OPENING PLENARY SESSION
Characteristics of the Informal Curriculum and
Trainees' Ethical Choices
ABST ltACT
[n Octobe 1995, th.e Association of American Medical
Colleges held its ~rst Conference on Students' and Resl
dents' E htcal and Profess lana l Developmem. ]n a pie~
nary ~s.sion and break-out &e, lon, the 150 pardcipants 1
representing a " Lde variety of medical and ptofesstonal
spedalties and rolest discus ed the fac O:tS and programs
tha affect medical trainee$' developmen of ethical and
professional :smnda:rds of be:hflY'ior:.
The n1aiu challenge of Add esslng s udCj,its' profes-
sional development is he enonnou.s range of inR uenc.es
on. tha1t developtuem, many of which., uch 3S the de-
dines in civic respomlbilhy and good mannen through-
out 11he Ullited State~;, fan o tside the. scope of acad0mic
medicine. Noneth_,eless, many inO tJencet> fa tl within r0a.ch
of medical edu:carors. ln fl. preconf.etence survey, pan lei
pan~s- ranked e jght issues. re l:atecl to gradua:dng ethical
physicians.. The respondenl5 ranked highest the inade-
quacy of the understaudins of bow best ro inlil.uence stu-
Edward M. Hundert, MD
I became interested for three separate reasons in this crucial
issue of the moral and professional development of med-
ical students and residents. First, I came to medical training
with a background in moral philosophy and have been in-
volved in teaching ethics at Harvard Medical School for
about 15 years-an experience that, among other things, has
made me especially appreciate one of my favorite quotes from
Mark Twain, who once said: "To be good is noble; to teach
others to be good is nobler-and less trouble!"
Second, I am a psychiatrist with a particular interest in
young-adult development and in developmental neurobiol-
ogy. The production of physicians who will embody the
Dr. Hundert is associate dean for swdent affairs and professor of psychiatry,
Harvard Medical School, Cambridge, Massachusetts.
624 ACADEMIC MEDICINE, VoL. 71, No.6/jUNE 1996
denrs' e.:Mcal deveioprm.'"t'lt~ fOLiuwt:d by faculty use .of de
humaniz.il. g coping tnechanlsn'iS 1 and the "'busine.ss" of
mecliclr11!'s tt~kin~ .precedence Over academic.. goals.
The plenary ~kcrs discussed the "informal C.llrticu-
lum1) and Ehe ;'hidden curri.culum1' and the need far med-
kal facul.ty to take !i~doU5ly d.'lc great influen,ce they ba ve
on stud:e:n~~ and Eellidcnts' mmal and prdessto:naL de.vei-.
opment as they hcc.om~ phys~ci.aru. Whether consciously
or not 1 medical education programs arc prodlldng physi-
cians who dct not meet the cthical standards the profes
sion. has tra.d~tioru:ill y expe'Cted its members to meet.
In throe sed~ of break-<Jut sessian:s, the participants
nalyzed th nature of the ethical dilemmas dmi: med ic..J
students and resi.dent!l face from virtually the first day of
their rrnl.n.ln~. the u5e of rote playing in promoting ethlcal
deve.lopmetn, and ways to improve policies and o\'ercome
barrlers to chrm,ge.
Acad. M.ed. 1'996;71:624-633,
highest standards of professionalism and integrity is not only
a question for admission committees. There is much further
work to be done once people of integrity have been selected
to begin medical training. We now know enough about neu-
roplasticity to appreciate the continued plasticity of core
values into young adult life and the profound capacity of the
brain to change in response to environmental stimuli even
into adult life. 1 One of the few areas of universal agreement
concerning students' development is that medical training
can make students and residents more cynical and insensi-
tive. Ironically, I would offer this as perhaps the most con-
vincing evidence that whatever the neural structures in-
volved in professionalization, they clearly remain plastic
enough at this age to be influenced. We should, therefore, be
optimistic about reinforcing altruism and the highest stan-
dards of integrity.
Third, for over five years I have been an associate dean for
student affairs. Although I have always enjoyed my formal
ethics teaching, in the dean's office I have discovered just
how little a role the formal ethics curriculum plays in the
moral and professional development of our students and resi-
dents. And, while I continue to teach ethics, my research in-
terest in this field has shifted a lot. I date the start of this
shift to an encounter I had in my first year in Student Affairs
with two students who each came in complaining that the
other was misbehaving in the organizing of our international
exchange programs. The students each headed a separate
European exchange program that ran during spring break.
