What Lies Beneath: A qualitative analysis to uncover the hidden clerkship curriculum

Context: Every teaching activity contains a hidden curriculum, which may even eclipse the explicit one; it is thus important to recognize messages we did not intend to teach but that students nonetheless learned.

Objective: We aimed to uncover what “hidden” lessons students reaped and retained from the Family Medicine (FM) clerkship.

Study Design/Analysis: Students anonymously submitted their top 5 take-home points from the clerkship. Via an open coding qualitative approach, 3 researchers independently identified each written submission’s core message, giving each a label, or code, without a preconceived set of codes. We reconciled codes until reaching saturation. We grouped codes into categories, which we compared with each school’s explicit learning objectives. Concepts mentioned by students not among the explicit learning objectives constituted the hidden curriculum.

Dataset: The dataset had 1880 total de-identified reflections; we reached saturation after coding 668 reflections, equally representing the 2 schools.

Population Studied: 376 third-year FM clerkship students at 2 private medical schools in a Northeast US city, or 91% of the classes, participated. Both IRBs deemed the study exempt from review.

Instrument: Students were prompted to “list your top 5 FM take-home points” and submitted written responses.

Outcome measures: Outcomes were the code categories and their concordance with the explicit curriculum.

Results: 13 code categories emerged: practice scope, healthcare systems, FM role in the healthcare system, FM values, cultural competency/social justice, evidence-based medicine, clinical skills, patient centeredness, clinical pearls, personal impact, life skills/tips, traits of a family doctor, and FM practice challenges. The last 4 were not in our intended learning objectives.

Conclusions: This study investigated what FM students reported learning. Student reports of the challenges of FM practice did not align with our explicit clerkship goals. Although prior literature shows that overall, students react positively to the FM clerkship, if in clerkship education we transparently acknowledged practice difficulties and offered solutions, we might improve not only the educational experience but also perceptions of FM. The difference between what we think we teach and what students say they learn could assist educators nationally in improving messaging around practice challenges and help the 25x2030 initiative to produce more family physicians.