires flexibility and adaptability to each unique situation.

Organizations that are potent influencers within the medical profession have been very intentional about coaxing hidden curricula out of the shadows. Both The Physician Competency Reference Set and the AAMC Core Entrustable Professional Activities for Entering Residency include development of leadership abilities as fundamental qualities. Recently, as we revised the competencies for the undergraduate medical student curriculum, leadership was deliberately and repeatedly woven through our medical program goals as aspects of three domains: interpersonal and communication skills, interprofessional collaboration, and personal and professional development. We have expectations, learning experiences, and assessment tools linked with these skills in a way that visibly moves leadership from desired to required. Our medical curriculum now fully, and purposely, supports the emphasis of leadership as a necessary achievement. How we meet that goal will be ever-changing. Approaches, opportunities, skills, and needs are not static and our current strategies would be unrecognizable to us twenty, or even ten years ago. The message, however, remains clear. Expectations for graduates of professional programs continue to advance in both breadth and depth. By clarifying goals, implementing teaching strategies, and focusing on assessment strategies, we will be able to bring the formerly hidden curriculum into the mainstream. Being transparent and intentional is good for our students, good for our program, and ultimately good for society and the profession of medicine.

Pat Carr, Ph.D.
Assistant Dean for Medical Curriculum
UND School of Medicine & Health Sciences