They were competing with one another for resources, in-
cluding their fellow students' interest and sources for
fundraising. They had begun to steal each other's documents
in the shared student council office and were undercutting
one another in other insidious ways. When I looked at their
records before meeting with them, I discovered that they
were both MD-PhD students who were billed as future su-
perstars in academic medicine. As I spoke with them about
their behavior, I realized that if they did well with all of the
talent and resources at their disposal, they might well head
major research laboratories in the future. I put to them the
hypothetical scenario that they had indeed both become the
heads of major laboratories, working in overlapping areas of
basic science. I suggested to them that this was their big
chance to learn how to behave in this competitive academic
research situation. It will not surprise anyone that, as bright
as these students were, both looked at me as though I were
from another planet and urged me to stop "changing the
subject" and get back to what I was going to do about the
other guy stealing documents from their file drawer. At that
point I realized that we needed to harness what might be
called the "informal ethics curriculum."
The informal curriculum as I describe it here is different
from what Professor Fred Hafferty has called the "hidden
curriculum."2 Hafferty's hidden curriculum is the broader
concept because it includes the hidden transmission of the
dominant culture during formal classes, whereas the informal
curriculum is that subset of the hidden curriculum that hap-
pens outside classes, hospital rounds, and the like. 3 Because
this coexisting curriculum can either support or work in di-
rect opposition to the stated goals of the formal curriculum,
the work of this conference is urgent. The informal curricu-
lum is, naturally, much harder to study than the formal cur-
riculum. At least with the formal curriculum you know
where to find it. But the informal curriculum is what's hap-
pening every time the student or resident is not in a class or
on rounds, making it virtually everywhere and unavoidable,
two characteristics that account both for its power and its
complexity.
Thanks to a generous grant from the Culpeper Founda-
tion, I have spent the past few years collaborating with Dr.
Darlene Dougl'as-Steele, a sociologist with expertise in a
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field called ethnomethodology, which studies these phenom-
ena through the detailed analysis of people's conversations
in order to understand the social practices that influence
them. 4 Our goal was to capture on audiotape the kinds of in-
formal conversations and situations that have the biggest
impacts on students' and residents' moral and professional
development, and to do a thorough conversational analysis
using the techniques of ethnomethodology to extract the el-
ements of the informal curriculum that have the biggest ef-
fects. Once we understand it, we hope to improve the infor-
mal curriculum.
In a series of focus groups with students in each year of
medical school, we determined where and when the most
important informal interactions took place. The vast major-
ity of the situations the students described as the most influ-
ential were conversations with no faculty present. These of-
ten happened over lunch or dinner just after a course, or
during car-pooling from a remote clinical site, where the stu-
dents had seen an awkward doctor-patient interaction. In
each case a shared experience in the formal curriculum be-
came the raw material for an even more significant conver-
sation in the car or over lunch or dinner, where the students
(in the absence of potentially judgmental residents or fac-
ulty) wrestled with the question of whether "we just have to
grow up and realize this is the way the world is" or whether
"we're going to be a new generation of doctors who will do
better than that."
Recording the Informal Curriculum
We also solicited a group of students who were willing to
carry tape recorders around for two-week periods over the
course of the year, getting advanced informed consent from
the people with whom they shared apartments or the other
students in their patient-doctor groups or clinical rotations.
Most remarkably, we were also able to solicit the support of
one of the surgical residency directors, who helped us obtain
the advanced informed consent of every intern and resident
in a five-year general surgery program so that we could si-
multaneously study the informal curriculum for residents in a
specialty widely believed to have one of the most powerful
socialization processes in medicine. 5
In a forthcoming paper, Dr. Douglas-Steele, Janet Bickel,
and I lay out how this study has been unfolding, 6 but here I
offer a couple of case examples.
The most important thing we learned from literally hun-
dreds and hundreds of hours of transcribed tape recordings is
that the informal curriculum is "informal" only in the sense
that the rules are not written down and that the teaching
does not happen in classrooms or on ward rounds, but that it
is rule-governed in tightly bound ways that may be decipher-
able through just this kind of sociologic analysis.
VoL. 71, No.6/ jUNE 1996 625
 A third-year student. My first example comes from a fab-
ulous third-year medical student who has her tape recorder
on in the locker room as she changes out of her scrubs. She
talks about her frustration with how poorly her surgical rota-
tion seems to be going, despite the fact that she says she is
aware of the so-called unwritten rules and is not breaking
any of them. Then she enumerates her view of these unwrit-
ten rules-you have to be somewhat aggressive in volun-
teering answers, and not cost the team any time. The follow-
ing day the two senior residents on that student's team were
recorded talking about all of the unwritten rules that this
student was breaking, like asking questions in the OR in-
stead of just answering them, not appearing chagrined
enough when the answers she volunteered were wrong, and
even disappearing too often to attend of the lectures and
conferences of the formal curriculum (which the future sur-
geons of the class had figured out were "missable" in the ser-
vice of demonstrating a real commitment to surgery).
