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  1. To describe how medical learning environments are composed of a complex interplay of the formal curriculum, informal curriculum, and the hidden curriculum.

  2. To explain how the hidden curriculum of a medical school or healthcare organization influences professionalism in trainees and practicing physicians.

  3. To demonstrate how to assess and address these hidden rules in a learning environment.


It was the first day of orientation for new residents and fellows. Following a series of welcoming remarks from the school's dean and the vice president for health sciences, trainees were scheduled for a 2-hour block on professionalism. The lead individual responsible for this block had persistently lobbied the orientation planning committee to have professionalism assigned to a prominent place within the overall 2-day program. She, therefore, was pleased to find that the professionalism segment was to be “first up” and to directly follow the dean's and vice-president's opening remarks.

During the first break in this session, two incoming residents stopped by to say hello to one of the professionalism program faculty. “You know,” said the first, “none of this is going to matter all that much,” followed by the second, “Except to make us even more cynical.” Although the faculty member had a suspicion about where this conversation was headed, she responded, “How so?” The second resident continued, “What really matters is what we are going to see on Wednesday when we have our first clinic rotation. You taught us the bottom line in medical school—namely to pay attention to what you do rather than what you say. What you really mean by professionalism is shown in how you act.”

In this example,these two residents are articulating a key message about professionalism they acquired during undergraduate medical education via the hidden curriculum. The residents are describing the gap between what they were taught during their professionalism lectures and what they saw their role models do in practice—the latter of which, they also came to learn, signaled the real lesson. Obviously, faculty members do not intend to undermine the curriculum, and training programs expect the faculty to model the lessons taught in the lectures. So, how has this hidden curriculum evolved, what are the implications, and how can it be improved?

Over the last decades, professionalism has evolved (see Chapter 3, A Brief History of Medicine's Modern-Day Professionalism Movement). Numerous definitions have been created; curricula, codes, and charters have been developed; and educators have articulated competencies and milestones in professionalism. Despite all of this hard work and good intentions, there is a tension in the teaching of professionalism. Faculty may be impassioned in their commitment to improving student and resident education, but the creation of curricula or assessment tools has taken a path of least resistance. Finding 2 hours during resident orientation is operationally far easier and more readily justifiable (e.g., “See, we are doing something”), than undertaking ...

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