Relationship-Centered Care acknowledges the central importance of relationships in medical care. In a similar fashion, relationships hold a central position in medical education, and are critical for achieving favorable learning outcomes. However, there is little empirical work in the medical literature that explores the development and meaning of relationships in medical education. In this essay, we explore the growing body of work on the culture of medical school, often termed the “hidden curriculum.” We suggest that relationships are a critical mediating factor in the hidden curriculum. We explore evidence from the educational literature with respect to the student-teacher relationship, and the relevance that these studies hold for medical education. We conclude with suggestions for future research on student-teacher relationships in medical education settings.
Keywords: education, medical, culture, professional role, students, medical, relationship-centered care
A growing body of research and long tradition of clinical practice demonstrate that relationships in medical care play a critical role in the healing process.1–9 The term “Relationship-Centered Care” acknowledges the importance of these relationships, and expands the sphere of relevant relationships beyond the practitioner-patient relationship to include those that occur among practitioners, other health care personnel, families, communities, and others.10 In Relationship-Centered Care, all participants ideally appreciate the importance and uniqueness of their relationship to one another. As defined by Beach and Inui,11 Relationship-Centered Care is founded upon several core principles: (a) relationships in health care ought to include the personhood of the participants, (b) affect and emotion are important components of relationships, and (c) all health care relationships occur in the context of reciprocal influence.
Despite the recent interest in Relationship-Centered Care, medicine in our society has suffered from an erosion of public trust.12 An increasing number of voices have decried the “dehumanization” of medical practice in the U.S. health care system.13–15 In the past 2 decades, medical schools have responded by developing formal education programs that address aspects of Relationship-Centered Care.16 Courses at schools around the country now focus on a variety of content areas that include communications skills, ethics, arts and literature, and the history of medicine. In addition to such courses, many schools have also begun to incorporate formal rituals, such as the administration of the Hippocratic Oath or the “White Coat Ceremony,” into their slate of student activities.17,18 With the presence of such course content and ritual, one might assume that the formal training of students would lead to graduates that are compassionate, humanistic, and that develop high-quality relationships with patients, the health care team, and the community. However, available research suggests that this is not the case. A number of studies document an erosion of skills and attitudes during the medical school years.19–23 This “disconnect” between formal curricula and activities and graduates' demonstrated attitudes and skills has been reported to be the effect of another, “hidden” curriculum that exists in medical schools.24 In this essay, we will discuss research and observations to date about the hidden curriculum and the culture of medical education. We will then apply Relationship-Centered Care principles to the student-teacher relationship. We conclude by making suggestions for future research on the hidden curriculum and the significance of relationships in the formation of doctors.
From a narrative point of view, culture has been described as a group of individuals all enacting a shared story.25 The story itself can have many, even contradictory, layers, and is based on a set of premises that are taken for granted by all who tell and enact it.26 For example, North American culture defines specific parameters of conversational engagement that are based on the premise of the inviolability of personal space. When someone enters into a conversation and stands too close to his or her partner, the partner will often automatically and unconsciously back away until a comfortable distance exists between the conversants. In this way, the premise of inviolability of personal space has been maintained and enacted, even though no conscious thought was given to it by either conversant.27 In similar fashion, much of allopathic medical care is informed and directed by a set of premises that go undetected in professional oaths, mission statements, course syllabi and other artifacts of the explicit medical curriculum. This set of implicit premises has been called a number of names in the medical literature, including the “informal curriculum,” the “meta-curriculum,” and the “hidden curriculum.”24,28,29