With the permission of all parties, we showed the stu-
dent's transcript to the two residents and showed to all par-
ties a detailed analysis of the two interchanges. The discus-
sion of all the unwritten rules the student was breaking was
not just idle gossip or character defamation. It was accom-
plishing a particular piece of work, because these residents
were responsible for evaluating this student, and they
needed to develop a shared understanding of how they were
going to evaluate her. The residents not only agreed with
our analysis but also said they had learned something impor-
tant: they had no idea that the student was trying so hard.
We were able to explore how this appreciation might make
them better teachers, thereby improving the informal cur-
riculum. Likewise, the student learned a lot from reading the
residents' transcript. In a moving discussion, the student re-
vealed how important that bad rotation experience contin-
ued to be for her more than a year later. Knowing that the
residents had come to realize how hard she had tried helped
her to put the experience behind her, even though she had
begun to fear that this rotation might become something she
would continually trip over and might even turn her into a
house officer who perpetuated negativity.
The fellow. The process by which trauma victims can be-
come abusers, perpetuating the negative aspects of the infor-
mal curriculum, is complex, as illustrated by a tape recording
of a surgical chief resident just beginning his fellowship.
This surgical fellow has just described how he had trans-
ferred from a program where there was much less experience
with vascular surgery at the equivalent stage; but, of course,
he could not stress the program's shortcoming up front with
his attendings. Here is his description of what transpired
during and after his vascular rotation:
Anyway, there were two attendings, one of whom didn't
say a word, was just-! mean I think the guy must
626 Ac:\llEMJc MEnJcJNE,
speak; you know, he's like rationed to ten words a day
and when he uses his words up that's it 'til tomorrow.
Really didn't speak. But he at least was, if not benign, at
least not malignant. And another kind of blustery ob-
noxious guy, who seemed very chummy and I didn't
think much of it and was always to my face very kind,
polite, well-you know, a little derogatory, but to every-
body, and no more to me than to anybody else, but
never expressed any dissatisfaction, or anything with
how the job was going.
So, I finished the rotation. All the patients did rela-
tively well, we didn't have any unexpected deaths, no-
body really crashed, and I never heard another word
about it. Nobody ever said to me, "there's a problem
here," or anything like that, and I was two weeks into
my next rotation, maybe a month into it, and I got a
phone call . . . uhh to-to make an appointment to
see the chairman. So, I didn't know what to make of it.
Okay, so I went and they completely blind-sided me.
I went to see the chairman, who told me that-was I
aware of any problems on the vascular service, and I
said, "No, what are you talking about?"; and he showed
me, he mentioned there'd been a meeting- I guess
they have these serial meetings where the residents are
discussed in the absence of residents-And uh . . .
this guy had just gone off about me. And had basically
written a five-page, or three-page, or some long letter
about, you know, what a terrible resident I was, how I
should be fired or held back a year, blah-blah-blah-
blah-blah, you know.
Well. First I was kind of-first I was stunned. And
then I was angry. And, and the other thing that really
pissed me off was the chairman of that program has
known me for many, many years. You know. And all he
had to say to have avoided a big hassle was, you know,
"I know you and, this guy had a problem with you, I'm
not gonna make a big deal about it," or, "don't worry
about it; it's nu- nothing."
But he didn't say that, instead he said- I can't re-
member the exact words speci . . . - I know what I
think I heard, but I'm not sure this was really what was
said. What I think I heard, what I've always gone on
the assumption I heard was, you know, this is a real
problem. So all of a sudden I got real pissed; I mean,
you know, I don't-! don't-
! mean, I was pissed because, number one, it's a
teaching program, right? If someone has a problem with
you, they should sit you down, and if they don't think
you're up to par, get you up to par. I mean, I'm a bright
guy, you know, MD, PhD, AOA, you know, straight A,
the whole business. I mean, you know, there's no prob-
lem, you know, with my ability to learn and if some-
thing's not happening then somebody needs to spend a
VoL. 71, No.6/ jUNE 1996
 little extra time with me, you know.
Th-th-that's the way life is; not everybody is-is
gifted in all fields, and if someone has a problem with
something and you think they're a worthwhile human
being, you should make an investment in them. After
all, this is a training program, right? I make my commit-
ment to work hard; you should make your commitment
to teach me. You know, don't be telling me one thing to
my face, and then doing something behind my back.
Well, I was, I was really pissed. So I let it settle for a
week or two and then I - I came to a decision, since
my love is research, what I ultimately want to do any-
way, I said, "You know what? This is stupid," and so I
said, I said, "I don't have to put up with this, and you
know this whole surgery career has been nothing but
torture for me, I'm working my butt off, and then I'm
getting stabbed behind my back. I really don't need this
anyway." So I decided I would quit and move, and be-
come a pathologist.
[He then explains that when he told his chairman, the
chairman was "flabbergasted" and insisted that the resident
stay for a few more rotations, all of which went fine. He
started each rotation telling people to take their problems to
him, and he finished up the residency with all excellent
evaluations.]
