The hidden curriculum in which medical students learn to understand and manage unprofessional behaviour: a qualitative interview study

Objectives: Medical students frequently experience unprofessional behaviours (e.g. incivility, bullying), adversely impacting personal and professional development. Formal reporting is rare, suggesting students manage unprofessional behaviour through alternate means. This study investigated the role of a hidden curriculum in medical students’ understanding and
management of unprofessional behaviours in medical education.
Design: Third-year medical students were recruited from an Australian medical school. Semi-structured interviews were conducted, and thematic analysis was performed to identify themes in how unprofessional behaviour is experienced and managed.
Results: All 17 participants had experienced unprofessional behaviour, and most had witnessed it directed at others. Only two participants reported these experiences. Four themes were identified. (1) Students rationalised whether an incident was reportable based on severity of unprofessional behaviour, and adjusted their personal standards. (2) They described perpetrator power and position as barriers to reporting, where senior staff committing unprofessional behaviour held sway over students’ medical education. (3) This contributed to perceptions of the fallibility of reporting, that it carried a high risk of negative consequences, with unclear or no reward. (4) In the importance of debriefing, students preferred to manage unprofessional behaviour through informal peer discussions to make sense of their experiences, avoid future encounters, and collectively better understand the culture of medicine.
Conclusions: A hidden curriculum was identified whereby students learn to understand and respond to unprofessional behaviour based on their experiences at medical school. The culture of tolerance of unprofessional behaviour and silence in medicine must be addressed if change is to occur.