The culture of medicine has a profound influence on the behaviors of practicing physicians, because it shapes basic assumptions about what are “acceptable” and what are “unacceptable” medical practices.24 In the table, we present some content examples, in the form of assumptions, from the culture of medicine. The particular assumptions and their wordings were generated by medical school faculty members during a recent seminar by one of the authors (P.H.); these assumptions and others have been described in the body of sociological and anthropological work on the hidden curriculum.24,30–35Table 1also presents some of the cultural premises that underlie these assumptions. Understanding these premises is important, because they are the foundation of the story that is being enacted by faculty, residents, administration, hospital personnel, and students in medical schools across the country. While the assumptions such as those in Table 1 are often apparent to the individuals in a medical school, the premises often are not as easily recognized.36 Rather, they exist as a kind of “white noise” in the background, shaping behavior without being noticed. It is the premises that lead individuals to adopt the assumptions, because the premises frame the assumptions as “nothing to worry about; this is just how things are in the real world,” and suggest that it is folly to question or contradict the assumptions.25 Understanding and changing the premises, then, becomes a key task for those attempting to change medical school culture, because modification of premises represents a modification of the fundamental story being enacted by the individuals in the medical school. Recent work to reform the culture at several schools represents an attempt to understand and explicitly define the premises of the story being enacted.16,37
Many of the hidden curriculum's premises about patient care are also translated to the processes of teaching and learning in medical school. Thus, in a medical school environment, one often encounters a demand for “right” answers (avoidance of uncertainty); intimidation, public shaming, and humiliation (doctors must be perfect); the treatment of students as objects to be “filled up” with knowledge and facts (outcome is more important than process); unhealthy competition (medicine takes priority over everything else), and deference to experts, regardless of their teaching abilities (hierarchy is necessary).34,38,39Consider the following scenario described by a former medical student:
Pimping is teaching by intimidation. I had my first personal introduction to it my very first day of my very first rotation during my third year as a medical student … We all solemnly entered the conference room and sat down around the table. In came the chief of the medicine service. He put a CAT scan of the head up on the viewing box and turned on the light. The only CAT scan I'd ever seen before was on “Ben Casey” on TV! It was so quiet you could have heard a pin drop. His first words were, “Give me a differential diagnosis for what you see.” He looked around the table, then his eyes zeroed in on me: “You, give me a differential diagnosis.” My mouth went dry. What was I supposed to be able to say? I'd never before even seen one of those things up close. I said, “Brain tumor.” He snapped back, “No shit!” Then he persisted: “That's not a differential. Give me a list of all the possible diagnoses you should think of when you see a CAT scan of the head that looks like this.” I sat there dazed. How was I supposed to be able to do this on the first day? I didn't even know where the bathroom was on the medicine service, let alone know what pathologies of the head could present like that picture. I finally said, “I don't know.” I knew he thought he won a victory because the goal of pimping is to keep somebody under the gun long enough that they break under the strain, to find a vulnerable spot where they're deficient, and to make a show of it to everyone at the conference.29
In a study of intimidation in medical education, Mary Seabrook40 observed both emotional and learning effects among students who had been in similar scenarios. As we discuss below, emotions play an important role in students' retention of knowledge, conceptualization of phenomena, and future behaviors. In her study, Seabrook noted that the embarrassment, shame, and self-blame that students felt in response to being intimidated by their teachers led to their hiding what they did not know and fostered an environment where students were afraid to ask questions and clarify issues that they did not understand. Seabrook's findings are echoed by a long line of research that suggests historical depth and continuity in the culture of American medical education.28–35,38,39,41–46
Traditionally, medical education practices often place teachers and students into adversarial relationships.47The sum total of numerous relationships in which the student does not have a voice, is positioned as unimportant in the care of the patient, and is at best emotionally disconnected and at worst emotionally attacked by the teacher fosters the adoption of a professional stance that is emotionally distant from patients and from anyone who is beneath the student in the hierarchy of medical education. As Hafferty48has shown, this distancing, in the name of “professionalism,” occurs already in the preclinical years as well as in the later clinical years. Often, the result is a fragile student physician who has the seemingly impossible task of relating compassionately to fellow human beings called patients. The relational processes of the hidden curriculum assure the perpetuation of its content.
Educators around the country have begun to engage in activities to modify the hidden curriculum by changing institutional culture with respect to medical practice.16,37,49 The core principles of Relationship-Centered Care suggest that such efforts will only succeed in as much as they foster improvement in relationships between teachers and students. Empirical and theoretical work on adult education underscores the importance of these core principles. Below, we discuss each of the core principles as they relate to the student-teacher relationship.