. . . but something else had changed too during that
time. I was so angry, so pissed that I said, "You know
what? I'm out of here, I wouldn't know who gives a
shit about what the attendings think. I'm gonna do
what's right because it's right. Because it's best for the
patient, and I looked up the goddamn literature and
this is what the literature says to do, and if they don't
like it they can just go fuck off," you know, and I really
got kind of a nasty attitude, 1-l-let me- not to the
point of being disrespectful, that came later, but to the
point of saying, say, you know, "This is what the data
says and if you can't give me a reason why, you know,
why you want to do otherwise then I'm doing it this
way." And, a funny thing happens when you do that
kind of thing: first of all people sense that and they
don't fuck with you.
But what emerged out of that was an attitude of, I'm
not going to try to help anybody, as far as the attending
goes. I'm not going to be a nice guy, I'm not going to try
to please them, and it changed my whole priorities from
trying to please attendings, to, to doing what I felt was
the right thing to do and if it pissed somebody off, well,
that was just too goddamn bad.
You know, I mean, that's not a great attitude to have,
you need to have some kind of attitude in the middle,
but I - I think I fueled at least a solid year from
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about- from when this event happened un-until-
this past January, which was a solid year, uhh, fueled it
just solely on anger. And distrust.
And I learned a lot from that, I mean, maybe it'll
make me better in the end, but one of the things I
learned, I mean I have a list of things that, you know,
in general that I - that came out of it. One thing is, I
don't, I don't really trust anybody. For what, I mean.
The second thing is everybody always has a hidden
agenda, you know?
The desensitization and brutalization that can accompany
clinical training is not news to anyone here. But I think the
power of this one incident is startling, and it becomes in-
cumbent upon us to be aware of the influence that any one
encounter can have on some body's future. One of the impor-
tant lessons from this tape recording is that the criticism
should have been dealt with in less-formal conversations
than the biannual feedback meeting with the department
chair. The fact that it had to go to a formal session with the
chair meant that the integrity of the system broke down.
Interestingly, when we asked this surgical fellow's permis-
sion to use this tape at this conference, he was both hum-
bled and flattered, having believed his experience was un-
usual, never realizing how it was part of a much larger
pattern. He said he was especially pleased to think that oth-
ers might benefit from his experience.
How Can We Do Better?
In closing, I offer my personal perspective on how we might
harness the power of the informal curriculum in order to
drive this process of professionalization in a positive direc-
tion. But the informal curriculum is a very tricky thing to
harness, because as soon as you formalize it, you lose it. Like
modesty, just when you think you have the informal curricu-
lum, you do not!
It is clear, however, that there are predictable moments in
medical training when the opportunity to share in informal
dialogue with colleagues (without the presence of faculty)
could be particularly valuable, e.g., around the anatomy ex-
perience, preparation for Board exams, and so on. And so
at Harvard we have begun to institute numerous student-to-
student support systems and discussion groups, from a peer
counseling center, to resident assistants in the dormitory, to
anatomy lab rap sessions, to the other usual Student Council
and Big Brother, Big Sister-type orientation programs that
have become the norm at some schools.
But when I met last year with the rising second-year class
to discuss their role as the Big Brothers and Sisters for the
entering class, I asked about the impact of their own Big
Brother or Big Sister experience from the year before, when
they were the Little Brother or Sister. What I heard went
71, No.6/jUNE 1996 6 2 7
something like this: The entering student said to the second-
year student adviser, "Boy, I'm really anxious about starting
this gross anatomy business and dealing with these cadavers
and dissections," and the second-year student, thinking he
or she was being friendly and helpful, responded, "Oh don't
worry about it. Are you kidding? Anatomy is the easiest
course of the year at Harvard. Wait until you get to bio-
chemistry and physiology!" When a show of hands revealed
that this had been the experience for most students, we be-
gan a class-wide discussion of what might help the Big
Brother or Sister to say something more supportive. We
came to realize that the pattern of trauma victims becoming
abusers is not something that happens only to victims of in-
cest and sexual assault; it is part of a deep-seated, perfectly
normal, and, indeed, usually adaptive human process by
which we repress unpleasant experiences so that we can get
on with the work at hand. With only a little guidance from
me, the class soon came to see that in order to be really good
second-year advisers, they would actually have to de-repress
just how traumatic and anxiety-provoking it was to start
medical school and gross anatomy. As they explored the pos-
sible motivations for taking on the not-inconsiderable bur-
den of reconnecting with those difficult feelings in order to
enter into empathic dialogue, it became clear that there was
only one reason that anyone would ever want to engage in
such an unpleasant process: it would need to be important to
his or her self-perception of what it means to be a good med-
ical student, perhaps as important as understanding patho-
physiology or learning how to use a stethoscope.
