The hidden curriculum across medical disciplines: an examination of scope, impact, and context




Background: While research suggests that manifestations of the hidden curriculum (HC) phenomenon have the potential to reinforce or undermine the values of an institution, very few studies have comprehensively measured its scope, impact, and the varied clinical teaching and learning contexts within which they occur. We explored the HC and examined the validity of newly developed constructs and determined the influence of context on the HC.

Methods: We surveyed medical students (n =182), residents (n =148), and faculty (n = 140) from all disciplines at our institution between 2019 and 2020. Based on prior research and expertise, we measured participants’ experience with the HC including perceptions of respect and disrespect for different medical disciplines, settings in which the HC is experienced, impact of the HC, personal actions, efficacy, and their institutional perceptions. We examined the factor structure, reliability, and validity of the HC constructs using exploratory factor analysis Cronbach’s alpha, regression analysis and Pearson’s correlations.

Results: Expert judges (physician faculty and medical learners) confirmed the content validity of the items used and the analysis revealed new HC constructs reflecting negative expressions, positive impacts and expressions, negative impacts, personal actions, and positive institutional perceptions of the HC. Evidence for criterion validity was found for the negative impacts and the personal actions constructs and were significantly associated with the stage of respondents’ career and gender. Support for convergent validity was obtained for HC constructs that were significantly correlated with certain contexts within which the HC occurs.

Conclusion: More unique dimensions and contexts of the HC exist than have been previously documented. The findings demonstrate that specific clinical contexts can be targeted to improve negative expressions and impacts of the HC.


Metrics Loading ...

Author Biographies

Karen Schultz, Queen's University

Dr. Karen Schultz (she/her/hers) MD, CCFP, FCFP

Associate Dean, Queen’s University Post Graduate Medical Education

Professor, Queen’s University Department of Family Medicine

70 Barrie Street

Kingston, Ontario, Canada

K7L 3N6

Phone: 613-533-2543

Fax: 613-533-2132

Heather Braund, Queen's University

Braund is a health sciences education researcher and consultant with the Office of Professional Development and Educational Practice in the Faculty of Health Sciences and an assistant professor (adjunct) in the Faculty of Education, Queen’s University.

Mala Joneja, Queen's University

Joneja is an associate professor and the division chair for the Division of Rheumatology in the School of Medicine at the Faculty of Health Sciences, Queen’s University.

Shayna Watson, Queen's University

S. Watson is an assistant professor and family physician in the Department of Family Medicine in the School of Medicine at the Faculty of Health Sciences, Queen’s University.

John Drover, Queen's University

Drover is a professor and intensivist in the Departments of Critical Care Medicine and Surgery in the School of Medicine at the Faculty of Health Sciences, Queen’s University.

Laura MacMillan-Jones, Queen's University

L. MacMillan-Jones is a graduate of Queen’s University School of Medicine and Queen’s Family Medicine, now working as a family physician throughout rural Ontario.

Nancy Dalgarno, Queen's University

Dalgarno is the director of education scholarship in the Office of Professional Development and Educational Practice, and an assistant professor (adjunct) in the Department of Biomedical and Molecular Sciences in the Faculty of Health Sciences, Queen’s University.


Hafferty F, O'Donnell J. The hidden curriculum in health professional education. Dartmouth College Press; 2015.

Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med.1994;69(11):861-71.

Mulder H, Ter Braak E, Chen HC, Ten Cate O. Addressing the hidden curriculum in the clinical workplace: A practical tool for trainees and faculty. Med Teach. 2019;41(1):36-43.

Gofton W, Regehr G. What we don't know we are teaching: unveiling the hidden curriculum. Clin Orthop Relat Res. 2006;449:20-27.

Lawrence C, Mhlaba T, Stewart KA, Moletsane R, Gaede B, Moshabela M. The Hidden Curricula of Medical Education: A Scoping Review. Acad Med. 2018;93(4):648-656.

Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998;73(4):403-407.

Holmes CL, Harris IB, Schwartz AJ, Regehr G. Harnessing the hidden curriculum: a four-step approach to developing and reinforcing reflective competencies in medical clinical clerkship. Adv Health Sci Educ Theory Pract. 2015;20(5):1355-1370.

Bandini J, Mitchell C, Epstein-Peterson ZD, et al. Student and faculty reflections of the hidden curriculum. Am J Hosp Palliat Care. 2017;34(1):57-63.

Brown MEL, Coker O, Heybourne A, Finn GM. Exploring the hidden curriculum's impact on medical students: professionalism, identity formation and the need for transparency. Med Sci Educ.2020;30(3):1107-1121.

Ellaway R. The informal and hidden curricula of mobile device use in medical education. Med Teach. 2014;36(1):89-91.

Robbé IJ. Revealing the hidden curriculum and reducing cultural reproduction: Small steps on a long road. Med Teach. 2014;48(9):846-848.

White J, Brownell K, Lemay J-F, Lockyer JMJBME. "What do they want me to say?" The hidden curriculum at work in the medical school selection process: a qualitative study. MBC Med Educ. 2012;12(1):1-9.

Haidet P, Kelly PA, Chou C. Characterizing the patient-centeredness of hidden curricula in medical schools: development and validation of a new measure. Acad Med. 2005;80(1):44-50.

Lau F, Price M, Keshavjee K. From benefits evaluation to clinical adoption: making sense of health information system success in Canada. Healthc Q. 2011;14(1):39-45.

Cook DA, Brydges R, Ginsburg S, Hatala R. A contemporary approach to validity arguments: a practical guide to Kane's framework. Med Educ. 2015;49(6):560-75.

Kane M. Validating the interpretations and uses of test scores. J Educ Meas. 2013;50:1-73.