A commonly held assumption is that a central task of teaching is to deliver (or, as in a computer, to download) content to students, who then store that content in their minds for future retrieval and use.50 The personhood of the teacher and student in such a paradigm is lost, because the major focus of the educational activity becomes content delivery rather than creating an interpersonal context that fosters learning. A number of theorists have challenged the “downloading” assumption, arguing that learning is constructed, rather than merely delivered.50,51 In this alternate paradigm, students who are exposed to content and ideas delivered by the teacher will construct meaning from those ideas, connecting them to previous experience and knowledge, evaluating them, and making judgments about them.52 In such a paradigm, relationships become important, because they provide the context that shapes the construction of meaning, and thus, the construction of learning. Richard Tiberius describes the importance of relationship in this process:
The relationship between teachers and learners can be viewed as a set of filters, interpretive screens, or expectations that determine the effectiveness of interaction between teacher and student … within [effective] relationships, learners are willing to disclose their lack of understanding rather than hide it from their teachers; learners are more attentive, ask more questions, are more actively engaged … learning is contextual, and one of the most important contexts for human beings is other people who said it and what is the relationship of the learner to the teacher.53
A number of theorists and researchers in the education literature have observed that high-quality student-teacher relationships are associated with students' intrinsic motivation to learn.54–58 Such relationships have important effects both on learning and on students' sense of social identification.59,60 This “identity forming” aspect of the student-teacher relationship can have powerful effects on students' professional choices and behaviors, and can be harnessed by the teacher who attends to the personhood of themselves and the student.15,61,62
Research on learning and neurobiology suggests that the human brain's centers that process emotions are intimately connected with those that process and store incoming information.63 In other words, lessons learned in the context of strong emotions are altered by those emotions. Negative emotions such as anger or anxiety may interfere with the process of learning, because they alter the student's ability to efficiently process information.64 Similarly, positive emotions may lessen anxiety and lead the student to take more risks and pursue positive learning behaviors such as asking questions, challenging assumptions, and testing hypotheses.65 As emotional bonding is a fundamental aspect of human relationships,66 the emotional landscape of the student-teacher relationship provides a critically important context for the messages that the teacher is implicitly or explicitly communicating.
A number of authors have suggested that ideal student-teacher relationships are characterized by qualities such as flexibility, collaboration, mutuality, emotional investment, interdependence, and support for one's own identity.54,67–69 A central thread to these ideals is the concept of reciprocal influence, meaning that the learning interaction can lead to growth for both learner and teacher. In The Courage to Teach, Parker Palmer70 describes an ideal educational setting as the “community of truth,” asserting that such settings challenge the traditional roles of teacher as “expert” and student as “tabula rasa.” Rather, in the community of truth, all members present take on the role of “knower” as they gather around the subject of learning and interact with it and each other. The community of truth embodies reciprocal influence by acknowledging that students bring their own experiences to the learning interaction, and, in the process of engaging directly with the subject, the teacher, and each other, they may generate new insights not only among themselves, but in the teacher as well.
The literature on hidden curricula is increasingly illuminating the premises and processes of the culture of medical education.71 The literature on relationships in medical and adult education similarly illuminates the effects of relationships on learning of explicit curricular content.50,54 We conclude this essay with a call for research that integrates the lessons learned from these 2 lines of inquiry. By investigating the processes of the culture of medical education through the “lens” of student-teacher relationships, medical educators may be able to harness the power of relationships to modify students' adoption of the prevailing premises of the medical culture. In other words, educators need data that fosters an understanding of the relational processes that will help students to gain control over the story that they are enacting. We offer several initial questions for research along these lines: to what extent do positive or negative student teacher relationships mediate students' adoption of the implicit premises of the medical culture? What common themes characterize students' networks of relationships during medical school, and how do these themes impact the professional choices and behaviors of those students? To what extent do the relational behaviors of influential role models shape the relational behaviors of students with current or future patients? What characterizes the inner, unconscious elaborations of students' interactions with their teachers? How are current teacher-student relationships modified by students' internalized relationships with parents or other early emotionally crucial persons? What fundamental differences exist in relationships during the preclinical years as compared with the clinical years, and how do such differences affect the educational approaches used by teachers in these settings?
Most medical students, at some time in their training, will be told about the parallel meanings of the words “teacher” and “physician.” Most medical students will also be told that “patient education” is a core function of the medical interview. In a sense, we teachers are participating in the formation of not only diagnosticians or problem-solvers, but educators as well. The relationships we form with our students will be key sources of experience that those students will draw upon when they find themselves in the role of teacher with their patients.
The authors would like to acknowledge members of the Baylor College of Medicine Academy of Distinguished Educators for their participation in the brainstorming session that provided the examples of assumptions/messages of the hidden curriculum.
This work was supported by the Relationship-Centered Care Research Initiative, an initiative of the Fetzer Institute, Kalamazoo, Michigan. Dr. Haidet was supported by a career development award from the U.S. Department of Veterans Affairs.
The opinions expressed herein reflect those of the authors and do not necessarily represent the views of the U.S. Department of Veterans Affairs, Baylor College of Medicine, or the University of Oklahoma.
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