I believe that virtually all third-year medical students who
have ever been on the receiving end of harassment from in-
terns and residents have in that moment said to themselves,
"I'm not going to do this to my students." But how can in-
terns and residents be expected to reconnect with the
painful confusion and powerlessness of their own third-year
experience if they have not already begun to conceptualize
their professional identity in a way that includes a more
complex response to those early fears about anatomy?
We know that the second-year class will have all those in-
formal discussions with the entering class over lunch and in
the dormitory that might potentially make such a difference
to the professional development of both of the students in-
volved. And, while we would destroy the potential benefits
of that informal curriculum if we formalized it, I think that
formal sessions such as the class meeting I just described can
628 ACADEMIC MEDICINE, VOL.
prepare the students for an improved informal curriculum.
Taking a generational approach, we do what we can to im-
munize the new cohort to some extent from the current cul-
ture and try to effect a major change over the next 20 to 30
years. We are not limited to class meetings and peer support
groups in the preclinical or classroom setting. As Dr. Chris-
takis showed in his fabulous article "Ethics in a Short White
Coat," 7 within the hospital ward setting, students need a safe
space to discuss powerful experiences regularly, without fac-
ulty present. Such opportunities may be the most important
structure we as faculty can create for our students if we really
mean it when we say our job is to help them develop the
knowledge, skills, and attitudes to become a complete physi-
cian.
We also must have formal ethics teaching-preferably in-
fused throughout the entire curriculum. We need faculty de-
velopment programs in order to achieve a critical mass of
clinicians and scientists who feel enough ownership of the
learning objectives for ethics and professionalism while they
teach all the other material as well. If the faculty response to
the social or ethical questions raised in a pathophysiology
class is "don't you have some touchy-feely course where you
talk about those things?" then we are better off separating
out the ethics and social medicine teaching, but always at
the risk of its being perceived as less valued. Such separation
also unintentionally promotes the wrong impression: "some
times you're doing medicine" and "other times you're doing
ethics."
As we continue struggling with such perennial questions
about the structure of the formal ethics curriculum, we must
also develop an informal curriculum that will enable stu-
dents to feel that they are doing a good job as medical stu-
dents not only when they have learned the science and art
of medicine but equally when they have done a good job as
mentors to students and residents below them on the lad-
der-and not merely in the formal didactic teaching rounds,
but perhaps even more importantly in the cafeterias, locker
rooms, and call rooms where our students tell us that the
process of moral and professional development in medicine
takes place.
It has often been said that "ethics can't be taught-but it
can be learned." Let's all try to wrap our minds around the
change that would take place in medical education if we
stopped talking about "teaching hospitals" and instead
talked only about "learning hospitals!"
71, No.6/)UNE 1996
 Fred Hafferty, PhD
I come to you not as an ethicist, moral philosopher, or clin-
ician. Rather I am a medical sociologist, author of an arti-
cle on the hidden curriculum that used medical ethics as a
vehicle for my arguments. 2 While my credentials as an ethi-
cist may be suspect, I know a great deal about the nature of
professionalism and medicine's changing status as a profes-
sion.8
Like Edward Hundert, I believe that educators need to fo-
cus less on what is taught in medical school and more on
what is being learned. I wince when I hear educators or
deans talking about "curriculum reform" rather than "educa-
tional reform" or when they strive to integrate "courses"
rather than "experiences." Words are important; they help to
define the nature of things. And the words used by adminis-
trators to characterize their work (including the currently
trendy term "re-engineering") are accompanied by an under-
lying, usually unexamined, value structure. 9 It follows that
the first step to working purposefully with the hidden cur-
riculum is to abandon thinking about medical education as a
latticework of formal course offerings and instead to concep-
tualize medicine as a culture, medical school as an important
player in the transmission of that culture, and medical edu-
cation as a process of enculturation.
We count course offerings as proof that certain topic areas
are being covered as part of the educational process, for ex-
ample, courses on death and dying and medical ethics. But
this focus on course offerings creates its own reality, obscur-
ing the underlying fact that medical training always has
been about death and dying and about acculturating stu-
dents in the norms and values associated with working with
the death and the dying. 12 In short, a focus on formal course
offerings as the dominant indicator of educational content
only obscures the fact that at root medical training is a
process of moral enculturation. In transmitting to initiates
the normative rules regarding behavior and emotions, med-
ical school and the residency function as moral communi-
ties.11
Although we may use the label "informal" when we talk
about this side of the educational milieu, as Dr. Hundert's
presentation amply demonstrates, there is nothing casual,
idiosyncratic, offhand, irregular, or necessarily ad hoc about
this side of the educational process. It is a structurally neces-
sary counterpart to the formal curriculum and its content is
very much a part of medicine's cultural milieu. 12 I do agree
with Dr. Hundert that when we talk about characteristics
Dr. Hafferty is fJrofessor of behavior sciences, University of Minnesota-
Duluth School of Medicine, Dulwh, Minnesota.
