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Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 148-150

The hidden curriculum of COVID-19

Department of Emergency Medicine, Weill Cornell Medical College; Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA

Date of Submission09-May-2020
Date of Acceptance27-Jun-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Dr. Sara Raza Zaidi
Department of Emergency Medicine, Weill Cornell Medical College, 525 E. 68th Street, New York, NY 10065
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_54_20

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How to cite this article:
Zaidi SR, Garg M. The hidden curriculum of COVID-19. Int J Acad Med 2020;6:148-50

How to cite this URL:
Zaidi SR, Garg M. The hidden curriculum of COVID-19. Int J Acad Med [serial online] 2020 [cited 2022 Dec 10];6:148-50. Available from: https://www.ijam-web.org/text.asp?2020/6/2/148/287962

The overt curriculum of residency has changed due to exigencies created by the COVID-19 pandemic. A “hidden curriculum,” comprised of hospital's unspoken lessons and culture, has also shifted in the times of pandemic. Established medical authority and the notion of best practice no longer exist because so little is known about COVID-19. The emergency department (ED) structures and operations change shift by shift and reflect the evolving needs of the patients and providers. The metaphors surrounding physicians are often those of soldiers in a war, bringing up the notion of limitless sacrifice. However, a positive theme has been a newfound brotherhood among physicians of all specialties, uniting in care of pandemic patients. Awareness of these hidden curriculum themes is important, to address those that are malignant and to propagate the positive.

As a 4th-year emergency medicine (EM) resident mere months from graduating, I have become comfortable with the rhythms of our well-defined curriculum. My co-residents and I participate in weekly conferences, morning reports, and simulation sessions, all moored by the gravity of the American College of Graduate Medical Education-defined learning objectives. At this time of the year, I expected to be pushed further into the preattending role, to solidify the “best practices” of my field, and to survey my attendings for any last advice they may offer as I enter their ranks. In addition to medical knowledge and practical skills, I have come to understand the intangibles of an EM physician: the strength required in the voice that controls trauma resuscitations, the need to send others on breaks before myself, and much more. However, in this unexpected COVID-19 pandemic, EM and other physicians are undergoing an identity crisis. Are we soldiers who are fighting on the frontlines or are we civilians finding ourselves in positions for which we are trained, but unprepared? For those of us in the apprenticeship of residency, not only is our medical education and training affected on every level, but we are also partaking in a new “hidden curriculum” reflecting the uncertainty and attitudes of the times.

Medical education has changed fundamentally during the COVID-19 pandemic. Our residency weekly conference now occurs on a virtual platform, making small group learning and discussions challenging. Morning reports, which require the gathering of residents in a room during shift, have been canceled for the foreseeable future. Our lectures often mirror the new, pandemic-based reality of our clinical practice: formal teaching prioritizes COVID-19-specific ventilator management, adult respiratory distress syndrome treatment, end-of-life care, and how to speak to patients about Do Not Resuscitate/Do Not Intubate goals of care. However, interwoven with the ventilator lectures and latest protocol e-mails are subtle but pervasive attitudes and culture, the “hidden curriculum” of the pandemic. The hidden curriculum is a concept referring to the administration of organizational culture as well as the “'understandings,' customs, rituals, and taken-for-granted aspects” in medical education.[1],[2] While medical knowledge and ED protocols keep changing, these more subtle lessons for trainees may be the most enduring from COVID-19 times.

A main theme of the new hidden curriculum is the disruption of medical authority during the times of pandemic. It is particularly jarring for residents, who are used to considering their attendings, scientific research, and textbooks, as trusted sources of knowledge. However, when so much about COVID-19 is unknown, we see our authority figures searching the internet, listening to first person accounts from other countries, and discussing among each other. We see how in a world thirsty for information, politicians, social media, and news reporters more often step in to fill the void. For these same reasons, we have learned that in a pandemic, there is no such thing as “best practice.” The medicine of this crisis is both straightforward in terms of the few interventions available to us and also completely unknown. Our protocols have sometimes changed daily: whether to give steroids, fluids, antibiotics, antivirals, and antimalarials. ED structure and operations have also changed at a dizzying pace. Triage protocol, availability of medications, and discharge criteria are sometimes changed within the course of a shift. Staffing, personal protective equipment, and allocation of physical space are different for each hospital, and so, the solutions have been as varied as the dilemmas. All we can do is attempt to move and acquire resources to match each new blow as it comes. From a trainee perspective, it feels that the floor has given out beneath us.