Basow S. The hidden curriculum: Gender in the classroom. In: Paludi MA, ed. Praeger guide to the psychology of gender. Praeger Publishers/Greenwood Publishing Group; 2004:117-131.

Cheng LF, Yang HCJMe. Learning about gender on campus: an analysis of the hidden curriculum for medical students. 2015;49(3):321-331.

Cruess SR, Cruess RL, Steinert Y. Supporting the development of a professional identity: general principles. Med Teach. 2019;41(6):641-649.

McGurgan P, Carmody D, Tregonning A. Measuring the “iceberg”-quantifying the hidden and informal curriculum in clinical rotations using the hidden informal curriculum assessment tool (HICAT). MedEdPublish. 2015;5(2):1-19.

Osanloo A, Boske C, Newcomb W. Deconstructing macroaggressions, microaggressions, and structural racism in education: Developing a conceptual model for the intersection of social justice practice and intercultural education. Int J Organ Theory Develop. 2016;4(1):1-18.

Boateng GO, Neilands TB, Frongillo EA, Melgar-Quiñonez HR, Young SL. Best practices for developing and validating scales for health, social, and behavioral research: a primer. Front Public Health. 2018;6:149.

DeVellis RF, Thorpe CT. Scale development: Theory and applications. Sage publications; 2021.

Morgado FF, Meireles JF, Neves CM, Amaral A, Ferreira MEC. Scale development: ten main limitations and recommendations to improve future research practices. Psicol Reflex Crit. 2017;30(1):3.

Guion RM. Content validity—the source of my discontent. Appl Psychol Meas. 1977;1(1):1-10.

Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. Acad Med. 2015;90(6):718-25.

Sue DW, Capodilupo CM, Torino GC, et al. Racial microaggressions in everyday life: implications for clinical practice. Am Psychol. 2007;62(4):271-86.

Portelli JP. Exposing the hidden curriculum. J Curric Stud. 1993;25(4):343-358.

Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191-215.

Fernández-Ballesteros R, Díez-Nicolás J, Caprara GV, Barbaranelli C, Bandura A. Determinants and structural selation of personalefficacy to collectiveefficacy. Appl Psychol. 2002;51(1):107-125.

Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med.1998;73(4):403-7.

Baingana RK, Nakasujja N, Galukande M, Omona K, Mafigiri DK, Sewankambo NK. Learning health professionalism at Makerere University: an exploratory study amongst undergraduate students. BMC Med Educ. 2010;10:76.

Bernard AW, Malone M, Kman NE, Caterino JM, Khandelwal S. Medical student professionalism narratives: a thematic analysis and interdisciplinary comparative investigation. BMC Emerg Med. 2011;11:11.

Fins JJ, Gentilesco BJ, Carver A, et al. Reflective practice and palliative care education: a clerkship responds to the informal and hidden curricula. Acad Med. 2003;78(3):307-12.

Turbes S, Krebs E, Axtell S. The hidden curriculum in multicultural medical education: the role of case examples. Acad Med. 2002;77(3):209-16.

Kommalage M. Hidden and informal curricula in medical schools: impact on the medical profession in Sri Lanka. Ceylon Med J. 2011;56(1):29-30.

Lindberg OJ. Undergraduate socialization in medical education: ideals of professional physicians’ practice. Health Care. 2009;8(4):241-249.

Pingleton SK, Davis DA, Dickler RM. Characteristics of quality and patient safety curricula in major teaching hospitals. Am J Med Qual. 2010;25(4):305-11.

Kane MT. Validation. Educ Meas. 2006;4(2):17-64.

Maul A. Rethinking Traditional Methods of Survey Validation. Meas Inter Res Perspect. 2017;15(2):51-69.

Korlén S, Richter A, Amer-Wåhlin I, Lindgren P, von Thiele Schwarz U. The development and validation of a scale to explore staff experience of governance of economic efficiency and quality (GOV-EQ) of health care. BMC Health Serv Res. 2018;18(1):963.

Taber KS. The Use of Cronbach’s Alpha When Developing and Reporting Research Instruments in Science Education. Res Sci Educ. 2018;48(6):1273-1296.

Hinkin TR. A brief tutorial on the development of measures for use in survey questionnaires. Organ Res Methods. 1998;1(1):104-121.

Raykov T, Marcoulides GA. Introduction to psychometric theory. Routledge; 2011.

Brigley S, Young Y, Littlejohns P, McEwen JJ. Continuing education for medical professionals: a reflective model. Postgrad Med J. 1997;73(855):23-26.

Kulier R, Gee H, Khan KS. Five steps from evidence to effect: exercising clinical freedom to implement research findings. BJOG. 2008;115(10):1197-1202.

Christian E, Krall V, Hulkower S, Stigleman. Primary care behavioral health integration: promoting the quadruple aim. N C Med J. 2018;79(4):250-255.

Haverfield MC, Tierney A, Schwartz R, et al. Can patient–provider interpersonal interventions achieve the quadruple aim of healthcare? A systematic review. J Gen Intern Med. 2020;35(7):2107-2117.

Hsieh D. Achieving the quadruple aim: treating patients as people by screening for and addressing the social determinants of health. Ann Emerg Med. 2019;74(5):S19-S24.

Sikka R, Morath JM, Leape L. The Quadruple Aim: care, health, cost and meaning in work. BMJ Qual Saf. 2015;24(10):608-610.




How to Cite

Schultz K, Cofie N, Braund H, Joneja M, Watson S, Drover J, MacMillan-Jones L, Dalgarno N. The hidden curriculum across medical disciplines: an examination of scope, impact, and context. Can. Med. Ed. J [Internet]. 2023 Jun. 21 [cited 2024 May 27];15(1):15-2. Available from:



Original Research