ACADEMIC MEDICINE, VoL.
such as integrity, altruism, a fiduciary orientation, and trust-
worthiness, we must look to the hidden rather than the for-
mal curriculum for an understanding about how shared
meanings are developed. To be sure, we must also inventory
the formal educational process to identify the settings and
content in which such hallmarks of professionalism are
thought to be delivered within the formal curriculum.
The hidden curriculum is neutral: its content can rein-
force or undermine stated educational goals. There always
will be a latent counterpart to the formal structure of an or-
ganizational form, just as there will always be unintended
consequences to purposeful social action. 12 The goal of edu-
cational reform should be to recognize the content and form
of this normative underbelly and work with it and within it
to further the goals of professionalism. 13 At the same time,
we need to resist the temptation to rush through changes in
the hidden curriculum and thus meddle rather than remedi-
ate. The first step is to better understand the entity and how
it structurally and operationally relates to the formal curricu-
lum. We should try to define what we are changing, why we
are changing it, and with what intended outcome. We can-
not eliminate unintended consequences, but we can antici-
pate and modify their occurrence.
Locating the hidden curriculum within student-to-student
interactions is obvious, but we must remember that the hid-
den curriculum functions at all levels of the organization,
from what anthropologists call artifacts to the offices of
clinic chiefs, board rooms, and other seats of power. The
hidden curriculum is in the messages students receive from
faculty promotion criteria about the relative importance of
teaching. In other words, while students' peer contacts play
a critical role in the transmission of medical cultural values,
the locus of power lies elsewhere in medicine's training orga-
nizations and in the actions of administrators and faculty. I
hope that the groundbreaking research undertaken both by
Hundert and Douglas-Steele and by Feudtner and col-
leagues14 will lead to similar efforts to study medical faculty
and administrators. Otherwise, the hidden curriculum may
continue to be mistakenly cast as a student-based phenome-
non, leaving organizational powers safely in the background.
To maximize our understanding of the hidden curriculum,
we need to focus on work: the student's work of grappling
with uncertainty and managing an endless stream of exami-
nations, the clinician's work of juggling the practice guide-
lines and formularies of 14 different managed care plans, and
the administrator's work of reframing the content and goals
of medical education within a managed-care environment.
We also should try to identify how medical culture differs
from other types of organizational and occupational cultures.
I now turn to context and attending to the student's imme-
diate experiences as a way to generate ethical case studies. I
confess some ambivalence here. On the one hand, as Dr.
71, No.6/jUNE 1996 629
Hundert and Dr. Christakis point out, it makes no sense to
present second-year students exclusively with ethical scenar-
ios of plug pulling and informed consent, because medical
ethics is thereby cast as something that happens "out there"
or "further down the line." However, socialization is a
process that transforms the strange, the unusual, the discon-
certing, and even the abhorrent into something normal, fa-
miliar, usual, and reassuring. 11 Socialization is not a synonym
for induration or acclimation; it involves much more than
"getting used to things." Many of the values learned via the
hidden curriculum, especially in regard to rules about feel-
ings, are accompanied by norms that warn students against
becoming too reflexive and introspective and thus norms
that warn students against critically examining the forces
and processes that are shaping their professional identities.
Those who study organizational culture value the insider's
perspective but do not consider it definitive or defining. Dr.
Hundert's examples about how students learn to "not see"
wonderfully illustrate this point.
Every year while they are taking the lab portion of their
anatomy course, I ask the medical students how many of
them would consider donating their bodies to a medical
school to be used as anatomy cadavers. Every year the an-
swer is the same-a handful say "yes," but the overwhelm-
ing majority say "no." More interesting than their actual
preferences is how they say "no." Instead of using neutral
terms such as "dissect," "probe," or even "cut," students reply
using words like "rip," "slash," "tear," and "dismember." At
the same time, students tell me that they gain great solace
from the fact that their cadavers were donated, that the ca-
davers, when living, gave them permission. But what I find
most fascinating is that most medical students never ask how
these lay people came to give their "informed" consent. If
the students themselves are not so inclined, given their first-
hand and experiential knowledge, why did these lay people
say "yes"? Perhaps their consent was not so informed? Per-
haps they were altruistic but naive? Thus, accompanied by
norms not to get "too emotionally involved" or spend too
much time thinking about the cadaver as a former human
being, students are subtly introduced to a norm that is built
upon in a thousand other ways: at times they must do unto
others as they would not have done unto themselves. 11
Dr. Hundert's presentation brought to mind a few re-
sources that are helpful in taking a broad look at the hidden
curriculum. The first is the AAMC's Resource Guide: Promot-
ing Medical Students' Ethical Development, prepared by Janet
630 ACADEMIC MEDICINE, VoL. 71, No.6/]UNE 1996
Bickel. 15 The second is a report by Nicholas Christakis (the
brother of the next speaker) for the Acadia Institute and the
Medical College of Pennsylvania's Project on Undergraduate
Medical Education-"lmplicit Purposes of Proposals toRe-
form American Medical Education." This is an insightful
analysis of all 24 major national reports that have appeared
since 1910 on American medical education and presents a
most interesting view of resistance to change at the macro
level. 16 A shorter version of this report can be found in a re-
cent issue of JAMA. 17
Third is the work of Charles Bosk, a medical sociologist
and yet another of those among us who has benefited from
the tutelage of Renee Fox: Forgive and Remember: Managing
Medical Failure, a study of surgical training, 5 and the more
recent All God's Mistakes: Genetic Counseling in a Pediatric
Hospital. 18 In the former book, for example, Bosk concludes
that technical and judgmental errors are always subordinate
to normative errors concerned with assessments of character,
a feature well illustrated in Dr. Hundert's case examples.