In another angle of the hidden curriculum, the vernacular surrounding doctors has also changed in the times of pandemic. Words describing us include “deployed,” “in the trenches,” and “fighting on the frontlines against COVID-19,” such that we residents are internalizing the notion of the doctor as a soldier. Susan Sontag writes in her essay, “Illness as Metaphor,” that war is “defined as an emergency in which no sacrifice is excessive.”[3] The wartime metaphor is problematic because as trainees, we already find ourselves drafted into a culture of sacrificing our time, our health, our comfort, and our support systems. The pandemic has stretched the upper limit of sacrifice now more than ever before. There can be neither sheltering in place for soldiers nor limits to their sacrifices. This time, we may bring illness and death home to our own doorsteps. We have no luxury of distance from trauma that may have taken place in a far-away land, as the war is on US soil this time. Ambulances wail endlessly in the streets, businesses are barren, and everyone knows someone who is sick or even deceased. Many of us have sent away our families or have ourselves moved out, in efforts to keep our loved ones from becoming collateral damage. Of all healthcare workers, residents are especially vulnerable to burn out and other stressors due to long hours and increased responsibilities.[4],[5],[6],[7] We residents bear both mental and physical burdens but feel that we must “tough it out.” By being aware of the implications of this war metaphor in the hidden curriculum of the pandemic, we can temper them and create a space that allows physicians to seek support when needed.

However unclear the degree to which a doctor should sacrifice, the COVID-19 pandemic has revealed a new brotherhood of physicians. Regardless of specialty or titles, attendings, fellows, and residents are redeployed to the intensive care units and the ED, all in service of a common goal. Subspecialty training has become less relevant, as we all perform new duties and try to help in whatever capacity is needed. As one medical intervention after another fails, we realize that, sometimes, the best and only thing to do is to bear witness to a patient's pain, to hold a hand at the end of life, and to comfort the family as best as possible. We assure our patients and their families that they will not be left alone. Moreover, as we stand with redeployed residents and attendings from every department, medicine is stripped down to its very core and we are reminded of the soul of our calling.

The contemporary hidden curriculum is complex, reflecting both positive and negative aspects of the COVID-19 pandemic. Classic residency education has been disrupted, and medical authority no longer lies in trusted sources. Residents learn that preparation and experience do not always suffice; but being flexible and rapidly adapting is the best weapon against an unknown pathogen. The language of the pandemic should be carefully examined, as it can influence identity and behaviors. The wartime metaphor, in particular, can discourage physicians from seeking help when needed. Finally, the pandemic has dissolved the divisions among the medical specialties in a new spirit of collaboration. We are all struggling with how to navigate this new hidden curriculum during the COVID-19 pandemic. By being aware of these less recognized lessons, we can mitigate the malignant, promote the valuable, and have a proactive role in shaping the pandemic culture.

Financial support and sponsorship

There are no financial supports or sponsorships.

Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

The authors of this manuscript declare that this scholarly work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network (http://www.equator-network.org). Within the broader context of narrative medicine, this article discusses individual stories and patient encounters as integral aspects of the lived experience of health and illness.

  References Top

Hafferty FW. Beyond curriculum reform: Confronting medicine's hidden curriculum. Acad Med 1998;73:403-7.  Back to cited text no. 1
Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994;69:861-71.  Back to cited text no. 2
Susan S. Illness as a Metaphor and AIDS and Its Metaphors. New York: Picador; 1989. p. 99.  Back to cited text no. 3
Prins JT, van der Heijden FM, Hoekstra-Weebers JE, Bakker AB, van de Wiel HB, Jacobs B, et al. Burnout, engagement and resident physicians' self-reported errors. Psychol Health Med 2009;14:654-66.  Back to cited text no. 4
Eckleberry-Hunt J, Van Dyke A, Lick D, Tucciarone J. Changing the conversation from burnout to wellness: Physician well-being in residency training programs. J Grad Med Educ 2009;1:225-30.  Back to cited text no. 5
Hall LH, Johnson J, Watt I, Tsipa A, O'Connor DB. Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLoS One 2016;11:e0159015.  Back to cited text no. 6
Verougstraete D, Hachimi Idrissi S. The impact of burn-out on emergency physicians and emergency medicine residents: A systematic review. Acta Clin Belg 2020;75:57-79.  Back to cited text no. 7


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