Abstract
Underrepresented students in medicine (URM) have more negative perceptions of the medical school learning environment (LE), a phenomenon that can contribute to higher rates of burnout and attrition in these populations. The hidden curriculum (HC)—defined as a set of values informally conveyed to learners through clinical role-modeling—is a LE socialization construct that has been critically examined for its role in shaping students’ professional identities. Yet differences in how URMs and non-URMs experience the HC remain underexplored. The study used a pragmatic approach that drew on elements of grounded theory and employed both deductive and inductive reasoning. Investigators conducted qualitative, semi-structured interviews with a purposive sample of 13 URM and 21 non-URM participants at a Bronx, NY medical school. Interviews examined student experiences and reactions to the HC. Both cohorts witnessed patient disparagement and mistreatment. However, from these encounters, URM participants expressed more moral injury—the adverse emotional consequence of feeling pressured to accept ideologically incongruent values. URMs were also more likely to describe resisting the HC. Differences in group reactions appeared to arise from URMs’ identity resonance with patients’ lived experiences. Participants across cohorts emphasized increasing URM recruitment as one step toward mitigating these circumstances. URM participants experienced more distress and offered more resistance to the HC relative to non-URMs. The etiology of these differential reactions may stem from relative barriers in negotiating personal and professional identities. As such, URMs’ perceptions of the LE may be adversely impacted given their more negative interactions with the HC.
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Acknowledgements
The authors would like to thank the participants for their openness and willingness to discuss these critical issues.
Funding
Support for this study was provided by the Office of Medical Education at the Albert Einstein College of Medicine (AECOM).
None of the authors have any relevant financial disclosures to report.
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SN drafted the main manuscript text with guidance from AK and prepared tables and figures. Other authors (IB, WB, AF, PJ, MM) engaged in critical readings and revisions to the manuscript.
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Appendix: Interview guide
Appendix: Interview guide
The ideal learning environment
The Learning Environment includes multiple contexts: the organizational context which refers to the timing, sequence, and organization of course material; the interpersonal context, which refers to interactions between faculty, students, and patients; the learning spaces context, which refers to both physical/geographic spaces where learning takes place as well as virtual spaces; and the personal context, which refers to building professional identity, developing autonomy, and setting professional goals.
Given this definition, what do you think makes a good (or healthy) learning environment?
Prompts:
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Based on your assessment above, what aspects of Einstein’s Learning Environment are working well? Not working well?
The learning environment at Einstein
Please describe your thoughts and experiences related to the overall organization of the pre-clinical curriculum.
Prompts:
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Does the sequence of courses make sense? Why or why not?
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Was there any material you felt did not receive enough attention? Why or Why not?
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Does the curriculum feel timely/outdated? Why or why not?
Now let's think about individual courses. Think about a course that you would rate very highly. What is it about that course that makes it stand out?
Prompts:
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How does it compare to a course that you would not rate highly?
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What could course directors learn from your experiences with your favorite course?
OK. Now I’d like to ask you about the clinical learning environment. What has been your experience of the learning environment on your clerkships?
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Which clerkships have the best learning environments? How/why?
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Which clerkships have the worst Learning Environments? Tell me about that.
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What makes an effective learning environment on clerkship?
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How could Einstein’ improve its clerkship learning environment?
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Faculty interactions with students... What is your assessment overall of Faculty interactions with students?
Prompts:
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Availability, feedback and criticism, supportiveness, mentorship
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Can you tell me about one of the most positive interactions you’ve had with faculty?
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Negative interactions?
Student interactions with each other. What is your assessment of student interactions in general?
Prompts:
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Competitiveness—please give examples
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Mutual support—please give examples
Attitudes towards patients. Now I’d like to ask you for your assessment of attitudes and treatment of patients.
Prompts:
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To what degree do your teachers (faculty, attending and/or house staff) show appropriate respect and caring in presentations about patients? Please give examples.
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To what degree do your teachers (faculty, attending and/or house staff) show appropriate respect and caring in their interactions with patients? Please give examples.
Inappropriate language. Have you had the experience that faculty or students have made inappropriate or derogatory comments about other students, hospital staff, or patients?
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Please comment and give examples.
What the physical learning spaces that typically use?
For quiet study? Tell me about that
For group study? Tell me about that
What about lecture and classroom spaces? What are the strengths and weakness of these spaces? How would you improve them?
If you work at home, how conducive/suitable is your student housing for study? Tell me about that?
We know that students learn in different ways. In general, what is your preferred setting for learning (lectures, small groups etc.)? Why?
Tell me about how online lecture streaming first into your learning experience.
Prompts:
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1.
How often did you attend class in person? How did you decide which classes to attend?
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What are the advantages of lecture streaming vs. attending in person? Is there a downside?
Tell me
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2.
What about online resources? Can you comment on how helpful they were? Which ones did you use?
What are your thoughts on the physical learning environment at Einstein?
Prompts:
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Classrooms, library, and other learning spaces?
The experiences of URMs
Finally, I’d like to ask you to comment on whether you think the Learning Environment at Einstein, with its strengths and weaknesses, works equally well for all students?
We are particularly interested in understanding your thoughts on how the Learning Environment works for students from URM groups.
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Any suggestions for how the LE could be made healthier or hospitable for URM groups or other minority Groups?
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At Einstein? What could be improved?
Note: This interview guide will be reproduced in our manuscripts that will focus on other domains of the LE (i.e., organizational, physical).
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Nemiroff, S., Blanco, I., Burton, W. et al. Moral injury and the hidden curriculum in medical school: comparing the experiences of students underrepresented in medicine (URMs) and non-URMs. Adv in Health Sci Educ (2023). https://doi.org/10.1007/s10459-023-10259-2
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DOI: https://doi.org/10.1007/s10459-023-10259-2