Fourth is the American Board of Internal Medicine's Pro-
ject Professionalism. 19 The notion that characteristics of
professionalism can be identified, assessed, and promoted
should be incorporated to all levels of the educational
process. Fifth is the AMA's Code of Medical Ethics: Current
Opinions with Annotations, 20 which the AMA has distributed
to medical students around the country.
Finally, I mention the Liaison Committee on Medical Ed-
ucation's (LCME's) Medical Education Database. 21 Few
things shape the nature of work more than how that work is
evaluated. So, what does the LCME have to say about
the hidden curriculum and, in turn, medical ethics? The an-
swer is . . . basically nothing. In a sister document, Func-
tions and Structure of a Medical School, 22 the LCME pre-
sents statements concerning the total medical needs of
patients, the employment of scrupulous ethical principles,
and gaining patients' trust. But how are these values opera-
tionalized? In other words, when your medical school is
up for accreditation, what do you focus on in the review and
evaluation process? The answer is course offerings and what
is taught, not experiences and what is learned. I maintain
that the accreditation process needs to acknowledge better
the presence of an informal curriculum, acknowledging
that medical training is a process of moral enculturation.
In short, the process of professionalism and the hidden cur-
riculum must become more of a part of the evaluation
process.
 Dimitri Christakis, MD
hen Chris Feudtner and I were fourth-year medical
W students at the University of Pennsylvania, we taught
an ethics course to third-year students. The curriculum we
inherited included "do-not-resuscitate" orders, confidential-
ity, consent, and transplantation ethics, i.e., the staples of
many ethics courses today. Since to us it seemed pedagogi-
cally skewed to emphasize difficult decisions that students
would not make until much further along in their careers
while ignoring the decisions they make daily, we added a
section on what we called "ward ethics." 7 We attempted to
get at the informal curriculum using the students as our
guides.
The session itself had several distinct features:
Safe environment: No house officers or attendings were
present so that the students did not need to fear reprisals
or poor evaluations.
Stage-specific: Asking students to bring their own dilem-
mas ensured that the sessions were geared to the students'
professional and developmental levels.
Developmentally sensitive: We never trivialized the
novice concerns that students brought.
Participant-driven: We served as facilitators with no preset
agenda, so that whatever was on the students' minds was
discussed.
Advance preparation: Since every student was expected to
bring a written case complete with his or her thoughts,
they came prepared to discuss their feelings.
The cases we collected over the year formed the basis for a
survey we conducted of 1,853 clinical clerks at five south-
eastern Pennsylvania medical schools. 14 Our survey asked
about three specific misbehaviors that our experience had
suggested were commonplace:
Have you ever done anything you thought was wrong or
improper for fear of a poor evaluation? [40% responded
"yes"]
Have you ever done anything you thought was wrong or
improper to fit in with the team? [40% responded "yes"]
Have you ever purposefully misled a patient? [53% re-
sponded "yes"]
Seeking to understand the effects that facing these dilem-
mas had on students, we also asked:
Dr. Chrislakis is a fll!diarrics resident, Cltildren's Host>iral and Medical
Center, Seaule, \Vashingwn.
ACADEMIC MEDICINE,
Have you ever felt like an accomplice to unethical behav-
ior? [32% responded "yes"]
Have you ever felt bad or guilty about something you have
done on the wards? [67% responded "yes"]
Have you had occasions to rethink your ethical principles?
[67% responded "yes"]
Have some of your ethical principles been eroded or lost?
[62% responded "yes"]
Are you displeased with your ethical development? [38%
responded "yes"]
The responses to the last two questions-particularly
their disparity-tell us much about the content and the ef-
fects of the informal medical school curriculum: 62% of the
respondents reported that some of their ethical principles
had been eroded and/or lost. No course is designed to erode
students' ethics: these are lessons garnered outside the class-
room during medical education, and students may in fact re-
tain them better than they do the biochemical pathways
they memorize. Even more worrisome, 38% of the students
reported that they were displeased with their ethical devel-
opment. Paradoxically, I would have been relieved if this
percentage had been even higher, since 62% of the students
reported erosion of their ethical principles. Apparently,
medical education simultaneously promulgates a decline in
ethical standards and the acceptance of lower ones. Why
aren't medical educators more alarmed about this?
Too much of the literature on ethics education is predi-
cated on the mistaken notion that students' ethics are unal-
terable. Worse, too many educators conceptualize the prob-
lem as a few bad apples that more diligent screening should
simply keep out of the bushel of medical training. If nothing
else is accomplished at this conference, I hope that people
come to understand that we are not dealing with a few bad
apples spoiling a good bushel but a bad bushel spoiling many
good apples. We need to redirect our attention and our ef-
forts at reforming a system that places many decent, dedi-
cated, vulnerable individuals in situations where they do
things they regret and where they learn to accept such ac-
tions as part and parcel of becoming a physician.
Let me give you an example, culled from the 200 or so
cases that Chris Feudtner and I collected from students:
Following morning "lightning" rounds (during
which we had seen 20 patients in half an hour),
my resident asked me to write SOAP notes in five
charts. I felt uneasy because I had not actually ex-
amined these patients and wasn't sure if anybody
had done a routine morning physical exam. But
the whole team was doing it and I wanted to fit in,
so I complied.
VOL. 71, No.6/ jUNE 1996 631
 This student could very easily have been on Ed Hundert's
audiotape. A novice to the wards, she was trying her best to
accomplish five frequently conflicting goals common to all
medical students: to learn medicine, to be part of a team, to
care for patients, to perform well, and to get good grades. Al-

though fitting in with the team is not necessarily an undesir-
able goal, many students point out that early on it can become
of paramount importance to them-superseding their own
values, for example, to the point of falsifying a medical record.
Lest we simply condemn the residents who put students in
such positions, remember that they too face unreasonable de-
mands. Unreasonable demands beget unreasonable actions.
A system that works people 100 hours a week and more prop-
agates a vicious circle of ethical compromises. If undergradu-
ate medical education aims to prepare students to function as
residents in teaching hospitals, then it is a success; but if un-
dergraduate medical education aims to shape compassionate
and ethical physicians, it fails all too frequently.
The window for intervention is small and closes rapidly.
As the year progressed, the cases the students brought to the
ward ethics session changed not only in content but also in
perspective. For example, falsifying records in the name of
expediency was no longer an issue to most students by the
end of their third year; for many, this had become an adap-
tive strategy with which they could live. It has been re-
marked that the team-player ethos of medical education has
many similarities to the military and its unwritten rules. In-
deed, the medical wards at most tertiary care hospitals are
rife with battle epithets. Residents get "shelled" on call, tak-
ing "hits" and being "bombarded." Patients "torture" their
residents with midnight complaints. Residents "divide and
conquer" their admissions. Wars are notorious for changing
their participants forever.
As a new third-year clerk, I had the displeasure of being
pulled aside by my senior resident. In the relative privacy of
a conference room, he attempted to give me introductory
lessons to the wards. "You got to understand," he said. "This
is a war. Everyone tries to get patients into this hospital; we
try to keep them out." My job apparently was to be a recruit
in his fledgling army. The casualties of this ongoing war are
many, and include not just the patients caught in the cross-
fire, but also the values and ideals many bring with them to a
conflict they probably never envisioned themselves engaged
in. I began my work on medical student ethical development
trying to help students cope with the war. Now I believe we
must work to end the war.
So how do we change the prevailing war mentality of the
wards? First, we must recognize the systemic nature of the
problem. Figure 1 shows the nested nature of the academic
medical system. The "microsystem" is composed of individu-
als-students, housestaff, nurses, attendings, and patients.
The "macrosystem" includes such design-makers as promo-
8
Patient
Nurse Intern
Student
Residant Attending
Figure 1. The nested nature of the academic medicine system.
tion committees and department heads. Finally, what I call
the "exosystem" includes the NIH, HMOs, and the pharma-
ceutical industry, that is, agencies that, though geographi-
cally removed from the wards, greatly influence what occurs
there. Individuals within each system typically direct their
efforts inwards, following the path of least resistance, rather
than developing a systematic approach addressing the issues
relevant at each level of influence.
I recommend that increased national attention be paid to
improving the educational environment for graduate med-
ical education. Local action is needed to humanize the insti
tutional milieu in which residents and students learn and
teach. And personal action is required in many seemingly
small ways, e.g., in the degrees of respect medical team mem-
bers show each other. A single interaction with an attending
can profoundly affect a trainee. Individuals can play an enor-
mous role in obviating bad events or in resolving disputes in
positive rather than detrimental ways.
We know a great deal about what needs to be done to im-
prove the ethical development of physicians in training. Let
us rededicate ourselves to doing it.
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